Hi, my name is Nihar Desai from the Yale School of Medicine. I’m a cardiologist and a health services researcher. I want to welcome you to this presentation, “Making an Impact: The Implications of Optimizing Heart Failure Care and Delivering Value-Based Care.” This presentation is sponsored by Novartis Pharmaceuticals Corporation, and I was compensated for my time.
The objectives of our talk are listed here, so we’ll start off and we’ll review the epidemiology and the clinical course of heart failure. Then we’ll move into identifying some signs and symptoms of worsening heart failure. Then we’ll talk about the management of heart failure, focusing on the care surrounding a hospitalization. And then we’ll move into the interplay between optimizing heart failure care and quality and performance measures. And then we’ll close out by providing some practical insights to optimizing heart failure management and delivering value-based care.
So to start, I want to review the definition of heart failure, which is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or the ejection of blood.
We typically think about two prototypical states of heart failure: one, so-called heart failure with reduced ejection fraction or systolic heart failure, shown on the left-hand side of this slide, which is characterized by a weakened heart muscle. And on the other side of the screen, you can see heart failure with preserved ejection fraction, or what is oftentimes referred to as diastolic heart failure and characterized by a stiffened heart muscle. Of course, when we’re talking about ejection fraction, we’re talking about the percentage of blood that is pumped out of the heart during every beat.
This slide reviews some of the key epidemiology, biological characteristics, and clinical comorbidities of these two subtypes of heart failure. In the middle column, you can see the heart failure with reduced ejection fraction, and on the right- hand column, the heart failure with preserved ejection fraction.
Importantly, the left ventricular remodeling is eccentric in the reduced ejection fraction heart failure, as opposed to concentric in preserved ejection fraction. Importantly, we typically think of reduced EF in a younger patient population and preserved ejection fraction heart failure as typically in an older patient population.
There’s also a predilection for women to have preserved ejection fraction heart failure as opposed to reduced EF, which doesn’t really show any preference for sex or gender.
In terms of association with important clinical comorbidities, we think about preserved ejection fraction patients as having a very high incidence of coexistent hypertension and diabetes and probably a lesser proportion of coronary artery disease.
Importantly, when you think about the clinical constellation that patients have, the preserved EF patients typically have a much higher burden of other coexistent clinical comorbidities. You can see a pathology slide of a reduced EF heart in the top there and a preserved EF heart on the bottom, again, kind of highlighting some of the important biological and remodeling characteristics of these two different clinical syndromes.
I think it’s well-known and well-appreciated that the prevalence of heart failure is projected to increase pretty substantially over time. As shown, what we’re currently with is about 6.2 million Americans, aged greater than 20, that have heart failure; and that is projected to increase to over 8 million just by 2030.
There’s a number of important factors that lead to the increasing prevalence of heart failure. First, we have an aging population. That’s an important driver of the burden of heart failure. We have emerging therapies that have actually been associated with improved heart failure outcomes. Patients with heart failure are able to live longer, and that, of course, increases the prevalence. And then they’ve seen an increase in the prevalence of many of the contributory factors of heart failure, whether that be hypertension, diabetes, coronary artery disease, or other well-established risk factors.
We know that among patients that have heart failure, hospitalizations are incredibly common. So shown on the top portion of this slide is the fact that multiple hospitalizations are common, both amongst patients with reduced ejection fraction heart failure as well as preserved ejection fraction heart failure. In fact, it’s estimated that over a mean follow-up of 5 years, more than 80% of patients with either type of heart failure will have had at least one hospitalization.
It's also true that these patients with heart failure have a very high burden of rehospitalization or readmission. In fact, up to 20%, or more than one in five, of these patients with either type of heart failure will be rehospitalized within 30 days. Similarly, more than half, in fact, greater than 55% with either type of heart failure will be rehospitalized within 1 year.
This slide demonstrates very nicely that heart failure is a progressive clinical syndrome, and so what’s plotted on this slide is disease progression or time on the X axis and then cardiac function or quality of life on the Y axis. What it nicely captures is the fact that heart failure progression really involves episodes of acute decompensation, typically thought of as a hospitalization, and that during each of these instances, there is ongoing myocardial and renal damage that contribute to progressive organ dysfunction and decreased quality of life.
As the disease progresses, these oftentimes become more frequent, and there is an overall downward trajectory in terms of cardiac function and quality of life and also greater levels of healthcare resource utilization, complexity, and cost, particularly in the final phases of the clinical course.
It’s important to remember that as our patients with heart failure have these acute decompensations that there are usually important contributing factors that lead to the worsening of heart failure. In fact, 80% will have at least one of these precipitating factors, the most common of which are summarized on this slide. We typically think about things like acute myocardial ischemia, uncontrolled hypertension, atrial fibrillation or other arrhythmias, as well as medication nonadherence or dietary indiscretion, as well as other clinical comorbidities such as anemia, hyper- or hypothyroidism, and infection, amongst other key contributors.
This is a very important slide, which summarizes the fact that the signs and symptoms of worsening heart failure are generally similar between patients with reduced EF heart failure and preserved EF heart failure. In fact, the signs and symptoms of congestion are the most common presenting clinical features at the time of hospitalization.
And, typically, congestion is manifested by either dyspnea on exertion, peripheral edema, or rales, and that can occur in greater than 60% of patients with either heart failure with reduced ejection fraction or heart failure with preserved ejection fraction, summarized here in the figure below.
So we’ve talked about the importance of assessing volume status and congestion being one of the primary manifestations of acute decompensated heart failure. And so this slide then summarizes one of the key physical exam characteristics for assessing human dynamic status and volume status and that is by measuring the jugular venous pressure. So shown on the left-hand part of the slide here is, how you would have a patient ideally situated to make a JVP assessment.
The steps are on the right-hand side of the slide here. So first to visualize the JVP, you have the patient in that reclined position 45 degree angle and having them turn their head to the left. The second step is to then measure the height of the JVP column, specifically on the right-hand side of the patient. And you’re measuring that vertical distance in centimeters between the sternal angle of Louis and the level of the jugular venous pressure column that you are observing. And then the final step in terms of determining the jugular venous pressure is to take that height of the JVP that you have measured at 5 centimeters, which represents the fixed distance between the sternal angle of Louis and the right atrium’s midpoint. And we typically think of any JVP assessment greater than 10 centimeters of water as being synonymous with jugular venous distention or having a JVD.
I will say that as a clinician who sees patients every day both in the office and in the hospital setting, assessing the JVP is really one of the things that, I think, comes with practice. And a couple of tips that I might share with you is, first and foremost, is to measure the JVP in everyone. I think the more necks you look at, the more anatomy that you get comfortable with, and the more jugular venous pressures that you try and estimate using your eyes, I think you will become a much more skilled practitioner. This is definitely a skill that comes with repeated practice.
Secondly, I think one of the things that you can do if the assessment is difficult, especially if the patient has a thicker neck or maybe a more challenging exam, is you can add some light orthogonal onto the neck. That sometimes accentuates the fluctuations that you are looking for in the jugular venous pressure. And, really, what you want to be able to do is to differentiate the jugular venous pulsations from the carotid pulsations. And so really seeing the multiple wave forms that then characterize the jugular venous pressure wave form versus the carotid upstroke can be quite helpful as you try and master the jugular venous pressure.
But this is a very important part of the physical exam for a patient with heart failure because assessing volume status and hemodynamic status is really one of the pillars that’s going to guide you in terms of therapy and management.
It’s important to note that decongestion is the primary target of management, particularly during an acute decompensated heart failure episode on this 2x2 slide where shown on the top is the presence or absence of congestion at rest, typically assessed with things like orthopnea, rales, elevated jugular venous pressure, ascites, peripheral edema, and others. And on the left-hand side, you can see, is the perfusion adequate at rest, typically assessed by looking at the pulse pressure, altered mental status, worsening renal function, and other similar parameters.
The goal, of course, is to get our patients into the orange box where they are dry and warm. One of the key features that one has to assess is as you’re moving from congestion, obviously, the mainstay of therapy there will be diuretics; and then there will be other guideline-directed medical therapy that becomes increasingly important as you get that patient more into the dry and warm state.
The one figure going from the bottom right-hand side – if a patient is wet and cold, and it’s essentially a surrogate for low cardiac index or low cardiac output as well as elevated filling pressures. You may have to consider the use of inotropic therapy to support ventricular function to facilitate diuresis and, ultimately, moving that patient to the dry and warm phase.
I think one other key point that we have realized is that patients that have high-grade orthodema or congestion were much more likely to experience the composite outcome of death, readmission, or unscheduled urgent care or ED visit at 60 days postdischarge. This really highlights the need for us to really think about decongestion as the primary target of management and ensure that our patients are reaching euvolemia.
In addition to decongestion, the management of heart failure, with reduced ejection fraction, has multiple other facets or components. Of course, first and foremost, is lifestyle changes and patient education. We want to counsel our patients about weight loss, a heart- healthy lifestyle, cardiac rehab, exercise training, and medication adherence, the use of guideline-directed medical therapies, including RAAS blockers, beta-blockers, aldosterone antagonists, and others — device therapy if indicated with cardiac resynchronization, an implantable cardioverter defibrillator, as well as a ventricular assist device or other advanced therapies.
Along similar lines, transplantation is, of course, the gold standard for the treatment of refractory end-stage heart failure, and that 1-year post-transplant survival is just about 90%, about 88%.
And, finally, as patients continue with this progressive disorder, they may reach a time when palliative care becomes the most important aspect of their care, and I think engaging our palliative care specialists to really think about goals of care, advanced directives, address caregiver support, and put a care pathway in place for those patients is also incredibly important.
In contrast, the management of heart failure with preserved ejection fraction really focuses on symptoms and comorbidities. Importantly, as everyone knows, there’s no treatment that has yet convincingly been shown to reduce morbidity and mortality in patients with preserved ejection fraction heart failure.
So the goals, again, are really to alleviate symptoms, improve well-being, and then to manage those clinical comorbidities. There is evidence that diuretics improve the symptoms of congestion and/or dyspnea, and that’s consistent across the ejection fraction spectrum. We talked about that for reduced ejection fraction as well as preserved. Evidence that beta- blockers, RAAS inhibitors, mineralocorticoid receptor antagonists improve symptoms is really inconsistent for preserved EF patients.
So in 2017, ACC/AHA focus update really added mineralocorticoid receptor antagonists for consideration in selected patients, but I think the mainstay really of therapy is diuretics for volume and then really managing comorbidities, ensuring that the blood pressure is well-controlled. That if the patient also has diabetes, that that is well-controlled. And really emphasizing the importance of good comorbidity management with therapies that improve symptoms without exacerbating heart failure.
So this slide highlights a number of important elements of optimizing the care of patients with reduced ejection fraction heart failure, specifically the role of guideline-directed medical therapy.
So on the left-hand part of this slide, you can see a figure that shows the estimated treatment rates of US patients with reduced ejection fraction heart failure eligible for various guideline-directed medical therapies, specifically RAAS inhibitors, beta-blockers, aldosterone antagonists, and then hydralazine nitrate combination therapy.
In the blue, you can see eligible patients that are treated, the proportion of patients that are receiving those therapies, and in purple are the proportion of patients that are eligible for these therapies but are actually untreated. And so you can see for RAAS inhibitors, about one in five patients are actually not receiving this therapy. About 15% of patients are not receiving beta-blockers. Surprisingly, and I think staggering, that over 60% of patients with reduced EF heart failure that are eligible are not treated with an aldosterone antagonist. And, in fact, the vast majority of patients who are eligible for combination therapy with hydralazine and nitrate therapy are not receiving therapy.
So I think that slide nicely summarizes the fact that though our care of patients with reduced EF heart failure has gotten better in some ways, that there are important opportunities for us to really optimize the use of guideline-directed medical therapy.
So whereas the left-hand part of the panel shows whether someone is treated or not treated, the right-hand part of this slide actually shows whether the doses of the various guideline- directed medical therapies is compatible with what the guidelines would recommend and what we have learned from the important clinical trials.
And so shown here for RAAS inhibitors and beta-blockers are the proportion of patients who are receiving less than 50% of the target dose, between 50 and 100% of the target dose, and then in purple, the proportion of patients that are actually receiving the guideline-directed medical therapy at the target dose that the guidelines or the clinical trials would support.
And so, again, you can see that for RAAS inhibitors, it’s less than 20% of patients that actually receive that therapy at the target dose. And for beta-blockers, it’s slightly less than 30% that are actually receiving beta-blockers at the target dose.
When you put this slide together, the key takeaways are there are remaining opportunities for us to optimize the role and the prescribing of guideline-directed medical therapy and that for each of us to really think deeply about optimizing GDMT such that we are reaching the target doses that the clinical trials and the guidelines have set forth, specifically for RAAS inhibitors and beta-blockers shown here.
This slide emphasizes another key point in terms of management of heart failure that initiation or maintenance of guideline- directed medical therapy at discharge from a hospitalization is associated with improved outcomes. So on the left-hand panel here, you can see the percentage of patients that were newly initiated on GDMT at the time of hospital discharge; and on the right-hand panel, you can see the clinical outcomes that are associated with, in the top row, starting any therapy versus no therapy. And, again, for the reduced ejection fraction heart failure patients, you can see a hazard ratio of 0.41, a significant reduction in the association of adverse events, specifically mortality amongst patients that started a therapy versus those that did not start a therapy.
In fact, the converse is also true. If you look at patients that discontinued some aspect of their guideline-directed medical therapy versus those patients that had continuation or maintenance of their guideline-directed medical therapy, you can see that those that discontinued had a significant hazard for mortality, particularly those with reduced ejection fraction heart failure.
So the last several slides really synthesized several important concepts. One, the central role of guideline-directed medical therapy in the management of reduced EF heart failure. Really thinking deeply about whether there is an opportunity to initiate some element of guideline-directed medical therapy in a patient that is hospitalized for heart failure and then trying to avoid discontinuing or down-titrating guideline-directed medical therapy if that is possible.
One of the other key aspects of managing patients with heart failure is the adjunctive but important role of natriuretic peptides in both establishing the diagnosis as well as the prognosis for patients with heart failure. So natriuretic peptides are, of course, modifiable biomarkers that have been shown to be quite helpful, both for establishing the diagnosis. So at the time of hospital admission, the measurement of baseline levels of natriuretic peptides can be useful to think about the prognosis in an acutely decompensated heart failure patient. And then just as importantly, we’ve seen that assessing the natriuretic peptides at the time of hospital discharge can also be quite useful for looking at postdischarge prognosis.
Both of these are now guideline recommendations for the use of natriuretic peptides in the clinical practice guidelines.
Their use at the time of admission is a Class I, a Level of Evidence A recommendation. While checking the natriuretic peptides at the time of discharge have a IIa recommendation with the Level of Evidence B.
This slide, I think, summarizes some important principles about the changes in natriuretic peptides during a hospitalization.
So one could imagine that if we’re checking this at the time of admission and then we’re checking this at the time of discharge, that the delta in the natriuretic peptides can probably give us some important insights. And, in fact, what has been seen is that those patients that have a discharge BNP of less than 200 nanograms per liter have a reduction in 30-day mortality as compared to those that have substantial elevations in their natriuretic peptides.
Similarly, we’ve seen that reductions in the NT-proBNP have been associated with a substantial lower risk of 30-day heart failure readmissions. The other key takeaway is, yes, of course, we’d like to see the natriuretic peptides decrease during the course of a hospitalization; and static or rising levels of natriuretic peptides really indicate that this patient has high-risk features and may have additional morbidity and mortality from their heart failure syndrome.
One of the other key aspects of managing a heart failure patient, and I think the American College of Cardiology and the American Heart Association Guidelines have really emphasized this, is that the management of heart failure really requires a multidisciplinary approach. Of course, there will be the physician providers, cardiologists, the hospitalists, the primary care provider, as well as other providers – clinical nurse specialists or advance practice provider. But I think we also have to think about other members of our care team, whether that be the clinical pharmacist, the dietitian, the physical therapist, and other specialists, including social workers and other ancillary healthcare providers that actually all play an essential role in managing our patients with heart failure.
The essential skills, of course, are diagnosis and monitoring of progression, initiating, titrating, and monitoring treatment. We spent a lot of time kind of walking through how important that is. Patient education and then, of course, care coordination that, as the patient kind of moves from one care setting to another, that there really is going to be an all-hands on deck kind of approach. There really is a continuum of care and a continuum of support to help our heart failure patient and their caregiver team really optimize their care and optimize their outcomes, whether they’re in the hospital or they move and transition into an ambulatory environment.
I think a key aspect of that is shown on this slide, that a risk score-guided, multidisciplinary team care approach really can improve heart failure outcomes. And so whether you look at the inpatient heart failure score or the Intermountain Mortality Risk Score, which both use common laboratory markers, age to calculate risk and then stratify patients into low, moderate, or high risk. And for those high-risk patients, that intensive, daily, multidisciplinary rounds, again, with that sort of broad care team of physicians, advanced practice providers, nursing, pharmacy, potentially even a heart failure clinic nurse, a dietitian, social worker, care coordinator have been shown to significantly improve outcomes.
In fact, use of such an intensive daily multidisciplinary rounding structure can lead to about an 18% reduction in 30-day readmission and a 46% reduction in 30-day all-cause mortality. I think that the slide and the magnitude of benefit here really highlights the need for us to have a multidisciplinary approach for managing these patients with heart failure.
We also need to think about patients as they move from one care setting to another and whether that is from the hospital to the ambulatory side or from the ambulatory side to the hospital if they’re in the midst of an acute decompensation.
I think one of the things that all providers agree on is the importance of care coordination and communication between different providers on the care team.
And so I think it was near universal that providers surveyed thought that improving communication between inpatient and outpatient providers was either important or extremely important to really optimize the care of our patients with heart failure and ultimately improve outcomes for them.
One can think of key elements of that communication. If going from the hospital to the ambulatory setting, the communication from a hospitalist to the primary care provider would or should include things like current therapies, medications and treatments, whether there are any pending tests or recent test results that might inform the posthospital visit. Anticipated plans for lab monitoring and response assessment. And, finally, a detailed account of the recent hospitalization. What do we think the trigger for that hospitalization was? What happened? How did the patient respond? What is their dry weight? How are they feeling now What are their laboratory parameters and renal function? Natriuretic peptides? And what is the expectation around other postdischarge follow-up care? Of course, to the primary care provider but whether any other specialists or any other care providers will then be asked to care for that patient.
One can similarly think about the flip scenario of going from the ambulatory setting into the inpatient setting. There I think valuable information that can be provided to the hospitalist would be current therapies, medications and treatments, the HPI, the past medical history, any recent tests, what’s been going on for the patient? What type of evaluation has been done in the ambulatory setting? And whether there are any pending tests at the time of hospital presentation.
The key here is that whether the patient is moving from the inpatient to the outpatient, or from the outpatient to the inpatient, that the communication across the various members of the multidisciplinary team are really crucial to make sure that the patient gets the right kind of care in a safe, efficient, and high-quality kind of way.
You know, I think it’s not just enough for us to care for patients, but I think we really have to engage and empower them if we really want to improve outcomes. That what started from initial principles or ideas around developing a treatment plan and having patients comply with that or adhere with that, I think this really changed now. We’re really thinking much more holistically about patient engagement and patient empowerment through use of shared decision-making tools, motivational interviewing, other sort of important elements of doing that.
I think there are important areas where we can really empower patients to improve outcomes. One would be education support, so really informing them and empowering them to think about worsening signs and symptoms, doing the kind of self-care and monitoring that is required for them to achieve optimal outcomes, disease, medication, and nutritional management and also physical exercise training.
And, again, we’ve seen interdisciplinary disease management with a strong educational component is associated with a three-fold reduction in 30-day heart failure readmission as compared with standard of care. Similarly, we can think about employing different technological platforms to really help with patient engagement, whether that’s short video messages or on social media or text messages. And that the spread of educational messages through these technological platforms can really help reach patients who live remotely or may have socioeconomic challenges.
But I think it’s really crucial that we think about engaging and empowering our patients with heart failure to really equip them to best manage their disease and really improve their clinical outcomes.
So if we think about interventions to improve patient adherence to therapy, there’s multiple areas that we can kind of talk about for that. So, of course, first and foremost is training and education. Really explaining to them what their individualized treatment plan is, giving them brochures or newsletters, computer programs, other interactive learning materials. There are also patient focus groups and other vehicles for them to engage in the kind of training and education they really need to do the self-care and the self- management that is really critical to improving outcomes for these patients.
Importantly, reminder systems have a very important role to play here, whether that’s telephone calls or home visits or other kinds of technological solutions.
Supporting self-care, so the use of measuring instruments, whether that be a scale and other sort of biometric measurements. Keeping a diary of symptoms and medications and adverse effects. Those kinds of things can be very helpful as a patient can kind of develop a cadence around their clinical care and clinical syndrome and then share those with their care providers.
Really developing a scheme for diuretic titration. At what level of weight gain should a patient change their diuretic program? Pill organizers can be incredibly helpful, just given that many of our patients with heart failure have a number of comorbidities that require pharmacotherapy. Good updated medication lists I think are incredibly important, both from a safety standpoint so the patients have a good understanding of the medications they’re taking and why they’re taking them. But just as importantly, medications that may have been discontinued or modified or ones that they are no longer asked to take.
And then I think making sure that patients have access to a hotline or 24/7 call coverage. Who can they call if there’s a question, if there’s a problem, if there is something that has come up and they need to discuss that with a provider? What type of access do they have?
I think with some of our patients, we’ve seen that telemonitoring systems can be quite helpful. These actually can provide automated prompts to our patients. They can track weight and other vital signs like heart rate and symptoms, even medications. And also encourage patients to engage in the kind of lifestyle modifications that we know are going to be incredibly important for them.
And then, finally, I think there’s socioeconomic support. We’ve got to think holistically about the challenges that our patients face. And, again, as we mentioned, they may have a number of clinical comorbidities, but they may be facing other challenges in their own context or their own environment. So I think being very mindful about pharmacy costs, prescribing lower cost generics when possible, shared decision-making about out-of- pocket costs. Really informing them about what they can expect when they get to the pharmacy, so they aren’t surprised when they get there. Minimizing the use of multiple pharmacies, really trying to streamline, coordinate their pharmacy activities can be quite helpful. And then prescribing 90-day quantities for their refills can actually help as well.
So I think summarized on this slide are some practical interventions that can be taken prior to discharge to improve transitions of care for patients with heart failure. And, again, it really does take a village. It really does require a multidisciplinary team, and we’ve already seen that using a team like that is associated with actually pretty impressive improvements in clinical outcomes.
First, on the slide here is medication reconciliation. Again from a safety and a quality standpoint, really making sure that patients have a good understanding of their medical regimen, what they’re taking, what they’re not, what has changed, and really giving them a good understanding of why they are taking these different therapies is foundational to the management of heart failure.
Addressing barriers to care, and I think, importantly scheduling an early postdischarge communication. Not everyone can do an in- person visit within two or three days of hospital discharge. But having some kind of communication, maybe even over the telephone can be incredibly important to make sure that they’ve made that transition from the in-patient setting to the outpatient setting in a seamless way, they were able to fill their medications. They are continuing on the road to recovery.
Along similar lines, I think trying to schedule an in-person visit with a provider within that first week or so of discharge, I think this again is something that’s been shown to be quite, quite beneficial. Reinforcing heart failure education and a selfcare plan, how are they going to monitor their disease?
What are they going to do? What should they be looking for? Really equipping them and empowering them with the tools they need to really manage at home is going to be incredibly important.
And then, of course, ensuring integrated, interdisciplinary collaboration and coordination as they go from the hospital to the ambulatory setting. And as one set of providers and one team that was seeing that patient in the hospital sort of transitions to another set of providers and another team in the ambulatory setting, it’s really critical that there be good written documentation, communication, and clear follow-up of that patient so that they can make that transition in a very, very seamless way.
I think just as importantly, to transmit handoff documents to the postdischarge providers in a timely manner. If we are going to have a patient hopefully get into the office within a week or so of discharge, it’s very important that the primary care provider or the provider that’s going to see them at that first discharge visit have a full comprehensive summary of the hospitalization, whether there was any key tests or anything that was pending, and that really clearly articulates what the plan of care is so that everyone is well-aligned on the care plan going forward.
Again, it’s important to remember that an effective transition of care from the hospital to the home is associated with a pretty substantial reduction, about a 39% reduction in 30-day rehospitalization rates.
So we’ve spent the first part of the presentation really going into the epidemiology of heart failure, thinking about this complex clinical syndrome, the various treatments that we have sort of available, the importance of decongestion, of volume assessment, really having a multidisciplinary team, the role of guideline-directed medical therapy, not just in terms of getting it started but then also up-titrating and optimizing the doses of various different guideline-directed medical therapies.
I want to sort of switch gears a little bit and now talk about the interplay between heart failure care and value-based care. I think it’s fair to say that we’re in the midst of a pretty remarkable transformation in the payment system of the financing of healthcare, and we have really shifted away from volume-based models of care to what we call value-based models of reimbursement, where the reimbursement is really tied to the quality of care that’s delivered, to the efficiency of that care, and to the outcomes that are achieved.
And I think there’s a really important interplay between heart failure care and this broader transformation on the healthcare financing side to value-based care. And I don’t think that should be a surprise to anyone, specifically when you think about the fact that heart failure is the number one cause of 30- day readmissions amongst Medicare beneficiaries. So, we’ve already talked about the prevalence of heart failure, and now we see that it’s the number one cause of 30-day readmissions.
There’s a substantial increase in the cost of care. In fact, 127% projected increase in the total cost of heart failure care from 2012 to 2030, where it’s estimated to account for just about $70 billion in health care costs, the average cost of a hospitalization somewhere between $13 and $23,000 for a patient with heart failure, and 5-year mortality that is staggering at about 75%. And we know that that’s also variable across the country.
So, if you put all these numbers together and you sort of think about the prevalence of heart failure, the enormous toll that it places on patients and families and caregivers in terms of substantial morbidity and mortality, then you think about the spiraling costs and where we’ll be in just a few years, at about $70 billion in costs, and significant variation in the cost of a hospitalization, I don’t think it’s any mistake that heart failure actually has been a focal point of many of the value- based care programs that have been enacted nationally. In the subsequent slides we’ll, obviously, go through that in some additional detail.
One of the best examples that highlights this is the transition to value-based care that we had with the Hospital Readmission Reduction Program. So in 2010, as part of the Affordable Care Act, the Hospital Readmission Reduction Program was put into law. It ultimately went into effect two years later in 2012, and this program, for the first time, financially penalized hospitals if they had excessive all-cause, unplanned, 30-day readmission rates following an index heart failure hospitalization. It’s important to note that the penalty payment under this program was applied to the entire Medicare revenue of a hospital. And so if you have an increase in readmissions, and you have a decrease in the payment adjustment factor, ultimately, hospital payments are significantly reduced as part of this program.
And so I think this was the first example of a policy initiative that was really meant to improve quality for patients and also reap financial savings for providers and for policymakers in this case. Now this was initially kind of emphasized as just for Medicare beneficiaries, but what we’ve seen is that other commercial payers are now following suit and putting in place very, very similar programs.
Beyond the readmission story, I think there are a number of other important examples of value-based care models that have specific connections to heart failure, as we’ll see on the subsequent slides. For instance, the Hospital Value-Based Purchasing program, or HVBP, considers much more broadly the quality of care and the cost efficiency of the care that’s provided to patients.
Similarly, the MIPS program, or the Merit-Based Incentive Payment System program, does something very, very similar, looking holistically at the quality of care as well as a number of other elements of care but on the ambulatory side. In fact,it uses a weighted combined final score of four different performance categories.
The Bundle Payment for Care Improvement-Advanced, for BPCI-A, program provides a single retrospective bundled payment for all services rendered to a patient during a 90-day clinical episode. So in BPCI-A, you have an anchoring index hospitalization. A patient is then followed through that index hospitalization and the 90 days subsequent thereof, and there is a single bundled payment, or a target price, for all of the clinical services that are delivered to that patient during that 90-day episode.
And then, finally, the Accountable Care Organizations, the Shared Savings program in particular, where providers share the savings or losses of the services that they provide. And so what you can think of for an ACO is that there is a group of providers, or potentially even a hospital, that is bearing full financial risk for a population of patients. And if the total cost of managing those patients is higher than what the ACO has been kind of targeted or has been set for the ACO, there is a financial loss. And if the care is coordinated and efficient and of high quality and the total cost is actually less, then the organization can actually reap some of the financial savings or financial benefits of that.
Now, importantly, these four programmatic initiatives as sort of prototypical examples of value-based care models all play some role or have heart failure as an important element in them.
So, for example, shown here are examples of performance and quality measures within each of these value-based care models which are particularly relevant for our patients with heart failure. So the HVBP, or Hospital Value-Based Purchasing program, includes hospital performance with 30-day heart failure mortality as one of the key performance metrics that is used as part of this program.
Similarly, the MIPS program uses quality measures that are quite relevant for our patients with reduced EF heart failure. For instance, the proportion of those patients that are prescribed a RAAS inhibitor or a beta-blocker either at hospital discharge or in the outpatient setting. So we talked about the role of guideline-directed medical therapy and the use of guideline- directed medical therapy for patients with reduced EF heart failure, and here you can see that in the value-based care model, specifically MIPS, that that is one of the key performance or quality metrics for achieving success in that program.
Similarly, we’ve seen that in the bundled payment program, since you have a total cost of care and you have an index hospitalization and then 90 days that follow, improving performance, reducing rehospitalizations, and optimizing use of guideline-directed medical therapy would all be important elements for achieving success with heart failure, which is one of the clinical diagnoses that is included as part of the BPCI- A.
And similarly, when you think about the ACOs, which encourage providers to coordinate care to really optimize the quality and efficiency of that care, that heart failure patients because of the complexity and the prevalence are really one of the key drivers of an ACO success. And so I don’t think you’d have an Accountable Care Organization that can really deliver high quality, high value, efficient care if they aren’t providing that type of care to their patients with heart failure. So I think this slide very nicely summarizes the interplay between value-based care models on specific sort of national policy initiatives and alternative payment models and the care of heart failure patients specifically.
This slide here then I think emphasizes that once again. So in the center here, in the center box, you can see the opportunities to deliver high value heart failure care from admission to discharge. I think we’ve talked about these, but it’s a very nice summary here first to recognize and modify clinical markers. We talked about the use of natriuretic peptides to potentially do that. We talked about the importance of achieving decongestion, really getting out of clinical state, optimizing guide-directed medical therapy, either initiating GDMT if the patient is not on it or optimizing the dose if they are, really engaging the multidisciplinary team, and then improving the transition.
And one can really see the benefits of that not only for the patients’ clinical care and for improving outcomes but then also for a hospital or a provider groups’ participation in a number of these value-based care programs. So doing everything that’s kind of emphasized in that center box, you can see how that would facilitate performance in the Readmission Reduction program by reducing readmissions, improving performance in HVBP by reducing 30-day mortality, improving performance in MIPS or in BPCI-Advanced, as well as in an ACO.
One of the key takeaways then from this and why value-based care programs and alternative payment models I think are so important, and especially for patients with heart failure, is it really represents an instance where doing the right thing for the patient and delivering best care for the patient also means that the health system, the hospital, the provider groups are incentivized and recognized for delivering that care. And I think that’s really what value-based care models are all about. It’s really when you deliver the best quality of care, the most efficient care, and you achieve the best outcomes for your patients with heart failure that these value-based care models will actually reward you for that outstanding clinical work.
So with that, we’ve come to the conclusion of our presentation here. Final few points that I think we need to highlight once again. First, that hospitalization is a pivotal point in the clinical trajectory of heart failure regardless of whether the patient has reduced ejection fraction heart failure or preserved ejection fraction heart failure.
Second, that the identification of worsening heart failure is critical to managing patients with decompensated heart failure. We talked about some of the prototypical clinical manifestations of that and how important sort of decongestion is.
Thirdly, again, that decongestion, the optimizing of guideline- directed medical therapy, and the reduction of natriuretic peptides during a course of a hospitalization are some of the key treatment goals for a patient that is hospitalized with heart failure.
Fourth, the transition from volume- to value-based care in heart failure is really aimed at reducing readmissions, mortality, really improving the patient’s experience, and improving overall outcomes.
And, finally, applying practical approaches to heart failure care will aid in meeting the performance measures that have been set by these value-based care models.
So with that, I want to thank you for your attention during this program, “Making an Impact: The Implications of Optimizing Heart Failure Care and Delivering Value-Based Care.” Thank you again.