Gaps in Caring for Patients With Heart Failure

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Transcript: Deepak L. Bhatt, MD, MPH: Nancy, what are the unmet needs in heart failure at this point in time?

Nancy M. Albert, PhD, CCNS: Thanks for asking. We actually have quite a few unmet needs out there. First, we have patients who are getting older and frailer. They may have more cognitive decline. We have many comorbidities that we have to deal with these days, and it’s important to know the number of medications our patients take. But it’s more than that. Oftentimes, patients will complain of shortness of breath or fatigue. We may think it is anemia, or their COPD [chronic obstructive pulmonary disease], or their sleep-disordered breathing. So we may not be treating heart failure as assertively as we need to because we believe the problem is really something else.

We know that our hospitalization rate is really not taking the dent we were hoping for when the CMS [Centers for Medicare & Medicaid Services] changed the rules with Obamacare and rehospitalizations. What we’re seeing now is a trend toward more observation-unit care. If you add observation care and hospitalization together, we’re still at about the same rate of hospitalization we were in 2006. So we have a chronic condition—especially with HFrEF [heart failure with reduced ejection fraction] where we have treatment therapies—and we’re not really advancing our patients’ lives enough so they can stay out of the hospital.

I think there’s a lot of talk about adherence. You talked a little about it with diet. Patients need to be educated, but I don’t think adherence for patients is the only issue. I think this is even a problem among providers. We have a lot of providers who don’t order evidence-based therapies. They may order the right drug but not at the right dose, or somebody is taken off a therapy during hospitalization and it’s never restarted again in the posthospital discharge setting. So between transitions-of-care issues and patients getting older and maybe frailer and not remembering everything they need to do on their own, I think there are a lot of unmet needs out there that we need to try to target in the years to come.

Deepak L. Bhatt, MD, MPH: Those are really terrific points. There is 1 thing you mentioned that I just want to amplify, and I think it’s been a shame. This is pertinent to heart failure, but even more broadly, the policies are just sort of put on us without ever being tested. On drugs or devices in general, there has to be some level of testing and evidence. They’re just foisted upon us, and they sometimes don’t work or sometimes backfire, like this whole heart failure readmission attempt. It just really created a lot of stress on hospitals regarding financial penalties. It’s not really clear whether or not it helped anybody. It might have actually hurt patients.

Nancy M. Albert, PhD, CCNS: I think so. Of note, we’ve got these performance measures that are nationally pushed and, of course, everybody is pushing for the 7-day-follow-up visit and preventing readmission. But we’re not spending time asking if patients are on the right drugs—and, “Why aren’t you ordering it?” And, “What is that contraindication, and are you documenting it?” So we’re trying to get to this outcome but without knowing the processes in place that may lead us to the right outcome.

Transcript Edited for Clarity