Abstract
ᅟ
Similar content being viewed by others
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.Avoid common mistakes on your manuscript.
Introduction
Hospitals and payers have increasingly focused on improving outcomes for older adults hospitalized with common cardiovascular conditions. Epidemiologic data have shown that approximately one in five older adults hospitalized with acute myocardial infarction or heart failure is readmitted to the hospital within 30 days [1]. Many of these patients die in the weeks after hospital discharge [2]. To mitigate these risks, the federal government has created a number of financial incentives to motivate hospitals to improve their readmission and mortality performance [3, 4]. As a result, hospitals have achieved marked improvements over time in quality, especially with regard to their readmission rates [5, 6].
The Opportunity
The focus on readmissions and mortality has not however addressed the range of outcomes important to hospitalized older adults. For example, many older patients prioritize reduction in symptom burden or the maintenance of independence as primary goals of medical care. Others prioritize the optimization of mobility or health-related quality of life [7,8,9]. Indeed many organizations including the American Heart Association [10], American College of Cardiology [11, 12], American Geriatrics Society [7], and Patient-Centered Outcomes Research Institute [13] have stated that these patient-reported outcomes, also called health status outcomes, should be primary targets for medical care.
Unfortunately, improvements in health status outcomes after hospitalization have been hindered by major informational gaps. For example, little is known about expected recovery in symptoms, function, and health-related quality of life following hospital discharge, including how these outcomes relate to objective measures of physical function. Determinants of patient-reported outcomes are also poorly understood. In particular, little is known about how common toxicities of hospitalization such as immobility, poor sleep, and insufficient caloric intake relate to recovery and if specific resilience factors among patients attenuate the effects of these exposures. Finally, there is little knowledge about strategies that can improve health status after hospitalization, and in so doing, reduce health care utilization and costs.
The time is therefore now for academic and provider communities to move older patients’ experiences of hospitalization and recovery towards the forefront of clinical care. To achieve this goal, a dedicated agenda is needed to better understand health status and its determinants after hospitalization. Luckily, we have entered an era where novel technologies enabled by tablets, smart phones, and smart watches can be relatively easily deployed to capture patient-reported outcomes after hospitalization and define detailed trajectories of recovery. Of course, these technologies will need to be tailored to meet the needs of older adults, many of whom have sensory impairments and unfamiliarity with these mediums. This agenda will also need to examine if adverse exposures during hospitalization [14, 15] including frequent sleep disruptions and limited mobility worsen symptom burden, functional status, and health-related quality of life after hospital discharge. While data in humans are lacking, these common stressors from hospitalization are clearly linked to multiple adverse outcomes including depression, infections, and acute cardiovascular abnormalities among laboratory animals [16,17,18].
One may ask if data are even needed to justify making the experience of hospitalization more humane for older adults. Indeed, it is already known that quiet hours at nighttime, reduced overnight interruptions for vital signs checks and medication administrations, and relaxation techniques such as massages and warm tea can promote better rest within the hospital [19]. Similarly, data has shown that early mobilization and ambulation can reduce both hospital length of stay and debility [20, 21]. As a result, it may be prudent to make such commonsense interventions regular parts of hospital care whenever possible. We do this already for hospitalized children, who are generally allowed to sleep with minimal interruption and are rarely subject to painful procedures and diagnostic tests without clear justification [22]. Yet the application of these principles to hospitalized older adults is far from the norm.
Conclusion
We are at a critical juncture in improving post-hospitalization outcomes for older adults with cardiovascular disease. Cardiovascular readmissions have declined in recent years, though now appear to have reached a plateau [6]. Similarly, mortality rates are unchanging [23]. As a result, further gains in patient outcomes will likely require a pivot to other endpoints. Health status outcomes represent an ideal next target for quality improvement. These endpoints bring the voices of patients to the center of what we do as healthcare providers. While this focus will introduce new challenges, it will also bring forth tremendous possibilities as we try to better align medical care with the values and goals of patients.
References
Dharmarajan K, Hsieh AF, Lin Z, Bueno H, Ross JS, Horwitz LI, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309:355–63.
Dharmarajan K, Hsieh AF, Kulkarni VT, Lin Z, Ross JS, Horwitz LI, et al. Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort study. BMJ. 2015;350:h411.
Kocher RP, Adashi EY. Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. 2011;306:1794–5.
VanLare JM, Conway PH. Value-based purchasing—national programs to move from volume to value. N Engl J Med. 2012;367:292–5.
Zuckerman RB, Sheingold SH, Orav EJ, Ruhter J, Epstein AM. Readmissions, Observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016;374:1543–51.
Desai NR, Ross JS, Kwon JY, Herrin J, Dharmarajan K, Bernheim SM, et al. Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and Nontarget conditions. JAMA. 2016;316:2647–56.
Universal health outcome measures for older persons with multiple chronic conditions. J Am Geriatr Soc 2012;60:2333–41.
Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346:1061–6.
Huang ES, Gorawara-Bhat R, Chin MH. Self-reported goals of older patients with type 2 diabetes mellitus. J Am Geriatr Soc. 2005;53:306–11.
Rumsfeld JS, Alexander KP, Goff Jr DC, Graham MM, Ho PM, Masoudi FA, et al. Cardiovascular health: the importance of measuring patient-reported health status: a scientific statement from the American Heart Association. Circulation. 2013;127:2233–49.
Forman DE, Rich MW, Alexander KP, Zieman S, Maurer MS, Najjar SS, et al. Cardiac care for older adults. Time for a new paradigm. J Am Coll Cardiol. 2011;57:1801–10.
Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, et al. Knowledge gaps in cardiovascular care of the older adult p: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society. J Am Coll Cardiol. 2016;67:2419–40.
Patient-Centered Outcomes Research Institute. Engagement. Available at: http://www.pcori.org/about-us/our-programs/engagement. Accessed 3 April 2017.
Krumholz HM. Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med. 2013;368:100–2.
Detsky AS, Krumholz HM. Reducing the trauma of hospitalization. JAMA. 2014;311:2169–70.
McEwen BS. Central effects of stress hormones in health and disease: understanding the protective and damaging effects of stress and stress mediators. Eur J Pharmacol. 2008;583:174–85.
Sheridan JF, Feng NG, Bonneau RH, Allen CM, Huneycutt BS, Glaser R. Restraint stress differentially affects anti-viral cellular and humoral immune responses in mice. J Neuroimmunol. 1991;31:245–55.
Lu XT, Liu YF, Zhang L, Yang RX, Liu XQ, Yan FF, et al. Unpredictable chronic mild stress promotes atherosclerosis in high cholesterol-fed rabbits. Psychosom Med. 2012;74:604–11.
Inouye SK, Bogardus Jr ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669–76.
Mundy LM, Leet TL, Darst K, Schnitzler MA, Dunagan WC. Early mobilization of patients hospitalized with community-acquired pneumonia. Chest. 2003;124:883–9.
Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139–45.
O'Brien MR, Rosenthal MS, Dharmarajan K, Krumholz HM. Balloon animals, guitars, and fewer blood draws: applying strategies from pediatrics to the treatment of hospitalized adults. Ann Intern Med. 2015;162:726–7.
Centers for Medicare & Medicaid Services. Medicare Hospital Quality Chartbook, September 2014. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/downloads/medicare-hospital-quality-chartbook-2014.pdf. Accessed 3 April 2017.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Dr. Dharmarajan works under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures and is a consultant for and member of a scientific advisory board for Clover Health.
Dr. Dharmarajan is supported by grant K23AG048331 from the National Institute on Aging and the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. He is also supported by grant P30AG021342 via the Yale Claude D. Pepper Older Americans Independence Center.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Rights and permissions
About this article
Cite this article
Dharmarajan, K. Health Status After Hospitalization: A New Target for Geriatric Cardiology. Curr Cardiovasc Risk Rep 11, 16 (2017). https://doi.org/10.1007/s12170-017-0543-8
Published:
DOI: https://doi.org/10.1007/s12170-017-0543-8