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Abstract
Problem Statement or Scientific Question: Patients with heart failure are at increased risk for hospitalization. Identification of patients at risk and timely intervention to prevent hospital admission can be challenging. Our goal is to better identify those at risk for admission using remote monitoring.
Background/Project Intent: There is an estimated one million hospitalizations a year in the United States for the treatment of heart failure; accounting for significant morbidity and mortality for patients 1. Heart failure clinics are valuable in treating heart failure but cannot alone manage the increasing number of patients with heart failure. Remote monitoring has become an increasingly utilized tool to help identify and treat patients at risk for hospitalization. However, this approach is often reactive, waiting until the patient has symptoms before adjusting the plan. Proactive approaches we devices like CardioMEMS are available but often require another procedure. Medtronic as created a validated algorithm, based on multiple patients variables to predict who is at increased risk for a heart failure admission.2 By identifying those at high risk we may better target those who benefit from timely intervention and from the skill set of a heart failure clinic.
Methodology: Our population of patients with a Medtronic defibrillator or bi-ventricular pacemaker consists of over 1,000 patients in our Cardiac Device Clinic. For these patients, we implemented a Triage HF algorithm through Carelink. Patients are identified as low, medium, and high risk based on a combination of the follow criteria: intra-thoracic impedance, activity, nighttime heart rate, heart rate variability, atrial fibrillation burden, heart rate in atrial fibrillation, ventricular tachycardia episodes, shocks, and resynchronization pacing percentage. 2 For high risk patients, if the patient is already enrolled in the heart failure clinic, co-management is enabled, and the patient is contacted by the heart failure nurse for assessment. Further management is then decided by the heart failure team. If the patient is not enrolled in the heart failure clinic, they are scheduled with a heart failure advanced practice provider (APP) within 2 weeks for evaluation. During this visit, the provider will consider adjustment in medication and determine if the patient should be enrolled in heart failure clinic. If it is determined that the patient needs to be enrolled, co-management is enabled, and weekly transmissions are scheduled for close monitoring. Further intervention and adjustment of guideline directed medication and diuretic is managed by the heart failure team at that point.
Results: In the first seven weeks of the new Triage-HF triage protocol, 36 patients were identified as being high risk. Of those patients 22 (61%) had not previously been followed by the heart failure clinic. Of the 14 followed, only ten were actively managed by the heart failure clinic. From the 36 patients; 17 (46%) were seen in the office based on the protocol, 7 (19%) were scheduled for follow (and will be seen in the coming weeks or missed their appointment and are being rescheduled), 4 (11%) were set up for closely monitoring instead of a visit and 6 (16.6%) declined to be seen. Due to the high risk triage protocol 14 (39%) had an intervention on their diuretic or guideline directed medication. Most of those events occurred in clinic visits for patients not previously established with the heart failure clinic. In addition, many of those patients also saw increases in guideline directed medical therapy. Three patients were admitted in the first seven weeks (two for heart failure). All these admissions occurred after identification but before the patient could be seen in the office. None of the patients seen in the office were admitted for heart failure afterwards. Of the patients identified only 2 have been evaluated and returned to their primary cardiologist.
Value Proposition: Our project tackles multiple areas of value-based health care benefits. First, this new protocol aims to improve patient care by identifying those in need of timely specialized heart failure management. Furthermore, by identifying these patients earlier we look to decrease hospitalizations. This further improves care but also, by reducing spending, has an impact on society. This protocol can also improve provider care by helping us improve efficiency. The Triage-HF protocol allows the right provider to see the right patient at the right time, improving care efficiency. This may also improve patient satisfaction scores as patients feel like they are being cared for effectively.
Conclusions: : In the preliminary stages of our Triage-HF protocol, the process appears to be working. High risk patients are being seen in the heart failure clinic and seeing their medical therapy improved. In addition, previously unknown heart failure patients are being referred to the heart failure clinic. Using device technology to identify patients at risk for heart failure hospitalizations has allowed us to be proactive in managing this challenging group. Although there are limitations, as the algorithm has only been recently enabled, it is reassuring to see the number of interventions already performed. The high number of interventions, and lack of hospitalizations after being seen, suggests we have impacted hospitalizations. The small number of patients returned to their primary cardiologist also suggests that this pathway is identifying those who benefit from specialized heart failure care. It may imply that the patients who are at high risk for admission may also have more advanced heart failure and benefit from an advanced heart failure referral.
References: 1. Mozaffarian D, et al.; American Heart Association Statistics C and Stroke Statistics S. Heart disease and stroke statistics-2016 update: a report from the American Heart Association.Circulation. 2016; 133:e38–e360. doi: 10.1161/CIR.0000000000000350 2. Cowie M, et al.; Development and validation of an integrated diagnostic algorithm derived from parameters monitored in implantable devices for identifying patients at risk for heart failure hospitalization in ambulatory setting. European Heart Journal. 2013. 34. 2472-2480. Doi: 10.1093/eurheartj/eht083
Background/Project Intent: There is an estimated one million hospitalizations a year in the United States for the treatment of heart failure; accounting for significant morbidity and mortality for patients 1. Heart failure clinics are valuable in treating heart failure but cannot alone manage the increasing number of patients with heart failure. Remote monitoring has become an increasingly utilized tool to help identify and treat patients at risk for hospitalization. However, this approach is often reactive, waiting until the patient has symptoms before adjusting the plan. Proactive approaches we devices like CardioMEMS are available but often require another procedure. Medtronic as created a validated algorithm, based on multiple patients variables to predict who is at increased risk for a heart failure admission.2 By identifying those at high risk we may better target those who benefit from timely intervention and from the skill set of a heart failure clinic.
Methodology: Our population of patients with a Medtronic defibrillator or bi-ventricular pacemaker consists of over 1,000 patients in our Cardiac Device Clinic. For these patients, we implemented a Triage HF algorithm through Carelink. Patients are identified as low, medium, and high risk based on a combination of the follow criteria: intra-thoracic impedance, activity, nighttime heart rate, heart rate variability, atrial fibrillation burden, heart rate in atrial fibrillation, ventricular tachycardia episodes, shocks, and resynchronization pacing percentage. 2 For high risk patients, if the patient is already enrolled in the heart failure clinic, co-management is enabled, and the patient is contacted by the heart failure nurse for assessment. Further management is then decided by the heart failure team. If the patient is not enrolled in the heart failure clinic, they are scheduled with a heart failure advanced practice provider (APP) within 2 weeks for evaluation. During this visit, the provider will consider adjustment in medication and determine if the patient should be enrolled in heart failure clinic. If it is determined that the patient needs to be enrolled, co-management is enabled, and weekly transmissions are scheduled for close monitoring. Further intervention and adjustment of guideline directed medication and diuretic is managed by the heart failure team at that point.
Results: In the first seven weeks of the new Triage-HF triage protocol, 36 patients were identified as being high risk. Of those patients 22 (61%) had not previously been followed by the heart failure clinic. Of the 14 followed, only ten were actively managed by the heart failure clinic. From the 36 patients; 17 (46%) were seen in the office based on the protocol, 7 (19%) were scheduled for follow (and will be seen in the coming weeks or missed their appointment and are being rescheduled), 4 (11%) were set up for closely monitoring instead of a visit and 6 (16.6%) declined to be seen. Due to the high risk triage protocol 14 (39%) had an intervention on their diuretic or guideline directed medication. Most of those events occurred in clinic visits for patients not previously established with the heart failure clinic. In addition, many of those patients also saw increases in guideline directed medical therapy. Three patients were admitted in the first seven weeks (two for heart failure). All these admissions occurred after identification but before the patient could be seen in the office. None of the patients seen in the office were admitted for heart failure afterwards. Of the patients identified only 2 have been evaluated and returned to their primary cardiologist.
Value Proposition: Our project tackles multiple areas of value-based health care benefits. First, this new protocol aims to improve patient care by identifying those in need of timely specialized heart failure management. Furthermore, by identifying these patients earlier we look to decrease hospitalizations. This further improves care but also, by reducing spending, has an impact on society. This protocol can also improve provider care by helping us improve efficiency. The Triage-HF protocol allows the right provider to see the right patient at the right time, improving care efficiency. This may also improve patient satisfaction scores as patients feel like they are being cared for effectively.
Conclusions: : In the preliminary stages of our Triage-HF protocol, the process appears to be working. High risk patients are being seen in the heart failure clinic and seeing their medical therapy improved. In addition, previously unknown heart failure patients are being referred to the heart failure clinic. Using device technology to identify patients at risk for heart failure hospitalizations has allowed us to be proactive in managing this challenging group. Although there are limitations, as the algorithm has only been recently enabled, it is reassuring to see the number of interventions already performed. The high number of interventions, and lack of hospitalizations after being seen, suggests we have impacted hospitalizations. The small number of patients returned to their primary cardiologist also suggests that this pathway is identifying those who benefit from specialized heart failure care. It may imply that the patients who are at high risk for admission may also have more advanced heart failure and benefit from an advanced heart failure referral.
References: 1. Mozaffarian D, et al.; American Heart Association Statistics C and Stroke Statistics S. Heart disease and stroke statistics-2016 update: a report from the American Heart Association.Circulation. 2016; 133:e38–e360. doi: 10.1161/CIR.0000000000000350 2. Cowie M, et al.; Development and validation of an integrated diagnostic algorithm derived from parameters monitored in implantable devices for identifying patients at risk for heart failure hospitalization in ambulatory setting. European Heart Journal. 2013. 34. 2472-2480. Doi: 10.1093/eurheartj/eht083
Problem Statement or Scientific Question: Patients with heart failure are at increased risk for hospitalization. Identification of patients at risk and timely intervention to prevent hospital admission can be challenging. Our goal is to better identify those at risk for admission using remote monitoring.
Background/Project Intent: There is an estimated one million hospitalizations a year in the United States for the treatment of heart failure; accounting for significant morbidity and mortality for patients 1. Heart failure clinics are valuable in treating heart failure but cannot alone manage the increasing number of patients with heart failure. Remote monitoring has become an increasingly utilized tool to help identify and treat patients at risk for hospitalization. However, this approach is often reactive, waiting until the patient has symptoms before adjusting the plan. Proactive approaches we devices like CardioMEMS are available but often require another procedure. Medtronic as created a validated algorithm, based on multiple patients variables to predict who is at increased risk for a heart failure admission.2 By identifying those at high risk we may better target those who benefit from timely intervention and from the skill set of a heart failure clinic.
Methodology: Our population of patients with a Medtronic defibrillator or bi-ventricular pacemaker consists of over 1,000 patients in our Cardiac Device Clinic. For these patients, we implemented a Triage HF algorithm through Carelink. Patients are identified as low, medium, and high risk based on a combination of the follow criteria: intra-thoracic impedance, activity, nighttime heart rate, heart rate variability, atrial fibrillation burden, heart rate in atrial fibrillation, ventricular tachycardia episodes, shocks, and resynchronization pacing percentage. 2 For high risk patients, if the patient is already enrolled in the heart failure clinic, co-management is enabled, and the patient is contacted by the heart failure nurse for assessment. Further management is then decided by the heart failure team. If the patient is not enrolled in the heart failure clinic, they are scheduled with a heart failure advanced practice provider (APP) within 2 weeks for evaluation. During this visit, the provider will consider adjustment in medication and determine if the patient should be enrolled in heart failure clinic. If it is determined that the patient needs to be enrolled, co-management is enabled, and weekly transmissions are scheduled for close monitoring. Further intervention and adjustment of guideline directed medication and diuretic is managed by the heart failure team at that point.
Results: In the first seven weeks of the new Triage-HF triage protocol, 36 patients were identified as being high risk. Of those patients 22 (61%) had not previously been followed by the heart failure clinic. Of the 14 followed, only ten were actively managed by the heart failure clinic. From the 36 patients; 17 (46%) were seen in the office based on the protocol, 7 (19%) were scheduled for follow (and will be seen in the coming weeks or missed their appointment and are being rescheduled), 4 (11%) were set up for closely monitoring instead of a visit and 6 (16.6%) declined to be seen. Due to the high risk triage protocol 14 (39%) had an intervention on their diuretic or guideline directed medication. Most of those events occurred in clinic visits for patients not previously established with the heart failure clinic. In addition, many of those patients also saw increases in guideline directed medical therapy. Three patients were admitted in the first seven weeks (two for heart failure). All these admissions occurred after identification but before the patient could be seen in the office. None of the patients seen in the office were admitted for heart failure afterwards. Of the patients identified only 2 have been evaluated and returned to their primary cardiologist.
Value Proposition: Our project tackles multiple areas of value-based health care benefits. First, this new protocol aims to improve patient care by identifying those in need of timely specialized heart failure management. Furthermore, by identifying these patients earlier we look to decrease hospitalizations. This further improves care but also, by reducing spending, has an impact on society. This protocol can also improve provider care by helping us improve efficiency. The Triage-HF protocol allows the right provider to see the right patient at the right time, improving care efficiency. This may also improve patient satisfaction scores as patients feel like they are being cared for effectively.
Conclusions: : In the preliminary stages of our Triage-HF protocol, the process appears to be working. High risk patients are being seen in the heart failure clinic and seeing their medical therapy improved. In addition, previously unknown heart failure patients are being referred to the heart failure clinic. Using device technology to identify patients at risk for heart failure hospitalizations has allowed us to be proactive in managing this challenging group. Although there are limitations, as the algorithm has only been recently enabled, it is reassuring to see the number of interventions already performed. The high number of interventions, and lack of hospitalizations after being seen, suggests we have impacted hospitalizations. The small number of patients returned to their primary cardiologist also suggests that this pathway is identifying those who benefit from specialized heart failure care. It may imply that the patients who are at high risk for admission may also have more advanced heart failure and benefit from an advanced heart failure referral.
References: 1. Mozaffarian D, et al.; American Heart Association Statistics C and Stroke Statistics S. Heart disease and stroke statistics-2016 update: a report from the American Heart Association.Circulation. 2016; 133:e38–e360. doi: 10.1161/CIR.0000000000000350 2. Cowie M, et al.; Development and validation of an integrated diagnostic algorithm derived from parameters monitored in implantable devices for identifying patients at risk for heart failure hospitalization in ambulatory setting. European Heart Journal. 2013. 34. 2472-2480. Doi: 10.1093/eurheartj/eht083
Background/Project Intent: There is an estimated one million hospitalizations a year in the United States for the treatment of heart failure; accounting for significant morbidity and mortality for patients 1. Heart failure clinics are valuable in treating heart failure but cannot alone manage the increasing number of patients with heart failure. Remote monitoring has become an increasingly utilized tool to help identify and treat patients at risk for hospitalization. However, this approach is often reactive, waiting until the patient has symptoms before adjusting the plan. Proactive approaches we devices like CardioMEMS are available but often require another procedure. Medtronic as created a validated algorithm, based on multiple patients variables to predict who is at increased risk for a heart failure admission.2 By identifying those at high risk we may better target those who benefit from timely intervention and from the skill set of a heart failure clinic.
Methodology: Our population of patients with a Medtronic defibrillator or bi-ventricular pacemaker consists of over 1,000 patients in our Cardiac Device Clinic. For these patients, we implemented a Triage HF algorithm through Carelink. Patients are identified as low, medium, and high risk based on a combination of the follow criteria: intra-thoracic impedance, activity, nighttime heart rate, heart rate variability, atrial fibrillation burden, heart rate in atrial fibrillation, ventricular tachycardia episodes, shocks, and resynchronization pacing percentage. 2 For high risk patients, if the patient is already enrolled in the heart failure clinic, co-management is enabled, and the patient is contacted by the heart failure nurse for assessment. Further management is then decided by the heart failure team. If the patient is not enrolled in the heart failure clinic, they are scheduled with a heart failure advanced practice provider (APP) within 2 weeks for evaluation. During this visit, the provider will consider adjustment in medication and determine if the patient should be enrolled in heart failure clinic. If it is determined that the patient needs to be enrolled, co-management is enabled, and weekly transmissions are scheduled for close monitoring. Further intervention and adjustment of guideline directed medication and diuretic is managed by the heart failure team at that point.
Results: In the first seven weeks of the new Triage-HF triage protocol, 36 patients were identified as being high risk. Of those patients 22 (61%) had not previously been followed by the heart failure clinic. Of the 14 followed, only ten were actively managed by the heart failure clinic. From the 36 patients; 17 (46%) were seen in the office based on the protocol, 7 (19%) were scheduled for follow (and will be seen in the coming weeks or missed their appointment and are being rescheduled), 4 (11%) were set up for closely monitoring instead of a visit and 6 (16.6%) declined to be seen. Due to the high risk triage protocol 14 (39%) had an intervention on their diuretic or guideline directed medication. Most of those events occurred in clinic visits for patients not previously established with the heart failure clinic. In addition, many of those patients also saw increases in guideline directed medical therapy. Three patients were admitted in the first seven weeks (two for heart failure). All these admissions occurred after identification but before the patient could be seen in the office. None of the patients seen in the office were admitted for heart failure afterwards. Of the patients identified only 2 have been evaluated and returned to their primary cardiologist.
Value Proposition: Our project tackles multiple areas of value-based health care benefits. First, this new protocol aims to improve patient care by identifying those in need of timely specialized heart failure management. Furthermore, by identifying these patients earlier we look to decrease hospitalizations. This further improves care but also, by reducing spending, has an impact on society. This protocol can also improve provider care by helping us improve efficiency. The Triage-HF protocol allows the right provider to see the right patient at the right time, improving care efficiency. This may also improve patient satisfaction scores as patients feel like they are being cared for effectively.
Conclusions: : In the preliminary stages of our Triage-HF protocol, the process appears to be working. High risk patients are being seen in the heart failure clinic and seeing their medical therapy improved. In addition, previously unknown heart failure patients are being referred to the heart failure clinic. Using device technology to identify patients at risk for heart failure hospitalizations has allowed us to be proactive in managing this challenging group. Although there are limitations, as the algorithm has only been recently enabled, it is reassuring to see the number of interventions already performed. The high number of interventions, and lack of hospitalizations after being seen, suggests we have impacted hospitalizations. The small number of patients returned to their primary cardiologist also suggests that this pathway is identifying those who benefit from specialized heart failure care. It may imply that the patients who are at high risk for admission may also have more advanced heart failure and benefit from an advanced heart failure referral.
References: 1. Mozaffarian D, et al.; American Heart Association Statistics C and Stroke Statistics S. Heart disease and stroke statistics-2016 update: a report from the American Heart Association.Circulation. 2016; 133:e38–e360. doi: 10.1161/CIR.0000000000000350 2. Cowie M, et al.; Development and validation of an integrated diagnostic algorithm derived from parameters monitored in implantable devices for identifying patients at risk for heart failure hospitalization in ambulatory setting. European Heart Journal. 2013. 34. 2472-2480. Doi: 10.1093/eurheartj/eht083
Implementing TRIAGE-HF, a Protocol to Identify Patients at Risk for Heart Failure Hospitalizations
Meena Rao
Abstract
Problem Statement or Scientific Question: Patients with heart failure are at increased risk for hospitalization. Identification of patients at risk and timely intervention to prevent hospital admission can be challenging. Our goal is to better identify those at risk for admission using remote monitoring.
Background/Project Intent: There is an estimated one million hospitalizations a year in the United States for the treatment of heart failure; accounting for significant morbidity and mortality for patients 1. Heart failure clinics are valuable in treating heart failure but cannot alone manage the increasing number of patients with heart failure. Remote monitoring has become an increasingly utilized tool to help identify and treat patients at risk for hospitalization. However, this approach is often reactive, waiting until the patient has symptoms before adjusting the plan. Proactive approaches we devices like CardioMEMS are available but often require another procedure. Medtronic as created a validated algorithm, based on multiple patients variables to predict who is at increased risk for a heart failure admission.2 By identifying those at high risk we may better target those who benefit from timely intervention and from the skill set of a heart failure clinic.
Methodology: Our population of patients with a Medtronic defibrillator or bi-ventricular pacemaker consists of over 1,000 patients in our Cardiac Device Clinic. For these patients, we implemented a Triage HF algorithm through Carelink. Patients are identified as low, medium, and high risk based on a combination of the follow criteria: intra-thoracic impedance, activity, nighttime heart rate, heart rate variability, atrial fibrillation burden, heart rate in atrial fibrillation, ventricular tachycardia episodes, shocks, and resynchronization pacing percentage. 2 For high risk patients, if the patient is already enrolled in the heart failure clinic, co-management is enabled, and the patient is contacted by the heart failure nurse for assessment. Further management is then decided by the heart failure team. If the patient is not enrolled in the heart failure clinic, they are scheduled with a heart failure advanced practice provider (APP) within 2 weeks for evaluation. During this visit, the provider will consider adjustment in medication and determine if the patient should be enrolled in heart failure clinic. If it is determined that the patient needs to be enrolled, co-management is enabled, and weekly transmissions are scheduled for close monitoring. Further intervention and adjustment of guideline directed medication and diuretic is managed by the heart failure team at that point.
Results: In the first seven weeks of the new Triage-HF triage protocol, 36 patients were identified as being high risk. Of those patients 22 (61%) had not previously been followed by the heart failure clinic. Of the 14 followed, only ten were actively managed by the heart failure clinic. From the 36 patients; 17 (46%) were seen in the office based on the protocol, 7 (19%) were scheduled for follow (and will be seen in the coming weeks or missed their appointment and are being rescheduled), 4 (11%) were set up for closely monitoring instead of a visit and 6 (16.6%) declined to be seen. Due to the high risk triage protocol 14 (39%) had an intervention on their diuretic or guideline directed medication. Most of those events occurred in clinic visits for patients not previously established with the heart failure clinic. In addition, many of those patients also saw increases in guideline directed medical therapy. Three patients were admitted in the first seven weeks (two for heart failure). All these admissions occurred after identification but before the patient could be seen in the office. None of the patients seen in the office were admitted for heart failure afterwards. Of the patients identified only 2 have been evaluated and returned to their primary cardiologist.
Value Proposition: Our project tackles multiple areas of value-based health care benefits. First, this new protocol aims to improve patient care by identifying those in need of timely specialized heart failure management. Furthermore, by identifying these patients earlier we look to decrease hospitalizations. This further improves care but also, by reducing spending, has an impact on society. This protocol can also improve provider care by helping us improve efficiency. The Triage-HF protocol allows the right provider to see the right patient at the right time, improving care efficiency. This may also improve patient satisfaction scores as patients feel like they are being cared for effectively.
Conclusions: : In the preliminary stages of our Triage-HF protocol, the process appears to be working. High risk patients are being seen in the heart failure clinic and seeing their medical therapy improved. In addition, previously unknown heart failure patients are being referred to the heart failure clinic. Using device technology to identify patients at risk for heart failure hospitalizations has allowed us to be proactive in managing this challenging group. Although there are limitations, as the algorithm has only been recently enabled, it is reassuring to see the number of interventions already performed. The high number of interventions, and lack of hospitalizations after being seen, suggests we have impacted hospitalizations. The small number of patients returned to their primary cardiologist also suggests that this pathway is identifying those who benefit from specialized heart failure care. It may imply that the patients who are at high risk for admission may also have more advanced heart failure and benefit from an advanced heart failure referral.
References: 1. Mozaffarian D, et al.; American Heart Association Statistics C and Stroke Statistics S. Heart disease and stroke statistics-2016 update: a report from the American Heart Association.Circulation. 2016; 133:e38–e360. doi: 10.1161/CIR.0000000000000350 2. Cowie M, et al.; Development and validation of an integrated diagnostic algorithm derived from parameters monitored in implantable devices for identifying patients at risk for heart failure hospitalization in ambulatory setting. European Heart Journal. 2013. 34. 2472-2480. Doi: 10.1093/eurheartj/eht083
Background/Project Intent: There is an estimated one million hospitalizations a year in the United States for the treatment of heart failure; accounting for significant morbidity and mortality for patients 1. Heart failure clinics are valuable in treating heart failure but cannot alone manage the increasing number of patients with heart failure. Remote monitoring has become an increasingly utilized tool to help identify and treat patients at risk for hospitalization. However, this approach is often reactive, waiting until the patient has symptoms before adjusting the plan. Proactive approaches we devices like CardioMEMS are available but often require another procedure. Medtronic as created a validated algorithm, based on multiple patients variables to predict who is at increased risk for a heart failure admission.2 By identifying those at high risk we may better target those who benefit from timely intervention and from the skill set of a heart failure clinic.
Methodology: Our population of patients with a Medtronic defibrillator or bi-ventricular pacemaker consists of over 1,000 patients in our Cardiac Device Clinic. For these patients, we implemented a Triage HF algorithm through Carelink. Patients are identified as low, medium, and high risk based on a combination of the follow criteria: intra-thoracic impedance, activity, nighttime heart rate, heart rate variability, atrial fibrillation burden, heart rate in atrial fibrillation, ventricular tachycardia episodes, shocks, and resynchronization pacing percentage. 2 For high risk patients, if the patient is already enrolled in the heart failure clinic, co-management is enabled, and the patient is contacted by the heart failure nurse for assessment. Further management is then decided by the heart failure team. If the patient is not enrolled in the heart failure clinic, they are scheduled with a heart failure advanced practice provider (APP) within 2 weeks for evaluation. During this visit, the provider will consider adjustment in medication and determine if the patient should be enrolled in heart failure clinic. If it is determined that the patient needs to be enrolled, co-management is enabled, and weekly transmissions are scheduled for close monitoring. Further intervention and adjustment of guideline directed medication and diuretic is managed by the heart failure team at that point.
Results: In the first seven weeks of the new Triage-HF triage protocol, 36 patients were identified as being high risk. Of those patients 22 (61%) had not previously been followed by the heart failure clinic. Of the 14 followed, only ten were actively managed by the heart failure clinic. From the 36 patients; 17 (46%) were seen in the office based on the protocol, 7 (19%) were scheduled for follow (and will be seen in the coming weeks or missed their appointment and are being rescheduled), 4 (11%) were set up for closely monitoring instead of a visit and 6 (16.6%) declined to be seen. Due to the high risk triage protocol 14 (39%) had an intervention on their diuretic or guideline directed medication. Most of those events occurred in clinic visits for patients not previously established with the heart failure clinic. In addition, many of those patients also saw increases in guideline directed medical therapy. Three patients were admitted in the first seven weeks (two for heart failure). All these admissions occurred after identification but before the patient could be seen in the office. None of the patients seen in the office were admitted for heart failure afterwards. Of the patients identified only 2 have been evaluated and returned to their primary cardiologist.
Value Proposition: Our project tackles multiple areas of value-based health care benefits. First, this new protocol aims to improve patient care by identifying those in need of timely specialized heart failure management. Furthermore, by identifying these patients earlier we look to decrease hospitalizations. This further improves care but also, by reducing spending, has an impact on society. This protocol can also improve provider care by helping us improve efficiency. The Triage-HF protocol allows the right provider to see the right patient at the right time, improving care efficiency. This may also improve patient satisfaction scores as patients feel like they are being cared for effectively.
Conclusions: : In the preliminary stages of our Triage-HF protocol, the process appears to be working. High risk patients are being seen in the heart failure clinic and seeing their medical therapy improved. In addition, previously unknown heart failure patients are being referred to the heart failure clinic. Using device technology to identify patients at risk for heart failure hospitalizations has allowed us to be proactive in managing this challenging group. Although there are limitations, as the algorithm has only been recently enabled, it is reassuring to see the number of interventions already performed. The high number of interventions, and lack of hospitalizations after being seen, suggests we have impacted hospitalizations. The small number of patients returned to their primary cardiologist also suggests that this pathway is identifying those who benefit from specialized heart failure care. It may imply that the patients who are at high risk for admission may also have more advanced heart failure and benefit from an advanced heart failure referral.
References: 1. Mozaffarian D, et al.; American Heart Association Statistics C and Stroke Statistics S. Heart disease and stroke statistics-2016 update: a report from the American Heart Association.Circulation. 2016; 133:e38–e360. doi: 10.1161/CIR.0000000000000350 2. Cowie M, et al.; Development and validation of an integrated diagnostic algorithm derived from parameters monitored in implantable devices for identifying patients at risk for heart failure hospitalization in ambulatory setting. European Heart Journal. 2013. 34. 2472-2480. Doi: 10.1093/eurheartj/eht083
Problem Statement or Scientific Question: Patients with heart failure are at increased risk for hospitalization. Identification of patients at risk and timely intervention to prevent hospital admission can be challenging. Our goal is to better identify those at risk for admission using remote monitoring.
Background/Project Intent: There is an estimated one million hospitalizations a year in the United States for the treatment of heart failure; accounting for significant morbidity and mortality for patients 1. Heart failure clinics are valuable in treating heart failure but cannot alone manage the increasing number of patients with heart failure. Remote monitoring has become an increasingly utilized tool to help identify and treat patients at risk for hospitalization. However, this approach is often reactive, waiting until the patient has symptoms before adjusting the plan. Proactive approaches we devices like CardioMEMS are available but often require another procedure. Medtronic as created a validated algorithm, based on multiple patients variables to predict who is at increased risk for a heart failure admission.2 By identifying those at high risk we may better target those who benefit from timely intervention and from the skill set of a heart failure clinic.
Methodology: Our population of patients with a Medtronic defibrillator or bi-ventricular pacemaker consists of over 1,000 patients in our Cardiac Device Clinic. For these patients, we implemented a Triage HF algorithm through Carelink. Patients are identified as low, medium, and high risk based on a combination of the follow criteria: intra-thoracic impedance, activity, nighttime heart rate, heart rate variability, atrial fibrillation burden, heart rate in atrial fibrillation, ventricular tachycardia episodes, shocks, and resynchronization pacing percentage. 2 For high risk patients, if the patient is already enrolled in the heart failure clinic, co-management is enabled, and the patient is contacted by the heart failure nurse for assessment. Further management is then decided by the heart failure team. If the patient is not enrolled in the heart failure clinic, they are scheduled with a heart failure advanced practice provider (APP) within 2 weeks for evaluation. During this visit, the provider will consider adjustment in medication and determine if the patient should be enrolled in heart failure clinic. If it is determined that the patient needs to be enrolled, co-management is enabled, and weekly transmissions are scheduled for close monitoring. Further intervention and adjustment of guideline directed medication and diuretic is managed by the heart failure team at that point.
Results: In the first seven weeks of the new Triage-HF triage protocol, 36 patients were identified as being high risk. Of those patients 22 (61%) had not previously been followed by the heart failure clinic. Of the 14 followed, only ten were actively managed by the heart failure clinic. From the 36 patients; 17 (46%) were seen in the office based on the protocol, 7 (19%) were scheduled for follow (and will be seen in the coming weeks or missed their appointment and are being rescheduled), 4 (11%) were set up for closely monitoring instead of a visit and 6 (16.6%) declined to be seen. Due to the high risk triage protocol 14 (39%) had an intervention on their diuretic or guideline directed medication. Most of those events occurred in clinic visits for patients not previously established with the heart failure clinic. In addition, many of those patients also saw increases in guideline directed medical therapy. Three patients were admitted in the first seven weeks (two for heart failure). All these admissions occurred after identification but before the patient could be seen in the office. None of the patients seen in the office were admitted for heart failure afterwards. Of the patients identified only 2 have been evaluated and returned to their primary cardiologist.
Value Proposition: Our project tackles multiple areas of value-based health care benefits. First, this new protocol aims to improve patient care by identifying those in need of timely specialized heart failure management. Furthermore, by identifying these patients earlier we look to decrease hospitalizations. This further improves care but also, by reducing spending, has an impact on society. This protocol can also improve provider care by helping us improve efficiency. The Triage-HF protocol allows the right provider to see the right patient at the right time, improving care efficiency. This may also improve patient satisfaction scores as patients feel like they are being cared for effectively.
Conclusions: : In the preliminary stages of our Triage-HF protocol, the process appears to be working. High risk patients are being seen in the heart failure clinic and seeing their medical therapy improved. In addition, previously unknown heart failure patients are being referred to the heart failure clinic. Using device technology to identify patients at risk for heart failure hospitalizations has allowed us to be proactive in managing this challenging group. Although there are limitations, as the algorithm has only been recently enabled, it is reassuring to see the number of interventions already performed. The high number of interventions, and lack of hospitalizations after being seen, suggests we have impacted hospitalizations. The small number of patients returned to their primary cardiologist also suggests that this pathway is identifying those who benefit from specialized heart failure care. It may imply that the patients who are at high risk for admission may also have more advanced heart failure and benefit from an advanced heart failure referral.
References: 1. Mozaffarian D, et al.; American Heart Association Statistics C and Stroke Statistics S. Heart disease and stroke statistics-2016 update: a report from the American Heart Association.Circulation. 2016; 133:e38–e360. doi: 10.1161/CIR.0000000000000350 2. Cowie M, et al.; Development and validation of an integrated diagnostic algorithm derived from parameters monitored in implantable devices for identifying patients at risk for heart failure hospitalization in ambulatory setting. European Heart Journal. 2013. 34. 2472-2480. Doi: 10.1093/eurheartj/eht083
Background/Project Intent: There is an estimated one million hospitalizations a year in the United States for the treatment of heart failure; accounting for significant morbidity and mortality for patients 1. Heart failure clinics are valuable in treating heart failure but cannot alone manage the increasing number of patients with heart failure. Remote monitoring has become an increasingly utilized tool to help identify and treat patients at risk for hospitalization. However, this approach is often reactive, waiting until the patient has symptoms before adjusting the plan. Proactive approaches we devices like CardioMEMS are available but often require another procedure. Medtronic as created a validated algorithm, based on multiple patients variables to predict who is at increased risk for a heart failure admission.2 By identifying those at high risk we may better target those who benefit from timely intervention and from the skill set of a heart failure clinic.
Methodology: Our population of patients with a Medtronic defibrillator or bi-ventricular pacemaker consists of over 1,000 patients in our Cardiac Device Clinic. For these patients, we implemented a Triage HF algorithm through Carelink. Patients are identified as low, medium, and high risk based on a combination of the follow criteria: intra-thoracic impedance, activity, nighttime heart rate, heart rate variability, atrial fibrillation burden, heart rate in atrial fibrillation, ventricular tachycardia episodes, shocks, and resynchronization pacing percentage. 2 For high risk patients, if the patient is already enrolled in the heart failure clinic, co-management is enabled, and the patient is contacted by the heart failure nurse for assessment. Further management is then decided by the heart failure team. If the patient is not enrolled in the heart failure clinic, they are scheduled with a heart failure advanced practice provider (APP) within 2 weeks for evaluation. During this visit, the provider will consider adjustment in medication and determine if the patient should be enrolled in heart failure clinic. If it is determined that the patient needs to be enrolled, co-management is enabled, and weekly transmissions are scheduled for close monitoring. Further intervention and adjustment of guideline directed medication and diuretic is managed by the heart failure team at that point.
Results: In the first seven weeks of the new Triage-HF triage protocol, 36 patients were identified as being high risk. Of those patients 22 (61%) had not previously been followed by the heart failure clinic. Of the 14 followed, only ten were actively managed by the heart failure clinic. From the 36 patients; 17 (46%) were seen in the office based on the protocol, 7 (19%) were scheduled for follow (and will be seen in the coming weeks or missed their appointment and are being rescheduled), 4 (11%) were set up for closely monitoring instead of a visit and 6 (16.6%) declined to be seen. Due to the high risk triage protocol 14 (39%) had an intervention on their diuretic or guideline directed medication. Most of those events occurred in clinic visits for patients not previously established with the heart failure clinic. In addition, many of those patients also saw increases in guideline directed medical therapy. Three patients were admitted in the first seven weeks (two for heart failure). All these admissions occurred after identification but before the patient could be seen in the office. None of the patients seen in the office were admitted for heart failure afterwards. Of the patients identified only 2 have been evaluated and returned to their primary cardiologist.
Value Proposition: Our project tackles multiple areas of value-based health care benefits. First, this new protocol aims to improve patient care by identifying those in need of timely specialized heart failure management. Furthermore, by identifying these patients earlier we look to decrease hospitalizations. This further improves care but also, by reducing spending, has an impact on society. This protocol can also improve provider care by helping us improve efficiency. The Triage-HF protocol allows the right provider to see the right patient at the right time, improving care efficiency. This may also improve patient satisfaction scores as patients feel like they are being cared for effectively.
Conclusions: : In the preliminary stages of our Triage-HF protocol, the process appears to be working. High risk patients are being seen in the heart failure clinic and seeing their medical therapy improved. In addition, previously unknown heart failure patients are being referred to the heart failure clinic. Using device technology to identify patients at risk for heart failure hospitalizations has allowed us to be proactive in managing this challenging group. Although there are limitations, as the algorithm has only been recently enabled, it is reassuring to see the number of interventions already performed. The high number of interventions, and lack of hospitalizations after being seen, suggests we have impacted hospitalizations. The small number of patients returned to their primary cardiologist also suggests that this pathway is identifying those who benefit from specialized heart failure care. It may imply that the patients who are at high risk for admission may also have more advanced heart failure and benefit from an advanced heart failure referral.
References: 1. Mozaffarian D, et al.; American Heart Association Statistics C and Stroke Statistics S. Heart disease and stroke statistics-2016 update: a report from the American Heart Association.Circulation. 2016; 133:e38–e360. doi: 10.1161/CIR.0000000000000350 2. Cowie M, et al.; Development and validation of an integrated diagnostic algorithm derived from parameters monitored in implantable devices for identifying patients at risk for heart failure hospitalization in ambulatory setting. European Heart Journal. 2013. 34. 2472-2480. Doi: 10.1093/eurheartj/eht083
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