Readmission rates for patients discharged with heart failure
    approach 50% within 6 months. Identifying factors to predict risk of readmission in these patients could help clinicians focus resource-intensive disease management efforts on the high-risk patients.

METHODS: The study sample included patients 65 years of age or older with a principal discharge diagnosis of heart failure who were admitted to 18 Connecticut hospitals in 1994 and 1995. We obtained patient and clinical data from medical record review. We determined outcomes within 6 months after discharge, including all-cause readmission, heart failure-related readmission, and death, from the Medicare administrative database. We evaluated 2176 patients, including 1129 in the derivation cohort and 1047 in the validation cohort.

RESULTS: Of 32 patient and clinical factors examined, 4 were found to be significantly associated with readmission in a multivariate model. They were prior admission within 1 year, prior heart failure, diabetes, and creatinine level 2.5 mg/dL at discharge. The event rates according to number of risk predictors were similar in the derivation and the validation sets for all outcomes. In the validation cohort, rates for all-cause readmission and combined readmission or death were 26% and 31% in patients with no risk predictors, 48% and 54% in patients with 1 or 2 risk predictors, and 59% and 65% in patients with 3 or all risk predictors.

CONCLUSIONS: Few patient and clinical factors predict readmission within 6 months after discharge in elderly patients with heart failure. Although we were unable to identify a group of patients at very low risk, a group of high-risk patients were identified for whom resource-intensive interventions designed to improve outcomes may be justified.
Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI. Predictors of readmission among elderly survivors of admission with heart failure. Am Heart J 2000 Jan;139(1 Pt 1):72-7

Patients with chronic congestive heart failure (CHF) require frequent re-hospitalization because of the exacerbation of CHF. It is of clinical importance to determine predicting factors for readmission to reduce this likelihood. Previous studies have focused primarily on the demographic and medical characteristics in selected subsets of patients. Therefore, within a broad cohort of consecutively hospitalized patients, we sought to identify not only demographic and medical predictors but also socio-environmental factors associated with readmission.

METHODS: We assessed demographic (age, sex), medical (etiology of CHF, New York Heart Association functional class, left ventricular ejection fraction, previous admission for CHF, length of hospital stay, comorbidity, and medications), and socio-environmental variables (occupation, financial resources, living alone, and follow-up visits) in 230 patients discharged with a diagnosis of CHF and recorded hospital readmission.

RESULTS: Within 1 year after discharge, 81 patients (35%) were readmitted. Five variables, including poor follow-up visits (odds ratio [OR] 4.9, 95% CI 2.0-11.8), previous admission for CHF (OR 3.3, 95% CI 1.8-6.1), no occupation (OR 2.6, 95% CI 1.2-5.5), longer hospital stay (OR 3.2, 95% CI 1.2-8.5), and hypertension (OR 2.0, 95% CI 1.1-3.7), were identified as significant independent predictors for readmission by multivariate logistic regression analysis. CONCLUSIONS: Our independent predictors of readmission support the importance of medical and socio-environmental factors in the deterioration of CHF. Therefore interventions to decrease readmission should also target social management in all hospitalized patients. Tsuchihashi M, Tsutsui H, Kodama K, et al. Medical and socio-environmental predictors of hospital readmission in patients with congestive heart failure.
Am Heart J 2001 Oct;142(4):E7 PMID: 11579371

This review article explores the association of psychological factors such as depression, anxiety, social support and coping styles, and the physical health and well-being of patients with CHF. (Excerpted from MacMahon KMA, Lip GYH. "Psychological Factors in Heart Failure: A Review of the Literature" Arch Int Med. March 11, 2002;162(5):493-620 (Link works but subscription, required)

"Despite therapeutic advances in the pharmacological management of heart failure, the 1-year mortality rate for patients with advanced heart failure still approaches 40%, which is the same for many of the more aggressive cancers. Even those with less serious heart failure who can live for many years often experience considerably impaired quality of life.2"

"Given the high mortality and morbidity associated with heart failure, it is not surprising that patients typically report psychological distress, reduced social functioning, and diminished quality of life.3 Quality of life is increasingly recognized as an important factor when studying the effects of interventions.4 Furthermore, psychological factors have also been implicated in precipitating hospitalization in a notable number of patients with congestive heart failure (CHF). It has previously been shown that emotional events (such as violent arguments or threatened separation from family members) preceded admission in 49% of patients with CHF compared with 24% of patients admitted with other medical conditions.5 The impact of psychological factors on cardiac function has been studied extensively in the areas of coronary artery disease and acute MI. Debates over the relationship between type A behavior and coronary artery disease have been raging for over 30 years.6 Recently, depression and anxiety following MI have become increasingly recognized and are now the target of many psychoeducational programs."

"For example, Dusseldorp et al7 conducted a meta-analysis of psychoeducational programs for patients with coronary heart disease, and these programs yielded a 34% reduction in mortality, a 29% reduction in recurrence of MI, and notably contributed to better exercise and dietary habits. Despite the difficulties of living with heart failure and the apparent success of psychoeducational programs following MI, it is only recently that clinicians have begun to pay greater attention to the psychosocial issues of CHF. Some authors now suggest that paying greater attention to the psychological correlates of chronic illness may pay dividends in terms of reduced number of hospitalizations by reducing the number of repeated hospitalizations if morbidity and mortality were influenced by psychological health.8"

"Of the longitudinal studies conducted, possibly the most intriguing is that of Murberg et al.38 who followed up the mortality of patients enrolled in their earlier study.32 Twenty patients died during the 24-month follow-up period, all from cardiac causes. Depressed mood was found to be a significant predictor of mortality, with 25% of depressed patients dying, whereas 11.3% of nondepressed patients died."

Selected References:
The lifetime prevalence of depression is about 7% in the control populations and 2 - 2 1/2 times that in patients with chronic medical illness (various references)
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2. Adams KF, Zannad F. Clinical definition and etiology of advanced heart failure. Am Heart J. 1998;135:S204-S215.
3. Bennett SJ, Pressler ML, Hays L, Firestine L, Huster GA. Psychosocial variables and hospitalization in persons with chronic heart failure. Prog Cardiovasc Nurs. 1997;12:4-11.
4. Cline MJ, Willenheimer RB, Erdhardt LR, Wiklund I, Israelsson BYA. Health-related quality of life in elderly patients with heart failure. Scand Cardiovasc J. 1999;33:278-285.
5. Perlman LV, Ferguson S, Bergum K, Isenberg EL, Hammarsten JF. Precipitation of congestive heart failure: social and emotional factors. Ann Intern Med. 1971;75:1-7.
6. Friedman M, Thorensen CE, Gill JJ, et al. Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the Recurrent Coronary Prevention Project. Am Heart J. 1986;112:653-665.
7. Dusseldorp E, van Elderen T, Maes S, Meulman J, Kraaij V. A meta-analysis of psychoeducational programs for coronary heart disease patients. Health Psychol. 1999;18:506-519.
8. Cleland JGF, Wang M. Depression and heart failure not yet a target for therapy? Eur Heart J. 1999;20:1529-1531
32. Murberg TA, Bru E, Aarsland T, Svebak S. Functional status and depression among men and women with congestive heart failure. Int J Psychiatry Med. 1998;28:273-291.
38. Murberg TA, Bru E, Svebak S, Tveteras R, Aarsland T. Depressed mood and subjective symptoms as predictors of mortality in patients with congestive heart failure: a two-year follow-up study. Int J Psychiatry Med. 1999;29:311-326.
58. Rich MW. Multidisciplinary interventions for the management of heart failure: where do we stand? Am Heart J. 1999;138:599-601.
59. Kostis JB, Rosen RC, Cosgrove NM, Shindler DM, Wilson AC. Nonpharmacologic therapy improves functional and emotional status in congestive heart failure. Chest. 1994;106:996-1001.
60. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multi-disciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333:1190-1195.
61. Levin R, Robertson IH, Cay EL, Irving JB, Campbell M. Effects of self-help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services. Lancet. 1992;339:1036-1040.