Background: Previous work at our major academic medical center found that compared to White patients, Black and Latinx patients with a primary diagnosis of congestive heart failure (CHF) were significantly less likely to be admitted to our specialized cardiology service rather than our general medicine service (GMS). This work additionally found that CHF patients admitted to GMS had lower 30-day cardiology follow-up rates and higher 30-day readmission rates, disproportionately affecting our Black and Latinx patients given their overrepresentation on GMS. In an effort to reduce these inequities, we utilized a health equity lens to design a multidimensional quality improvement intervention to improve CHF care on GMS.
Methods: We conceived of the Longitudinal Equity Action Plan (LEAP), which included: 1) a documentation support tool in the electronic medical record to review criteria for cardiology consultation and guideline recommended therapies, 2) enhancements to patient education by nursing and nutrition, 3) social work consultation with CHF-specific social determinants of health screening and interventions, including ride assistance and purchasing of a scale for select patients, 4) electronic referral to facilitate cardiology follow-up scheduling, 5) tools to support discharge documentation and, 6) post-discharge medication reconciliation calls by a pharmacist. To support LEAP, a project coordinator communicated with care team members and tracked the completion of interventions. All patients admitted to GMS with a primary diagnosis of CHF from September 2019 to March 2020 were included. We tracked several outcomes including 30-day readmissions, 30-day post-discharge cardiology follow-up, nursing education, social work and nutrition consultation, appropriate discharge documentation and adherence to guideline-directed therapy. For the primary analysis, we performed a controlled pre-post study design and compared all outcomes of patients admitted with CHF to GMS during the intervention period to the year prior to the LEAP intervention (pre-intervention group), as well as to CHF patients admitted to cardiology throughout entire period (control group).
Results: Overall, 79 patients received the LEAP intervention; there were 137 patients in the pre-intervention group and 338 patients in the control group. During the study period, there were similar proportions of Black and Latinx patients between the study groups. Patients in the LEAP intervention group had significantly lower 30-day readmission rates compared to the pre-intervention group (19.2% vs. 24.6%; p=0.024). Patients in the LEAP intervention group had significantly higher 30-day post-discharge cardiology follow-up visits scheduled compared to the pre-intervention group (56.5% vs. 42.0%; p=0.003), though there was no difference in attendance of these visits. There was also a significant improvement in rates of nursing education, social work and nutrition consultation (p<.0001 for all).
Conclusions: We designed a multidimensional intervention to improve CHF care on our general medicine teams that was associated with a significant improvement in 30-day readmissions and post-discharge cardiology appointment scheduling. Thus, by using a health equity lens, we were able to improve care for all CHF patients on GMS. More resources are necessary to improve post-discharge follow-up and establishment of care. It is possible for many aspects of this intervention to be successfully implemented at other hospitals.