Background: Patients admitted with heart failure (HF) have a 12 to 27%, 30-day readmission rate, resulting in decreased quality of life and increased cost of care. 2017 Heart Failure guidelines have recommended a pre-discharge pro-Brain Natriuretic Peptide (pro-BNP) to establish post-discharge prognosis in patients with HF decompensation. We designed a study to evaluate the role of percentage change in pro-BNP from admission to discharge, for patients admitted with decompensated HF and correlate it with 30-day readmission.
Methods: Prospective pilot study of patients admitted with decompensated HF. Patients < 18 years, pregnant, AMI, severe valvular disease, pericardial disease, myocarditis, cardioverted, chemotherapy, sepsis, and burns were excluded. Patients had pro-BNP measured on admission and discharge. All patients were evaluated and treated as per CHF guidelines. They were discharged at the primary team’s discretion when deemed clinically appropriate. Patients received post discharge call after 30 days, to evaluate compliance with medications, PCP/cardiology follow-up, ED visits and readmission.
Results: Fifty-six patients were included in analysis. Average age of cohort was 68.6 ± 12.4 years with 54% (30/56) female. Majority (61%, 34/56) of subjects were Hispanic. HTN was present in 96% (54/56), DM 55% (31/56) and CAD in 32% (18/56). Six (11%) patient had CKD stage <3 while 19 (34%) patients had CKD 3 to 5. The average Charlson Comorbidity Index for the cohort was 7. HFrEF was present in 48% (27/56) while 34% (19/56) had HfpEF. Average LOS of the cohort was 4.5±3.7 days.The 30day readmission rate was 23% (13/56). The average age of the readmission was 72 years. All of them had HTN, while 38% had DM and 31% had CAD. In the subgroup, 54% had CKD 3-5 and 23% had CKD stage <3. HFrEF presented in 46% while 38% had HfpEF. Average LOS was 3.8±2.4 days. The cohort had a 12% decrease in median percentage change in proBNP from admission to discharge. While readmission cohort had 1% change (decrease) in proBNP, 22% decrease was observed in the non-readmitted group (p=0.221). The interquartile range (IQR) for percentage change in proBNP in overall cohort was -42% to 27% (Q1-Q3), with readmission cohort being -19% to 46% and non-readmission group being -49% to 16%. On serial troponin evaluations, readmission group had 7% increase, while no change was seen in non-readmission group. The 30 day telephone follow-up of readmitted patients, revealed that 62% (8/13) were complaint with discharge medications. Only 31% had PCP visit after discharge, 23% had cardiology follow-up in 30 day period. Nine patients (69%) of readmission cohort had an ED visit with in the 30 day period in comparison with 6 (14%) from non-readmission group.
Conclusions: Preliminary data supports the value of change in proBNP to predict 30 day readmission among patients discharged with CHF decompensation. Ensuring compliance with guidelines, among all treating physicians, remains the cornerstone for managing these complex patients with CHF. Considering that majority of the readmitted patients visited the ED in the 30 days after discharge, establishing comprehensive care transition for these select group will help reduce their readmissions.