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April 7, 2011 Volume VII, No. 39

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

According to new research from the American Heart Association, after one year, 54 percent of heart failure patients discharged to skilled nursing facilities (SNF) had died of any cause. Learn more about heart failure patients who need SNF care in this week's issue, along with the interaction of smoking, breast cancer risk and obesity status.

Also this week, learn about promising treatments for reducing autism-related behaviors and the side effects of each.

Your colleague in the business of healthcare,
Jessica Papay
Editor, Disease Management Update

This week's DM news:

Table of Contents

  1. Elderly Heart Patients & Skilled Nursing Care
  2. Smoking & Breast Cancer Risk Among Obese Women
  3. ACOs & CMS’s Shared Savings Rule
  4. Reducing Heart Failure Readmissions
  5. Wellness Programs & Incentives
  6. Obesity & Weight Management Benchmarks
  7. Reducing Autism-related Behaviors
  8. Fifth Annual Medical Home Survey

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Publisher:
Melanie Matthews, mmatthews@hin.com

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Elderly Heart Failure Patients Who Need Skilled Nursing Care Often Sicker, Have Poorer Outcomes

Elderly patients with heart failure who need skilled nursing care after hospital discharge are often sicker, at higher risk for poor outcomes and are more likely than other patients to die or be rehospitalized within one year, according to American Heart Association (AHA) research. Researchers analyzed data on 15,459 Medicare patients — enrolled in the AHA’s Get With The Guidelines®-Heart Failure program at 149 hospitals in 2005 and 2006 — and discharged from the hospital after three or more days of heart failure treatment. The researchers found that:

  • About one-fourth of patients were discharged to a SNF.
  • Thirty days post-discharge, 14 percent of patients discharged to SNFs had died of any cause, compared to 4 percent of those who returned home from the hospital.
  • At one year, 54 percent of patients discharged to SNFs had died of any cause, compared to 29 percent of patients discharged to home.
Furthermore, there was a higher rehospitalization rate among patients discharged to SNFs. Thirty days after initial hospital discharge, 27 percent of patients discharged to SNFs were rehospitalized for any cause, compared to 24 percent of patients discharged to home. One year after discharge, rehospitalizations were common in both groups, although the difference between them remained steady, with 76 percent of skilled nursing and 72 percent of home patients readmitted to the hospital. Patients discharged to SNFs were more likely than other patients to be older, female, hospitalized longer and to have other complications in addition to heart failure. Skilled nursing use varied by region. The highest rate was in the northeastern United States, where nearly one-third of heart failure patients left the hospital for SNFs. The lowest was in the west, where about one-fourth required this type of care.

According to researchers, "Even after adjusting for patient differences, a strong predictor of mortality in the next year was discharge to a SNF. This has important implications for talking to patients and their families during the initial hospitalization for heart failure. They need to have clear expectations for survival and rehospitalization. Options for advanced therapies and end-of-life care, including hospice and advanced directives, should be discussed for these high-risk patients."

Heart failure affects nearly 6 million Americans, and is the primary cause of hospitalizations among Medicare patients. Although many of these patients are discharged to SNFs, the type of treatment they receive often varies. A SNF is similar to a nursing home, but can also provide specialized care, such as physical therapy, for patients unable to resume independent living. Skilled nursing patients may by nature face extra challenges, including less mobility, cognitive impairment or poor in-home support — all of which are determinants to outcomes.

To learn more about this research, please visit:
http://www.newsroom.heart.org/index.php?s=43&item=1299

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Could Smoking Influence Breast Cancer Risk in Obese Women?

Smoking increases the risk of breast cancer, but the risk differs by obesity status in postmenopausal women, according to a Women’s Health Initiative observational study. A significant association between smoking and breast cancer risk was observed in non-obese women, but not in obese women. The results were similar regardless of whether obesity was defined by BMI or waist circumference. The study included 76,628 women aged 50 to 79 years old who had no previous history of cancer. Participants were part of the Women’s Health Initiative observational study and were recruited between 1993 and 1998 at 40 U.S. centers and were followed until 2009.

The study results indicated that non-obese women with a BMI less than 30 who had a history of smoking had a significantly higher risk for breast cancer. Those who smoked from 10 to 29 years had a 16 percent excess risk; those with a 30- to 49-year history of smoking had a 25 percent excess risk; and those with 50 or more years of smoking had a 62 percent excess risk. However, this same association was not found among women with a BMI over 30. The researchers then examined the data according to waist circumference to determine if the type of fat distribution — general compared with abdominal obesity — affected the results. When obesity status was defined by a waist circumference greater than 88 cm, similar results were found.

"Smoking and obesity are among the leading causes of morbidity and mortality, both of which have substantial consequences on health," said the researchers. "This is only the first study to examine the interaction between smoking, obesity and breast cancer risk. The main conclusion from this research is that more studies are needed to confirm these results. We found an association between smoking and breast cancer risk among non-obese women, which is understandable because tobacco is a known carcinogen. However, we did not find the same association between smoking and breast cancer risk among obese women," said the researchers.

To learn more about this research, please visit:
http://www.aacr.org/home/public--media/aacr-press-releases.aspx?d=2321

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Analyzing CMS’s Medicare Shared Savings Final Rule — Implementation Advice for ACOs

Greg Mertz, senior project director with the Healthcare Strategy Group, has advice for both providers and payors on how to maximize participation in an ACO.




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Reducing Heart Failure Readmissions

This week's expert is Toni Cesta, Ph.D., RN, FAAN, senior vice president of operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, New York.

Question: Can you describe the initiative that focuses on heart failure readmissions and alternatives to admissions for those patients?

Response: Our program is called the Smooth Transitions Equal Less Readmissions (STELR) program. We are focused on a number of different elements. We are looking at the ED as the first time in which we interact with the patient and possibly can prevent a readmission. The ED case manager has to work very closely with the physicians to make sure that if the patient doesn’t need to be admitted, we can provide some alternative to admission. On the floors, we have trained our staff nurses to do patient education on heart failure, or we give them pillboxes and scales and other tools to help them care for themselves when they go home. We are also working with a home care agency so every heart failure patient gets a referral to home care for at least one initial visit at home, particularly focused on medication reconciliation in the home so that the patient is not confused when they get home about which medications they are supposed to take. Finally, making sure every discharged patient has an appointment with a healthcare provider within seven days of discharge. This is the most vulnerable time frame for readmission, if the patient is not seen within those first seven days. We are making a big push for our clinic, as well as our private patients, for somebody in the community to see them within seven days of discharge.

For more information on reducing heart failure readmissions and case management, please visit:
http://store.hin.com/product.asp?itemid=4148

We want to hear from you! Submit your question for Disease Management Q&A to info@hin.com.

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Which 5 Wellness Programs Respond Best to Incentives?

Financial and benefits-based incentives are used to promote participation in health and wellness programs. We wanted to see which health improvement programs have shown the most positive response to incentives.


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2010 Benchmarks in Obesity and Weight Management

This white paper captures the top strategies organizations are implementing to prevent and reduce obesity and related conditions and costs, based on responses from 131 healthcare organizations to the Healthcare Intelligence Network's Obesity and Weight Management e-survey.

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Treatments Show Promise in Reducing Autism-related Behaviors, Though Some Have Side Effects

Some medical and behavioral treatments show promise for reducing certain behaviors in children with autism spectrum disorders (ASDs), but more research is needed to assess the potential benefits and harms, according to a new HHS AHRQ report.

The report found that two commonly used medications — risperidone and aripiprazole — show benefit in reducing some behaviors, including emotional distress, aggression, hyperactivity and self-injury. However, these medicines are associated with significant side effects, such as rapid weight gain and drowsiness. The review found that no medications used for ASDs improved social behaviors or communication skills. The report also found that several medications show promise and should be studied further, but that secretin, which has been studied extensively, has shown no effectiveness.

Children with ASDs have difficulty in social interaction, behavior and communication. Some children with ASDs may also have impaired cognitive skills and sensory perception. Based on limited evidence, behavioral interventions also showed promise for improving some symptoms and behaviors, but their effects varied. For example, early intensive behavioral and developmental interventions seemed to improve cognitive performance, language skills and adaptive behavior in some groups of children, the report found. Other interventions, which focused on parent training and cognitive behavioral therapy, may be useful for children with ASDs to improve social communication, language use and potentially symptom severity, researchers said.

The researchers noted that further study is needed to identify which children are likely to benefit from particular interventions. The authors were also critical of the fact that current studies contain few comparisons of medical interventions with behavioral interventions as well as combinations of the two, despite the fact that most children undergo multiple treatments at the same time. Because of these limitations in the available evidence, researchers were not able to compare treatments and interventions to each other. In addition, they noted that every case of ASD is different and did not conclude that one type of treatment is superior.

ASDs — which include autistic disorder, Asperger syndrome, and pervasive developmental disorder-not otherwise specified — affect an estimated one in every 110 children in the United States. Treatment goals for ASDs often focus on improving social communication and addressing certain behaviors. Other treatments also target anxiety, attention difficulties and sensory difficulties. Goals for treatment often vary by child.

To learn more about this research, please visit:
http://www.ahrq.gov/news/press/pr2011/autismpr.htm

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Fifth Annual Survey on Patient-Centered Medical Homes

What is the shape of patient-centered care today? One year post-healthcare reform, we're taking our fifth annual look at adoption and support of the patient-centered medical home model. Describe your organization's progress and outcomes in this area by April 30 and you'll receive a free e-summary of the results — and be entered in a drawing to win our newest medical home resource, "Guide to Physician Performance-Based Reimbursement."

To participate in this survey and receive its results, please visit:
http://www.surveymonkey.com/s/medicalhome

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