Importance of a Heart Failure Disease Management Program for Chemotherapy-Induced Toxicity

Delivering cost-effective, high-value care is a major goal of healthcare institutions across the United States that will continue to dominate healthcare reform in the years ahead. In an effort to control the cost of healthcare, reducing hospital admission rates has become a national priority.¹ Hospital readmission rates, particularly excessive 30-day readmission rates for select diagnoses, are now being closely monitored by CMS, the single largest payer for healthcare services in the United States. The Hospital Readmission Reduction Program, developed by CMS in 2012, assesses financial penalties in hospitals with excess readmissions, and initial efforts have focused on heart failure (HF), acute myocardial infarction, and pneumonia. Excessive readmission rates for patients with these diagnoses are subject to a reimbursement penalty, which has a major impact on the management of cancer patients because a large number (52.8%) of new cancers are diagnosed among Americans 65 years and older, who are therefore treated through Medicare.² Although specialty hospitals (ie, some cancer centers) are currently exempted from this initiative, the process of public reporting began back in 2013.

Cancer care has undergone tremendous progress in recent years with the development of effective anticancer therapies, resulting in increased survivorship. However, as several new anticancer agents with cardiovascular side effects entered the therapeutic armamentarium, cardiotoxicity has presented a major challenge and added to the complexity of cancer care. As the population ages, the number of cancer cases will continue to rise at the same time that coronary artery disease starts to manifest. Moreover, multiple comorbidities associated with aging increase the complexity of care, requiring multiple providers and specialists to care for a patient over the course of cancer therapy and creating the risk of fragmented and inefficient care. Several reports have described the fragmentation of care delivery among patients with cancer and a lack of effective communication among multiple providers and specialties involved in patient care.^3-5 Disintegrated care in patients with multiple comorbidities, including the cardiotoxic effects from cancer treatments, can lead to unplanned hospitalizations and visits to the emergency department that could be avoided.

The Heart Success Program

To promote collaboration and efficiency, we developed an interdisciplinary team—based Heart Success Program (HSP) to coordinate the management of concurrent cardiomyopathy (CMP) and HF while the patient is receiving cancer treatment. The goals of the program are multipronged:

* Develop patient-centered care with active patient involvement in the management of their illness.

* Implement evidence-based pharmacologic therapy for HF based on current clinical guidelines.

* Increase compliance with the CMS core measures for HF.

Through an interdisciplinary team approach, HSP provides a means of communication between the oncology and cardiology teams to streamline work efforts and facilitate the care of patients with cancer and concurrent HF. HSP is an example of implementing the Institute of Medicine (IOM) recommendation as outlined in its report, “Delivering High-Quality Cancer Care,” which identified the need to address the complex care needs of persons with multiple coexisting diseases, increased side effects from treatment, and greater need for social support.⁵

The HSP promotes patient-centered care through individualized patient and family education that enables patients to become active “co-managers” of their disease. To ensure patients’ understanding of the key points of disease management, nurses reinforce learning through the “teach-back” method⁶ while in the hospital, which is reviewed again at discharge.

Outcomes

In 2013, a 48-bed medical oncology telemetry unit was selected as a pilot for HSP implementation due to its high volume of HF incidence related to chemotherapy-induced cardiomyopathy. One year following the implementation of the HSP pilot, 112 (6.6%) of the 1702 patients discharged from the unit had a confirmed diagnosis of HF. Of those patients, 98 (87.5%) were discharged alive, while 14 died in the hospital. Of the 98 discharged patients, 41 (41.8%) were readmitted to the hospital within a year. Only 2 patients had hospital readmission for HF exacerbation (one at 19 days and the other at 51 days). The remaining 39 patients were readmitted for reasons other than HF, including fever, pneumonia, anemia, respiratory failure, and chemotherapy-related issues. In addition, a remarkable decrease in 30-day hospital readmissions from any cause was documented—from 37% to 1.02%, before and after implementation of the HSP, respectively.

There was 100% compliance with CMS core measures for evaluation of left ventricular function and initiation of angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin-receptor blocker for patients with left ventricular dysfunction with ejection fraction of <50%. Additionally, there was remarkable improvement in the documentation of discharge instructions—92%, up from 27% documentation compliance at baseline. Published literature has shown that comprehensive discharge planning and post discharge support for patients with HF significantly reduce hospital readmission rates.⁷ Even though HF is not a primary medical diagnosis in a cancer hospital, HSP has already laid the groundwork with this quality improvement initiative for cancer patients with HF.

Patient Satisfaction

The patient satisfaction survey scores in the pilot unit have improved from 79.7% (baseline) to 91.7% after the implementation of HSP, particularly in the provision of discharge information. Patient satisfaction with the thoroughness of the staff’s discharge instructions and with the information provided about key symptoms has increased by almost 11%. Patient satisfaction was measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that allows patients to assess their satisfaction with the care they received during hospitalization.⁸ The survey, administered by an independent agency that collects data from patients through mail-in questionnaires after hospital discharge, is focused on 4 main areas: communication with nurses, communication about medicines, care transitions, and discharge information. This instrument allows patients to voice their personal experiences with healthcare while providing meaningful and comparable data to all hospitals. While hospitals can use these patient satisfaction scores for quality improvement, they also increase transparency in the quality of care provided to the general public by different institutions.

Conclusion

EBO

The future of cancer care encompasses a host of novel challenges. It is no longer sufficient to exclusively focus on the cancer diagnosis and associated treatments. Comprehensive cancer care must include preexisting chronic illnesses as well as cancer treatment related illness and disability. An interdisciplinary team approach is needed to avoid fragmentation and inefficiency to deliver cost-effective high-value care. The novelty of HSP lies in its focus on HF in the context of cancer diagnosis and treatment, and it provides a model for engaging patients and family members as partners with a shared goal of reducing the burden of HF among people with cancer. HSP holds promise for the future creation of similar initiatives aimed at other chronic health problems that affect the overall management of cancer patients.

Anecita Fadol, PhD, RN, FNP, FAANP, is assistant professor in the departments of nursing and cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX.

References

1. Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6(4):444-450.

2. SEER stat fact sheets: all cancer sites. National Cancer Institute website. http://seer.cancer.gov/statfacts/html/all.html. Accessed April 29, 2015.

3. Aubin M, Giguere A, Martin M, et al. Interventions to improve continuity of care in the follow-up of patients with cancer. Cochrane Database Syst Rev. 2012;7:CD007672.

4. Ayanian JZ, Zaslavsky AM, Guadagnoli E, et al. Patients' perceptions of quality of care for colorectal cancer by race, ethnicity, and language. J Clin Oncol. 2005;23(27):6576-6586.

5. Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population; Board on Health Care Services; Institute of Medicine. Levit LA BE, Nass SJ, Ganz PA, eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: Institute of Medicine of the National Academies; 2013.

6. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83-90.

7. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004;291(11):1358-1367.

8. CAHPS hospital survey. The Hospital Consumer Assessment of Healthcare Providers and Systems website. http://hcahpsonline.org/home.aspx. Accessed April 29, 2015.

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