This letter is to serve as a brief synopsis of our experience with the Cardiac 360 program, which incorporates the NI-Medical Non Invasive Cardiac System (NICaS) impedance cardiography (ICG) device. We piloted this program at two nursing homes locations starting in January of 2014. In order to fully grasp the potential impact of using this program to assist in the assessment and management of residents with heart failure in the nursing home setting – Readmission Reduction – I will provide a brief overview of the burden of heart failure.
Heart failure is a syndrome of inadequate delivery of oxygen and nutrients to the tissues of the body, which can be due to a pumping or a relaxing problem of the heart. Many different cardiac disease states will present with heart failure. Heart failure affects over 6 million people in the United States with about 700,000 new cases annually. The majority of admissions to the hospital for heart failure are, in fact, readmissions for heart failure. Approximately 22% of people discharged from the hospital with heart failure will be readmitted within 30 days and approximately 50% will be readmitted within 6 months. Heart failure is the number one Medicare discharge diagnosis and the direct and indirect costs of heart failure are about $40 billion annually.
The reasons for the huge financial and functional burden of heart failure are many including an incomplete understanding of the pathophysiology of heart failure, misdiagnoses, suboptimal use of evidence-based therapies, and a lack of a clinically useful, accurate, and consistent means of assessing one’s cardiovascular physiology in real-time. The NICaS utilizing the ICG technology provided by NI-Medical could be just the solution to address all of these limitations.
The Cardiac 360 program incorporates an interdisciplinary team approach to reducing heart failure admissions and re-admissions from the nursing home back to the hospital. Physicians and nurse practitioners are trained in advanced principles of cardiovascular hemodynamic as well as the pathophysiology of heart failure. In addition, the team receives weekly case based learning applying these principles and ICG results towards the effective management of heart failure patients. The program is overseen both by a cardiologist with extensive experience in managing heart failure patients and a board certified physician in geriatric medicine.
From a clinical standpoint, NICaS is able to provide accurate (highly correlated with invasive hemodynamic monitoring), consistent, and real-time data of one’s cardiovascular physiology.
This would facilitate the ability to improve our understanding of one’s cardiovascular state, provide a clue as to what in causing the current state, facilitate titration of medications to more optimal levels, and provide a means of assessing one’s response to medication adjustments.
When coupled with a physician or nurse practitioner with a strong understanding of basic cardiovascular physiology, the NICaS device has the potential to revolutionize the management of heart failure in the NH setting and to, more importantly, improve outcomes for residents with this dreaded syndrome.
With this introduction in mind, we piloted the Cardiac 360 Program to improve outcomes (as assessed by reduced readmissions to the hospital for heart failure). We identified approximately 40 residents with a history of heart failure. A baseline NICaS measurement was obtained in all residents. Subsequent NICaS assessment was based on the type of resident (short vs. long term), the current clinical condition, the goal of therapy, and the baseline scan. If possible, NICaS scans were performed at regular frequencies (weekly if short-term or weekly if long-term until the resident was deemed stable then at longer intervals ranging between 2-4 weeks).
The results of the program were quite impressive. There were no readmissions to the hospital from either site for heart failure in over 6 months. The majority of residents could be optimally titrated on evidence-based medications for heart failure and taken off medications that were not addressing the pathophysiology of the resident as suggested by the NICaS analysis. In addition, we had numerous reports of residents subjectively feeling better and of objective clinical improvement of many residents by the NH staff.
A few things are clear in our opinion:
- The Cardiac 360 Program utilizing NICaS technology provided by NI-Medical can effectively provide Readmission Reduction, reduce heart failure admissions and readmissions from the nursing home back to the hospital;
- The physician or nurse practitioner must understand the NICaS reading and common reasons for abnormalities encountered. The NICaS alone is insufficient to guide patient care without the proper training;
- The NICaS is accurate, but more importantly, it is consistent. This allows one to assess the clinical response to medication adjustments in a resident over time;
- The NICaS takes the guesswork out of managing difficult residents with heart failure. It facilitates expeditious optimization of these residents;
- It affords a comfort level for medication titration not previously seen in these residents;
- The use of NICaS will, undoubtedly, result in less unanticipated discharges from the NH for decompensated heart failure when used by properly trained clinicians;
- NICaS will identify residents with impending heart failure before they decompensate allowing time to make necessary adjustments that will prevent the decompensation.