Heart Failure Home Management Challenges and Reasons for Readmission: a Qualitative Study to Understand the Patient's Perspective

Abstract

Background: Heart failure patients have high 30-day hospital readmission rates. Interventions designed to prevent readmissions have had mixed success. Understanding heart failure home management through the patient's experience may reframe the readmission "problem" and, ultimately, inform alternative strategies.

Objective: To understand patient and caregiver challenges to heart failure home management and perceived reasons for readmission.

Design: Observational qualitative study.

Participants: Heart failure patients were recruited from two hospitals and included those who were hospitalized for heart failure at least twice within 30 days and those who had been recently discharged after their first heart failure admission.

Approach: Open-ended, semi-structured interviews. Conclusions vetted using focus groups.

Key results: Semi-structured interviews with 31 patients revealed a combination of physical and socio-emotional influences on patients' home heart failure management. Major themes identified were home management as a struggle between adherence and adaptation, and hospital readmission as a rational choice in response to distressing symptoms. Patients identified uncertainty regarding recommendations, caused by unclear instructions and temporal incongruence between behavior and symptom onset. This uncertainty impaired their competence in making routine management decisions, resulting in a cycle of limit testing and decreasing adherence. Patients reported experiencing hopelessness and frustration in response to perceiving a deteriorating functional status. This led some to a cycle of despair characterized by worsening adherence and negative emotions. As these cycles progressed and distressing symptoms worsened, patients viewed the hospital as the safest place for recovery and not a "negative" outcome.

Conclusion: Cycles of limit testing and despair represent important patient-centered struggles in managing heart failure. The resulting distress and fear make readmission a rational choice for patients rather than a negative outcome. Interventions (e.g., palliative care) that focus on methods to address these patient-centered factors should be further studied rather than methods to reduce hospital readmissions.

Keywords: care management; care transitions; heart failure; patient-centered outcomes research; qualitative research.

Conflict of interest statement

The authors would like to disclose the following potential conflicts of interests:

Jonathan Sevilla-Cazes, MD, MPH: None

Kathryn H Bowles, PhD, RN, FAAN, FACMI: None

Faraz S. Ahmad, MD: None

Tom Gallagher: None

Shreya Kangovi, MD, MSHP: None

Lee R Goldberg, MD, MPH: Medtronic

Lynn Alexander: None

Anne Jaskowiak, MS, BSW: None

Barbara Riegel, PhD, RN, FAAN, FAHA: None

Frances K Barg, PhD, MEd: None

Stephen E Kimmel, MD, MSCE: Bayer, Pfizer.

Figures

Figure 1

Conceptual Framework. Tension between adherence to and adaptation of recommendations is a challenge to home heart failure management. This process is fueled by a cycle of limit testing and a cycle of despair. As the cycles progress and symptoms worsen, patients view readmission as a rational choice.