Heart failure (HF) is among the most common and costly diseases in the United States and is the leading cause of hospitalization in older adults. Approximately 20% of patients hospitalized with HF will be readmitted within 30 days after discharge and more than half will be readmitted two or more times in a year. Despite more than a decade of national campaigns, financial penalties, and innovation to improve transitions of care, high rates of rehospitalization continue to put enormous strain on the U.S. healthcare system. Current HF guidelines recommend early outpatient follow-up within 7-14 days after discharge as a strategy for improving transitions of care and reducing readmissions. To date, however, implementing timely follow-up care for patients has been a challenge. Access to care is a fundamental Social Determinant of Health (SDOH) that is now targeted by the World Health Organization and Healthy People 2020 to improve the availability and timeliness of quality health care. According to recent estimates, nearly 1-in-6 adults have reported some degree of difficulty accessing their routine medical care; and those who lack adequate access to care have more emergency room visits, higher rates of hospitalization, and overall worse outcomes than those with sufficient access to ambulatory care. Our proposal will use a patient-centered approach to examine access to care and the underlying barriers to care that challenge early outpatient follow-up and increase the risks of readmission in HF patients transitioning from hospital to home. Using an innovative mixed-methods design, the specific aims of this research are twofold: First, examine how patient-reported access to care is associated with early outpatient follow-up and 30-day readmission. Our hypothesis is that HF patients who report difficulty accessing care will have significantly lower rates of early follow-up and subsequently higher rates of 30-day readmission than patients without difficulty accessing their care. Second, engage patients to identify their key barriers to accessing care and ascertain their recommendations for best addressing these barriers. Our hypothesis is that HF patients with difficulty accessing routine care will provide actionable knowledge of the major barriers they face and provide key insights for implementing successful strategies to improve their access to care. The major aims of this proposal are highly aligned with the National Institute on Aging?s mission to develop the translational science needed to support effective interventions that improve the health of older adults. Bringing together a complementary team of interdisciplinary investigators, the findings from the proposed research will provide needed qualitative and quantitative evidence to implement a large-scale clinical trial (R01) that will improve early outpatient follow-up in HF patients. In doing so, we seek to mitigate the potential ?double jeopardy? of those with difficulty accessing care?who face high rates of rehospitalization and yet may fail to benefit from a widely promoted intervention to reduce readmissions. Our long-term goal is to advance the interdisciplinary study of HF to establish innovative yet practical strategies to improve outcomes in vulnerable segments of the population.

Public Health Relevance

Heart failure is the leading cause of hospitalization in older adults and represents an enormous public health burden. Despite more than a decade of national campaigns, financial penalties, and innovation to improve transitions of care from hospital to home, high rates of rehospitalization continue to put enormous strain on the U.S. healthcare system. We propose a mixed-methods investigation of patients? access to care to provide needed patient-centered evidence of key barriers and practical strategies for improving outpatient follow-up after discharge to reduce subsequent readmissions.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Exploratory/Developmental Grants (R21)
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Health Services Organization and Delivery Study Section (HSOD)
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Salive, Marcel
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Duke University
Public Health & Prev Medicine
Schools of Medicine
United States
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