Dr. Topol,

1.   Premature discharge of patients admitted with HF is being aggressively driven by hospital administrators, many of whom receive "grades", compensation, promptions, and accolades that are inversely propostional to ALOS, with HF accounting for the highest number of Medicare admissions every year.

2.  In some cases #1 also applies to individual physicians.

3.  It has been my observattion that GPs, IMs, and most cardiologists do not treat admitted HF patients aggressively enough, do not follow well-proven heuristics and are not comfortable using recent medications and processes (viz. ultrafiltration, bio-impedence monitoring). Hospitalization is consequently unnecessarily prolonged, unless LOS is then shortened by discharge prior to true euhydration and balancing of electrolytes.

4.  Post-discharge patients can frequently be stablized and kept out of the ED/hospital without the installation of an implanted device.  The only items required for the prevention of readmission are: a) a digital scale with big numbers in each HF patient's home; b) a nurse;  c) a telephone; d) a computer with a list of patient medications and a running record of each patient's physiologic parameters, e) an algorithm by which the nurse is empowered to direct a limited number of treatment options (diuretic dose and frequency, fluld intake, instructions to see their physician...).  You get the idea.

5.  # 4 only works in the presence of an insightful hospital administration (a rare commodity, indeed)  and an inspired Physician Champion with fire in his/her belly to make the system work, oversee quality and institute opportunities for improvement.

It is quite easy to understand these concepts.  What is not so easy is understanding why there is such resistance to their implementation.

 Jan R. Weber, MD, MBA 

FACC, FAHA, FACP

I am a heart patient that recevied n ICD in 2005 and a replacement in 2009.  The replacement was due to my ICD's  battery losing its strength.

The removal of the old ICD and installation of the CRT-D was completed in less than 6 hours and I was on my way home.  I am currently monitored by a wireless device (by my bed) and I will probably not require re-hospitalization.  This will reduce the excessive cost of re-hospitalization and hopefully extend my life.

It might be of interest to know/ understand if re-admission could have been delayed if proper treatment with vasopressin receptor 2 antagonists ('vaptans') had been administered at signs of exacerbation- base in hyponatremia.

 Currently available implantable pressure sensors would make an impact and improve care especially if the provided important pressure data would be linked in a closed loop with a drug delivery system. One could contemplate for instance utilization of an implantable drug reservoir or a trans-dermal drug eluting patch. Interestingly, a special subpopulation of CHF patients who undergo percutaneous cardiac ablation due to atrial fibrillation may benefit from deployment of an implantable pressure sensor on the inter-atrial septum (closing the transseptal hole behind). This sensor would additionally monitor heart rhythm and could theoretically be passive without having to be connected to either an implantable battery or a pacemaker.

I see a lot of apathy on the part of physicians regarding Heart Failure; presumably because it is chronic, does not have any dramatic interventions (usually) that can "fix" it. The Interventional Radiologists are in the intervention business, the IM and FP docs defer to the Cardiologists and sometimes cannot differentiate between Heart Failure types, or will not. Since HF is a Quality (Core) Measure for CMS, the physicians in our facility call nearly all HF "Cardiomyopathy" so that they can evade the forms. They like to rush HF patients off to a teritiary care hospital, taking the onus off them. I bet this is endemic in the US.

My husband age 62 has had CHF since 12/99 and has had, 3 ICD devices since then.  These ICD devices have been changed due to battery life.  The last one is now has the pace maker.  He is paced 90% of the time.  He is now at End Stage Heart Failure and his ICD had been firing at a alarming rate until his physicians  put him on a high dose of Amirodarone and Mexiletine to stop the atrial fibalations. We were told by his Cardiologist if the ICD fires twice to go to the hospital. We do this and  Hospital admissions, for his ICD has been a hit and miss from the ER Physicians.  We are either sent home or he stays several days.  With the same conclusion,  see your personal doctor or if he  stays, he is  put on the Hoilter montior and endures blood tests that say "he is within the right numbers" now we go home. We make appointments for physicans and live another day. We do have the wonderful ICD unit that takes his reading every other day, but with us it is a revolving door.  I am not sure if Hospitals ER's know how to evulate the ICD's. Especially now with his latest ICD going off twice, we are at a diffucult place in our lives. He stayed 5 days, same conclusion, he has End Stage Heart Failure and now we wait for the ICD to go off.