Neighborhood matters for transitional care and heart failure hospital readmission in older adults

Highlights

• Neighborhood disadvantage was not associated with 30-day readmission.

• Neighborhood disadvantage decreased odds of provider follow-up and care coordination.

• Care coordination was associated with provider follow-up for most elderly patients.

• Elderly patients living in most disadvantaged neighborhoods may miss transitional care.

Abstract

A retrospective correlational design with existing data was utilized to examine the relationship between early provider follow-up, nursing care coordination intensity, and 30-day hospital readmission in older adults with heart failure and determine if an interaction exists with neighborhood disadvantage. Forward logistic regression was conducted to determine which variables predicted early provider follow-up and readmission. Ordinary least squares regression, logistic regression, and bootstrap confidence intervals were used to test for mediation and moderation. A direct relationship between early provider follow-up and decreased readmission was identified, but no indirect relationship through care coordination intensity. Neighborhood disadvantage did not moderate the effect of provider follow-up on readmission. Early provider follow-up and care coordination intensity were related and moderated by neighborhood disadvantage, but not for those living in highly disadvantaged neighborhoods. Neighborhood disadvantage is a key factor that may negatively influence participation in transitional care interventions in the elderly heart failure population.

Introduction

Neighborhoods are the places where people live and interact with each other,¹ which can have a significant impact on health and well-being.² The physical, social, and economic conditions of a neighborhood represent a set of shared circumstances that over time become so integrated as to create a unique phenomenon that is greater than the sum of individual circumstances.³ It is known that individuals with poverty, unemployment, low education, and inadequate housing are more likely to experience poor health.⁴ However, there is also evidence that these factors at the neighborhood-level are associated with health outcomes independently of individual-level socioeconomic status.⁵ Neighborhood conditions are considered upstream factors that impact health indirectly through a variety of causal pathways and are largely out of control of the individual.³ Research is needed to understand how and when neighborhood influences the delivery of health care and health outcomes for vulnerable populations, such as older adults with heart failure (HF).

Large cohort studies indicate that overall new diagnoses for HF have been declining over time, but incidence sharply increases with age,^6,7 thus making older adults a high-risk population for HF. Additionally, the number of people living with HF continues to rise as people live longer and treatments improve.⁶ A recent estimate for the prevalence of heart failure in adults 65 years and older is 8006 per 100 000 population, which is over 6 times the prevalence for adults under 65 years.​⁷ Hospitalizations for HF represent a significant burden for the US health care system, hospitals, communities, and individuals. The national rate of hospitalizations for Medicare beneficiaries from 2017-2019 was 17 per 1000; hospitalization rates varied by state, ranging from 9.8 to 22.3 per 1000.⁸ These hospitalizations for older adults with HF represent a significant cost for Medicare. Readmission within 30 days after discharge for a HF hospitalization is regarded as a reflection of low quality of care and hospitals are held accountable for excessive readmission rates through reduced CMS payments.⁹ However, there is debate over how much hospitals can control the factors that lead to readmission because all HF populations are not alike.

Individual factors, such as black race, older age, male gender, and comorbidities, as well as longer hospital length of stay, are risk factors for HF readmission10, 11, 12 Patients with HF who are ≥55 years old have an increased likelihood of all-cause readmission for each additional 10 years of age, with the oldest (>75 years) having the highest risk.¹³ In older cohorts, risk is also attributed to more chronic disease and comorbidity. Approximately one-third of HF readmissions for older adults are due to acute decompensated heart failure, while non-cardiovascular conditions account for over half of HF readmission etiologies.^10,14 At the population level, racial disparities exist for HF readmission, with patients of black race having up to 16 times higher odds of 30-day readmission compared to those of white race.^12,15 Social risk factors of populations, such as widespread poverty, disability, housing instability, and living in a disadvantaged neighborhood have been associated with higher readmission rates in HF.¹⁵

Strategies for HF readmission reduction are complex and require a great degree of coordination between the hospital and early post-discharge outpatient settings. Transitional care management includes multidisciplinary interventions that promote coordination and continuity of care for patients between healthcare settings to improve outcomes and prevent hospital readmission.¹⁶ Primary care providers have largely driven efforts to improve transitional care and reduce readmissions for patients with HF. But the registered nurse (RN) in care coordination is also an integral part of HF readmission reduction efforts, with competencies in support for self-management, advocacy, education, communication, coaching, the nursing process, population health management, collaboration, and care planning.¹⁷ Further, much of the current research in transitional care and HF readmission reduction focuses on interventions by providers, minimizing the impact of nursing activities, and does not consider the effect of upstream factors on population-specific outcomes.

Neighborhood conditions are quantitatively described through large population data sets, such as the U.S. Census and American Community Survey, which contain information on demographic, social, economic, and housing subjects.¹⁸ Most research on neighborhood and health outcomes has focused on a combination of population factors that reflect the level of disparity, or disadvantage, which exists at a location (zip code, census block group) at a given point in time. Social risk factors of populations, such as widespread poverty, disability, housing instability, and living in a disadvantaged neighborhood have been associated with higher HF hospital readmission rates.¹⁵ Neighborhood disadvantage is an important upstream risk factor for populations with HF; it has been associated with increased risk for incident HF,¹⁹ mortality from HF,²⁰ and HF readmission.21, 22, 23