SHM Converge Scientific Abstract ePoster Gallery-CHF Readmission Analysis at Lincoln Medical Center, South Bronx

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This study examined why congestive heart failure (CHF) readmissions remain high at Lincoln Medical Center in the South Bronx despite standard interventions such as patient education, guideline-directed medical therapy, cardiology referral, and post-discharge care coordination. The investigators focused on patient-related contributors, especially social determinants of health (SDoH) and burden of treatment (BoT), among patients readmitted with CHF decompensation between April and May 2023.<br /><br />All readmitted patients completed telephone surveys assessing SDoH, BoT using the Patient Experience with Treatment and Self-management (PETS) measure, and quality of life using ED-5D. Among 25 participants, the average age was 66.7 years; 68% were male. Most had heart failure with reduced ejection fraction (HFrEF), an average of 4.88 comorbidities, and 14% had a mental health diagnosis. Substance use was also common, with 20% reporting non-alcohol substance use and 20% alcohol use disorder. Although all participants had insurance, many faced significant social and treatment-related challenges.<br /><br />The average SDoH burden was 3.4 per patient. Overall, 43% had at least one SDoH burden, and 50% had problems in at least one BoT domain. The main reasons for readmission were medication nonadherence (47%), active substance use (17%), and missed follow-up appointments with subsequent loss to follow-up (50%).<br /><br />The authors conclude that current healthcare systems and guidelines are poorly designed for patients with complex needs and high social burden. They emphasize the need for more holistic, patient-centered approaches that address both medical and social factors to improve outcomes in heart failure patients.

Asset Subtitle

May Hnin Pwint Soe

Meta Tag

Author List Alejandrina Cuello Ramirez, Aurelia Hernandez, Chee Yao Lim, Ciriaco Landolfi, Inderpreet Singh, Kenneth Johan, Laverne Yip, May Hnin Pwint Soe, Nikolozi Bostashvili, Rubina Shah, Vidya Menon

Category Research

Concept Heart Failure

Concept Readmission

Concept Social Determinants of Health

Concept Treatment Burden

Concept Adherence

Distinguished Non-Finalist

Presenter Organization Lincoln Medical Center, Bronx, NY

Presenting Author May Hnin Pwint Soe

Track Quality Improvement

Keywords

congestive heart failure

readmission

social determinants of health

burden of treatment

heart failure with reduced ejection fraction

medication nonadherence

substance use

patient-centered care

South Bronx

care coordination

Heart Failure

Readmission

Social Determinants of Health

Treatment Burden

Adherence