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

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.

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.