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Running Head: GROUP MEDICAL APPOINTMENTS FOR HEART FAILURE 1

Group Medical Appointments in Heart Failure Patients

Nadine Martins

Maryville University

Capstone Chair: Boniface Stegman, PhD, MSN, RN

Capstone Committee Member: Joanne Kern, PhD, DNP, APRN, ANP-BC

Date of Submission: August 14, 2018

GROUP MEDICAL APPOINTMENTS FOR HEART FAILURE

Table of Contents

Abstract..........................................................................................................................................5

Chapter I.........................................................................................................................................6

Purpose...........................................................................................................................................7

Background....................................................................................................................................7

Significance of Project...................................................................................................................9

Advanced Practice Nursing..........................................................................................................9

Nursing.........................................................................................................................................9

Healthcare..................................................................................................................................10

Practice Support for Project.......................................................................................................10

Benefit of Project to Practice......................................................................................................11

Chapter II.....................................................................................................................................13

PICOT Question.........................................................................................................................13

Literature Search History...........................................................................................................13

Integrated Review of Literature Themes..................................................................................14

Theme one: GMA reduce HF hospital readmission rates..........................................................14

Theme two: GMA increase patient’s satisfaction......................................................................15

Theme three: GMA improve patient’s self care skills...............................................................16

Theme four: Retrospective studies can help predict HF readmissions......................................17

Theme five: Early follow-up can reduce HF readmissions........................................................19

Literature Critique......................................................................................................................20

Strengths.....................................................................................................................................20

Weaknesses................................................................................................................................21

Gaps...........................................................................................................................................21

Limitations.................................................................................................................................22

Concepts and Definitions............................................................................................................22

2


Theoretical Framework...............................................................................................................23

Chapter III...................................................................................................................................25

Methodology.................................................................................................................................25

Needs Assessment.........................................................................................................................25

Design............................................................................................................................................26

Data Collection Instruments.......................................................................................................27

Analysis Plan................................................................................................................................28

Resources......................................................................................................................................28

Budget...........................................................................................................................................28

Timeline........................................................................................................................................28

Protection Human Subjects........................................................................................................28

Chapter IV....................................................................................................................................30

Data Analysis................................................................................................................................30

Sample........................................................................................................................................30

Results...........................................................................................................................................31

Validity..........................................................................................................................................32

Chapter V.....................................................................................................................................33

Discussion.....................................................................................................................................33

Strengths.....................................................................................................................................33

Limitations.................................................................................................................................34

Reliability...................................................................................................................................34

Application to Research.............................................................................................................34

Application to Practice...............................................................................................................35

Application to DNP....................................................................................................................35

Conclusion....................................................................................................................................35

3


References.....................................................................................................................................37

Appendix A...................................................................................................................................41

Appendix B...................................................................................................................................42

Appendix C...................................................................................................................................44

Appendix D...................................................................................................................................45

4


Abstract

Group Medical Appointments in Heart Failure Patients

Background: Heart Failure (HF) 30-day hospital readmission rates are on the rise in the HF

population. Statistics on HF 30-day readmission rates during the years of 2004 to 2006 showed

found that during this time period HF readmission rates were around 22-23% of all patients in

the sample of a study by Ross et al., (2009). Unfortunately, not much data has been collected on

ways to reduce these readmissions.

Objective: The purpose of the scholarly project was to examine the association between group

medical appointments (GMA) and HF 30-day hospital readmission rates.

Design: Quantitative pilot study held at small community hospital in Maryland from March to

May 2018.

Results: Study sample included two patients from one hospital. Neither patient was readmitted

during initial 30 days following hospitalization.

Conclusion: Due to small sample size, no statistical conclusion could be drawn from the study.

Further research is needed on HF and utilizing GMA to potentially lower 30-day readmission

rates.

Keywords: 30-day heart failure readmission rates, diagnosis of heart failure, congestive heart

failure, chronic systolic heart failure, chronic diastolic heart failure, heart failure with reduced

ejection fraction, heart failure with preserved ejection fraction, group medical appointments,

outcomes.

5


Chapter I

Medicare started running analyses on 30-day hospital readmission rates for certain

specific diagnoses back in 2009 with the rationale that patients readmitted to the hospital in less

than 30 days are a result of poor care or “missed opportunities” to provide better care (Ross et

al., 2009). From the year 2004 to 2006 HF 30-day readmission rates were around 22-23% of all

patients in the sample of a study by Ross et al., (2009). Hernandez et al., (2010) found similar

results when analyzing readmission rates around 21% of patients in their sample group

experienced 30-day hospital readmissions.

Analyzing hospital readmission rates and implementing policies that target lowering

these rates have widespread potential (Ross et al., 2009). There is significant variation on how

early HF patients follow up with a health care provider after hospital discharge, but patients who

follow up earlier have a lower rate of 30-day rehospitalization (Hernandez et al., 2010). A study

by Murtaugh et al. compared the effectiveness of two “treatments” (early home health follow-up

and early physician follow-up within one week) after a HF patient was discharged from the

hospital (2017). The study findings showed the combination of these two treatments significantly

decreased the possibility of hospital readmission (Murtaugh, et al., 2017).

Group medical appointments (GMA) may be a way to help reduce HF 30-day re-

hospitalization rates. By definition, a GMA is an appointment that includes two or more patients,

and usually focuses on some aspect of a patient education session related to the group’s common

medical diagnosis. The GMA focuses on disease management and patient education, thus is an

opportunity for patients with a common diagnosis to share their successes and also their struggles

with one another. The GMA can become a support group in combination with a medical

appointment (Bartley and Haney, 2010).

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It is duly noted that HF 30-day hospitalizations are a significant problem, and different

approaches and further research are necessary to find new ways to try to reduce re-

hospitalizations and improve patient’s outcomes.

Purpose

The PICO(T) question for this scholarly project is: “In adult heart failure patients are

group medical appointments more effective in reducing 30 day hospital readmission rates and

improved patient satisfaction rates when compared to individual standard provider medical

appointments?” The purpose of the project is to conduct research regarding utilizing a GMA

within the month initially following hospital discharge in addition to usual outpatient hospital

follow-up care to attempt and lower 30-day HF hospital readmission rates and improve patients

self care skills.

Background

Heart failure (HF) is the inability of the heart to pump blood throughout the body

effectively, according to the American Heart Association (AHA). The number of adults living

with HF in the United States has increased between the years 2009 and 2014. From 2009-2012

there were about 5.7 million adults who lived with HF, and by 2011-2014 that number had

increased to 6.5 million (AHA, 2017). The AHA has projected the number of people living with

HF will increase by 46 percent by the year 2030, resulting in eight million more adults who have

HF (2017).

GMA are becoming increasingly popular and have a more widespread use. A study

compared GMA to “usual care appointments” and found that GMA improved patient’s access to

care and increased patient satisfaction with the care they receive and their relationship with their

care provider (Heyworth, et al., 2014). It is important to study the use of GMA in order to

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reduce HF re-hospitalizations because HF “continues to be the leading cause of hospitalization

among older adults” (Lin et al., 2008, p. 1210). A six-month trial utilizing GMA for HF patients

revealed improved patient compliance with their recommended regimen, decreased HF

hospitalizations, decreased depression and improved patient self-care skills (Lin et al., 2008).

Another study found HF patients who attended GMA versus standard care appointments had

improved knowledge about their disease process and concluded that GMA would be a good way

to provide patient and family education in a supportive environment (Yehle et al., 2009).

Research was conducted in a nurse practitioner (NP) led, community cardiology practice

related to the utilization of GMA for HF patients. This pilot study used four separate GMAs and

a total of 20 patients to assess patient and staff satisfaction, how to bill for a GMA and also the

feasibility of utilizing a GMA (Paul et al., 2010). Findings from the study included patients and

staff having a high reported level of satisfaction with GMA and that billing charges were

comparable to usual appointments (Paul et al., 2010). This made the GMA a viable option for

use in a cardiology practice (Paul et al., 2010).

A large clinical trial was conducted by Smith et al., (2015) which compared GMA to

usual care for HF patients in terms of assessing patient’s self care skills and HF rehospitalization

rates. The results for the trial were favorable for implementing GMA as part of HF patient care.

Patients rated the GMA as highly helpful on a questionnaire and a statistical analysis showed that

re-hospitalizations for HF decreased by 33% when patients attended GMA and were followed for

a 12-month period (Smith et al., 2015).

Another trial was conducted which tested the use of GMA and the results regarding the

amount of time until first re-hospitalization or death (Smith et al., 2014). Patients were randomly

assigned into one of two groups: standard care or standard care and GMA and followed for 12

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months. Findings included patients having better adherence to their HF medications and a longer

period of survival without hospitalization while the intervention took place (Smith et al., 2010).

Further research is needed to find ways to sustain these benefits for the rest of a patient’s life

(Smith et al., 2010).

Significance of Project

Utilizing GMA for patients with chronic diseases has been initiated for different reasons.

Bartley and Haney (2010) discuss how to implement GMA to improve patients access to care,

improve patients outcomes and patient satisfaction with care.

Advanced Practice Nursing

Studying GMA’s use in a HF setting is significant to advance practice nurses, specifically to the

NP because it allows the NP more availability to see more HF patients in a timely manner after

hospital discharge. GMAs are in essence improving patient’s access to care.

Nursing

This project is significant to nursing as a whole because nurses can be utilized in the

conduction of GMA for HF patients. Bartley and Haney discuss how a registered nurse (RN)

might be used to record findings; help with patient education and maintaining smooth flow of the

meeting (2010). Using GMA in the HF patient group is also significant to nursing because it

allows advance practice nurses (e.g. NPs) to utilize their independent practitioner skills, because

NPs could theoretically conduct an entire GMA on their own in certain states, without the

supervision of a physician (Bartley and Haney, 2010).

In this case, the NP works in a state where NPs have independent practice privileges, the

GMA will be conducted by the NP alone, but a physician will always be onsite if any backup

9


support is needed. According to Watts et al., (2008) NPs play a crucial role in meeting

challenges such as patients’ access to care and managing chronic illnesses. The study concluded

NPs have multiple roles in GMAs, but have the maximum benefit in helping patients learn about

self-management, and in being the patient’s decision making support (Watts et al., 2008).

Healthcare

At least 33% of Medicare patients felt their barrier to healthcare was not a financial

barrier, but actually lack of provider accessibility (Bartley and Haney, 2010). This scholarly

doctoral project will be significant to healthcare in general because it aims to decrease 30-day

hospital readmission rates, which indicates better planning and healthcare provided for the

patient and ultimately means improved patient outcomes (Ross et al., 2009).

Practice Support for Project

The practice where this project will take place will support the research project by

providing a conference room where the GMA can take place. Front desk staff will be involved in

checking patients in and directing them to the conference room where the GMA will take place.

The researcher will conduct/lead the GMA and examine the electronic health record (EHR) to

assess if patients were readmitted after 30 days. The local hospital’s research coordinator will

help the researcher recruit HF patient’s to attend the GMAs and help run a statistical analysis of

the study’s findings.

Benefit of Project to Practice

This doctoral scholarly project will benefit the researcher’s place of practice by

researching an alternate way to provide HF patient care, HF outpatient hospital follow-up and a

support group for HF patients. The project will be conducted with the hope that it will benefit the

10


practice by continuing to routinely conduct GMA for HF patients, even once the project is

finished. It will benefit the practice by improving access to care for HF and allowing the

researcher/NP to see more patients in a timely, efficacious manner.

Conclusion

The scholarly project aims to utilize GMA for HF patients who have just been discharged

from the hospital. HF patients who have been discharged from the hospital will be enrolled in

and attend one 30-minute GMA session in addition to their routine hospital follow up care and

routine outpatient appointments. The goal is to research if utilizing GMA will help decrease HF

30-day rehospitalization rates and if it improves patient’s self-care skills and satisfaction. The

researcher will conduct each GMA session with the hope that this will benefit her current

practice by improving HF patient’s access to care and also making the researcher’s schedule

more effective, and allow the researcger to see more patients than in a usual 30-minute time

frame. The overarching goal of this scholarly project is to improve HF patient’s outcomes by

enrolling them in GMAs.

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Chapter II

Chapter One provided an overview about heart failure (HF) and impacts HF 30-day

hospital readmissions have on patients, nursing, advanced-practice nursing and healthcare in

general. Medicare started running analyses on 30-day hospital readmission rates for certain

specific diagnoses back in 2009 with the rationale that patients readmitted to the hospital in less

than 30 days are a result of poor care or “missed opportunities” to provide better care (Ross et

al., 2009). Statistics on HF 30-day readmission rates during the years of 2004 to 2006 showed

that during this time period HF readmission rates were around 22-23% of all patients in the

sample of a study by Ross et al. (2009).

PICOT Question

The PICO(T) question for this scholarly project is: “In adult heart failure patients are

group medical appointments (GMA) more effective in reducing 30-day hospital readmission

rates and improved patient satisfaction rates when compared to standard medical appointments?”

The purpose of this scholarly project is to utilize GMA post HF hospital discharge in hopes of

decreasing HF hospital readmission rates.

Literature Search History

The search of the literature included searching the EBSCO Host database using the

following search engines: Academic Search Complete, Academic Search Elite, Academic Search

Premier, CINAHL Plus with Full Text, Cochrane Register of Controlled Trials, Cochrane

Database of Systematic Reviews and MEDLINE Complete. Initially, the literature was searched

for studies between the years of 2012-2017. Queries within the databases included searching

“Heart failure AND group medical appointments” and this search yielded no results. Next the

search for “heart failure OR group medical appointments” found 163, 896 results, but not

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specific to the PICOT question. Then a search “heart failure readmissions AND group medical

appointments” and “heart failure readmissions OR group medical appointments” found 1,717

and 1,925 results respectively. After the date restriction was removed, the search was for “heart

failure AND group medical appointments” and “heart failure AND shared medical

appointments”. During these searches two results and eight results were found, respectively.

Google scholar was searched for “heart failure AND group medical appointments” and

“heart failure AND shared medical appointments” and found 183,000 and 106,000 results

respectively. Several articles from this search were relevant to the PICO(T) question.

Integrated Review of Literature Themes

The purpose of the literature review is to find evidence-based interventions that reduce

HF 30-day hospital readmission rates. Past and present studies were also analyzed to find what

common outcome themes there are for HF patients who attend GMA. The literature review

articles arranged into five themes: GMA reduce HF hospital readmission rates, GMA increase

patient’s satisfaction, GMA improve patient’s self care skills, retrospective studies can help

predict HF readmissions and early follow-up can reduce HF readmissions.

Theme one: GMA reduce HF hospital readmission rates

In a study that compared patients who had early, intense home health follow up and

physician appointments after hospital discharge, versus later, less intense hospital follow up,

Murtaugh et al. (2017) found that patients who had earlier, collaborative follow up had a lower

risk of hospital readmission. Lin et al. (2008) did a study that utilized GMA for six months in

patients who had HF and compared outcomes from this group to standard appointment outcomes.

They found an increase in the patients compliance with use of indicated HF medications, and

reduced hospital readmissions - including reduced HF readmissions (Lin et al., 2008). Another

13


study found while patients were enrolled in a GMA they had longer hospitalization-free time

period and also a longer survival time (Smith et al., 2014).

In contrast, one study did not find that shared medical appointments (SMA) decreased HF

hospital readmission rates. Carroll et al. (2017) implemented SMA for HF patients in addition to

routine, standard care at the HF clinic. Patients attended four weekly face-to-face SMA sessions

and then graduated to what was considered “monthly booster sessions” (Carroll et al., 2017).

The patients were all followed for a total of 12 months of follow up, and monitored for

hospitalization and mortality outcomes. Results of the SMA group did not show any decrease in

re-hospitalization rates or overall mortality (Carroll et al., 2017). Carroll et al. (2017) did note

that patients were not recruited to be in the intervention group (SMA group) unless they had

previously been hospitalized for HF, and thus likely all these patients had advanced disease,

worse compliance and were not likely a true representation of patients in earlier stages of the HF.

Theme two: GMA increase patient’s satisfaction

Paul et al. (2010) found that HF patients and staff members had a higher rate of

satisfaction with GMA than regular one on one follow up appointments. They also noted there

were less cancellations for GMA than there were for the usual, one on one appointment. Smith et

al. (2015) conducted a study that presented key characteristics of conducting GMA in a HF

patient demographic and found when asked in a survey, patients rated GMA 4.8 out of 5 on

“helpfulness”.

Another study led by Heyworth et al. (2014) assessed the effects of SMA on patient

satisfaction. Their findings revealed patients who attended a SMA versus a usual medical

appointment were more likely to rate their satisfaction with care as very good, and also rated

their care as more accessible and perceptive of their needs (Heyworth et al., 2014). Smith et al.

14


(2015) found patients who attended GMA highly rated other patients who attended the sessions.

This brings in the point that GMA/SMA can also function as a support group as patients who

attend the GMA all have the same diagnosis.

Theme three: GMA improve patient’s self care skills

Lin et al. (2017) found patients were more compliant with medications, but also rated

their depression lower on the Beck depression scale when attending GMA. Patients also had

higher reported self-care management skills when they attended GMA versus when they attended

standard appointments (Lin et al., 2017). Another study found patients who attended a GMA

were more likely to have better adherence with their HF medications during the time period

when they attended a GMA (Smith et al., 2014).

Yehle, Sands, Rhynders and Newton studied the effect of SMA on HF patients and their

self care skills. Patients were randomized into standard appointment groups and into SMA

groups (2009). They completed validated surveys/questionnaires at baseline and at eight weeks.

Findings showed patients who attended SMA revealed increased knowledge scores at the end of

eight weeks of SMA (Yehle et al., 2009).

Theme four: Retrospective studies can help predict HF readmissions

“Structured care” does not improve quality of life. A study done in the Netherlands

assessed if adding structure into care for HF patients would improve patients’ health related

quality of life (Bøsch et al., 2009). Structured items such as providers having regular clinical

meetings about HF patients, following a HF protocol, immediately making the next appointment

after a visit, and others were studied to assess if patients had a improved health-related quality of

life, but findings showed structure care did not improve patient’s quality of life (Bøsch et al.,

2009).

15


Risk factors studied for predicting HF readmissions. Desai and Stevenson (2012)

discuss using research to predict factors that have a high association with HF hospital

readmission and discuss the difficulty in being able to accomplish this task. They discuss

implementing a re-design on heart failure management may be best for decreasing HF hospital

readmissions. The study also discussed how decreasing HF readmissions may not be

synonymous with improving HF patient’s outcomes (Desai & Stevenson, 2012).

In a study Dharmarajan et al. (2013) analyzed Medicare fee-for-service claims to pinpoint

any patterns present in 30-day hospital readmission rates for patients hospitalized with HF, acute

myocardial infarction (MI) or pneumonia. For the purpose of this scholarly project, we will focus

on the data found related to HF patients. Readmission rates for patients with HF was “31% from

days 0 through 3, 33% during days 0 through 7, 34% during days 0 through 15 and 35% during

days 0 through 30 after discharge” (Dharmarajan et al., 2013, p. 358).

They concluded though readmission rates were at their highest in the immediate days

following discharge, readmissions remained frequent throughout the entire month following

discharge. Thus the findings imply the entire 30-day period is a time where patients are at higher

vulnerability for readmission to the hospital (Dharmarajan et al., 2013). The findings of this

study highlighted the importance for transitional care to prevent hospital readmissions

(Dharmarajan et al., 2013).

Yet another study used statistics to analyze the relationship between a previous HF

admission and a patient’s risk for 30-day readmission to the hospital (McLaren et al., 2016).

Their hypothesis was that analyzing the relationship between the number of previous admissions

could help predict the risk a patient has for 30-day hospital readmission. The study findings

concluded patients who had zero previous admissions for HF had a 14% chance of being

16


readmitted. Those with one previous admission were at 20% risk for readmission and patients

with two or more previous HF admissions were at 33% risk for rehospitalization (McLaren et al.,

2016).

O’Connor and Fiuzat (2010) studied the factors associated with HF rehospitalization and

questioned using HF readmissions as a way to characterize if the patient received quality of care.

They compared mortality rates from 2002 and 2006 and found sicker patients who were more

likely to die in 2002 remained alive longer in 2006 (O’Connor & Fiuzat, 2010). The increased

longevity for “sicker” patients is hypothesized to allow for greater exposure to hospital

readmission. One of the reasons for increased HF readmission rates in the United States (US)

may be in general decreased length of hospital stay and the fact that many patients still show

significant signs of congestion at discharge (O’Connor & Fiuzat, 2010).

A systematic review protocol was written with the intent to analyze risk factors that were

associated with readmission to the hospital for patients who had HF with a reduced ejection

fraction. Schjødt, Larsen, Johnsen, Strömberg and Løgstrup conducted this systematic review of

the literature in hopes to identify specific risk factors that predict a patient being readmitted to

the hospital for HF within the first year after initial hospital discharge (2017).

Theme five: Early follow-up can reduce HF readmissions

Intensive nursing care combined with early physician follow up was studied in hopes of

reducing readmissions among heart failure patients (Murtaugh et al., 2017). They found that

neither treatment decreased hospital readmission by itself, but the interventions when combined

had the ability to reduce the chance of HF hospital readmission by about eight percent (Murtaugh

et al., 2017).

17


Hernandez et al. (2010) studied the use of early physician follow up on HF 30-day

hospital readmission rates and analyzed data on over 30,000 patients from 225 different

hospitals. In their analysis they found patients who were discharged from a hospital that had a

higher rate of early follow-ups had a lower risk of being readmitted to the hospital within the

first 30 days following hospital discharge (Hernandez et al., 2010).

Hobbs, Escutia, Harrison, Moore and Sarpong (2016) studied the use of telemonitoring,

telephone follow-ups or telephone follow-up combined with patient care to try and help reduce

HF hospital readmission rates. Findings were inconclusive and discussed the need for additional

research on the utilization of these interventions in hopes of establishing their success at reducing

HF hospital readmission rates (Hobbs et al., 2016).

Watts et al. (2008) studied nurse practitioner’s (NP) unique strengths to leading a

SMA/GMA. While the NPs had multiple different roles, they were the greatest at teaching self-

management, helping patients make decisions and designing the system delivery (Watts et al.,

2008).

Literature Critique

There is quite a bit of research and literature available in regards to HF, 30-day hospital

readmission rates and interventions to reduce 30-day hospital HF readmission rates which

include GMA/SMA. This next section in chapter two is to discuss the existing literature’s

strengths, weaknesses, gaps and limitations.

Strengths

The majority of all studies critiqued for this literature review had large sample sizes,

which allowed for a wide variety in patient demographics. A strength found in the literature

analysis, Dharmarajan et al. (2013) make a point regarding the high percentage of heart failure

18


hospital readmissions during the initial 30 days after hospital discharge. Their analysis of the

research provides a strong reason why transitional care, or care that transitions the patient from

inpatient to outpatient, is important.

This example from the literature can be translated as a reinforcement for using GMA as

transitional care. In another example Hobbs et al. (2016) conducted a thorough literature review,

gave a complete description of their literature search and also mentioned limitations of their

study. These factors all combined are strengths for the validity of the article. Many of the articles

had common, overarching themes as mentioned previously which included GMA decreasing

hospital readmission rates, improving patients satisfaction with care and also improving patients

self care skills. Additional themes in the literature included retrospective research helping to

predict patients at risk for HF hospital readmission and early follow-up reducing HF readmission

rates. Overall, the literature supported the purpose and PICOT question of this scholarly project.

Weaknesses

In the review of the literature, a few of the studies had small sample sizes, which is a

threat to reliability and reproducibility. Smith et al. (2014) supports this criticism when they

admitted their study had promising results in reducing HF hospital readmissions and HF survival

rates, however the sample size was small and from a single site. Another weakness in one of the

studies included patients being more or less being hand selected for the study, and thus there

having no randomization. Carroll et al. (2017) noted limitations of their study: patients were not

randomized into different treatment arms, and only referred to the HF clinic after they had been

hospitalized for HF.

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Gaps

A significant amount of the existing did not include a literature review for the research

study/article. This gap is a threat to validity and also does not give a good background of

reviewing existing literature before conducting research.

Some of the existing studies did not achieve their hypothesized results. Carroll et al.

(2017) did not find better outcomes among study participants who were assigned to a SMA in

relation to HF hospitalizations or mortality. Further studies are needed to evaluate HF SMA and

the ability to decrease healthcare cost burden and improve patient outcomes (Carroll et al.,

2017).

Limitations

The critique of the literature found the several of the articles did not discuss the

limitations of their studies. Desai and Stevenson’s article did not discuss weaknesses or strengths

(2017). The article is simply a discussion of desiring to prevent HF hospital readmissions by

recognizing factors that can predict readmission (Desai & Stevenson, 2017). However, they

mention predicting and preventing HF readmissions may not be all that it appears and may not

completely correlate with patient outcomes (Desai & Stevenson, 2012).

Another limitation of the literature is that the majority of the research did not specifically

address ways to decrease HF 30-day hospital readmission rates. Research addressed reducing HF

readmission rates in general, but not readmissions in the 30-day window. Further research is

needed regarding ways to decrease HF 30-day readmission rates, and that is the aim and purpose

of this scholarly project.

Concepts and Definitions

In order to give a clear understanding of key terms and concepts, definitions are provided

20


below:

Heart Failure: is the inability of the heart to pump blood throughout the body effectively,

according to the American Heart Association (AHA, 2017).

Group/Shared Medical Appointment (GMA/SMA): one-on-one medical appointments conducted

simultaneously, in a series within a group of patients (Bartley & Haney, 2010).

Outcomes: the word outcome by definition means “something that follows as a result or

consequence” (The Merriam-Webster online dictionary, 2017).

30-day heart failure readmissions: readmission to the hospital within 30 days of hospital

discharge with the admitting diagnosis of heart failure.

Patient satisfaction: a patient’s satisfaction with their medical care and with their medical care

provider.

Patient self-care skills: the extent of the patient’s ability to care for themselves, take their

medications and follow medical instructions without a caretaker’s assistance.

Health Belief Model: A nursing theory developed by Becker in 1976 that focuses on patient

compliance and preventative care seeking (Polit & Beck, 2017).

Nurse Practitioner: an advance practice nurse; mid-level care provider that functions much like a

physician, but trained with a nursing background.

Theoretical Framework

A nursing theory that coincides well with utilizing GMA in HF patients is the Health

Belief Model (HBM). The HBM focuses on patient compliance and preventative care seeking

(Polit & Beck, 2017). They mention that according to HBM patient’s compliance and health-

seeking behavior is influenced by how severe they perceive the threat of their illness (Polit &

Beck, 2017). HBM focuses on patient’s perceived susceptibility, severity, benefits, costs and

21


motivation. How a patient perceives their susceptibility is based on how convinced they are that

their diagnosis is accurate and true (Polit & Beck, 2017). Patient’s who are convinced their

diagnosis is accurate will be more motivated to comply with therapy and to try to improve their

outcomes. The HBM coincides well with this scholarly project because GMA can be used to

implement a comprehensive education program regarding HF, the disease process, recommended

medical regimen and rationale, exercise, daily weights, salt and fluid limitations. In this way, the

hope and aim of this scholarly project is to help convince patients of the accuracy and severity of

their diagnosis and thus improve patient’s compliance with therapy and also increase their health

seeking behaviors (Polit & Beck, 2017).

Applying the HBM into practice will help the researcher focus on the importance of

providing thorough patient education related the patient’s diagnoses and try to understand how

best to relay the brevity of the patients prognosis. Since the HBM focuses on patient compliance

and preventative health seeking behaviors, the researcher needs to practice providing simple yet

thorough patient education regarding important patient self care tips that will help to reduce

patient’s readmission to the hospital (Polit & Beck, 2017).

Conclusion

Previous research has been done regarding GMA within the heart failure population.

Several overarching themes found in the existing literature are that GMA reduces HF

readmission rates, has higher patient and staff satisfaction rates than conventional one-on-one

appointments and can improve patient’s self care skills. Two additional themes found were

retrospective studies can help decrease HF readmissions and early follow-up can reduce HF

readmissions. The HBM proposes that patients are more motivated to comply with their

prescribed therapy and treatment if they are convinced their diagnosis is accurate and understand

22


the full brevity of their situation. Utilizing GMA to conduct outpatient HF appointments can help

provide better patient education and treatment in order to produce better patient outcomes. There

is a gap in the literature that does not address specifically if 30-day hospital readmission rates are

reduced when GMA is implemented for adult HF patients. The researcher hopes to narrow this

gap by researching the PICO(T) question: “In adult heart failure patients are group medical

appointments more effective in reducing 30-day hospital readmission rates and improved patient

satisfaction rates when compared to individual standard provider medical appointments?”

23


Chapter III

The PICO(T) question for this doctoral scholarly project is: “In adult heart failure (HF)

patients are group medical appointments (GMA) in addition to standard hospital follow up care

more effective in reducing 30-day hospital readmission rates when compared to standard

individual standard provider medical appointments?” The purpose in the project is to conduct

research regarding utilizing a GMA educational session within the month initially following

hospital discharge. This GMA will be in addition to usual outpatient hospital follow up care to

attempt and lower 30-day HF hospital readmission rates and improve patient’s self care skills.

Methodology

Patients will be recruited for the study via personal invitation from the researcher.

Patients will be recruited during inpatient hospitalization for heart failure exacerbation.

Recruitment will be verbal and the researcher will use a scripted dialog to recruit patients for the

study. Each patient will attend one GMA within 30 days after hospital discharge. Descriptive

statistics will be used to analyze if patients who attend GMA have a lower 30-day HF

readmission rate when compared to standard care patients.

Needs Assessment

Chapter One provided an overview about heart HF and impacts HF 30-day hospital

readmissions have on patients, nursing, advanced-practice nursing and healthcare in general.

Medicare started running analyses on 30-day hospital readmission rates for certain specific

diagnoses back in 2009 with the rationale that patients readmitted to the hospital in less than 30

days are a result of poor care or “missed opportunities” to provide better care (Ross et al., 2009).

Statistics on HF 30-day readmission rates during the years of 2004 to 2006 showed that during

this time period HF readmission rates were around 22-23% of all patients in the sample of a

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study by Ross et al. (2009). HF 30-day readmission rates are also an issue at the local

community hospital where patients will be recruited for the study.

This scholarly project will benefit the local hospital (Meritus Medical Center) and the

researcher’s outpatient place of practice by researching an alternate way to provide HF patient

care and education, HF outpatient hospital follow-up and a support group for HF patients. This

pilot study will hopefully make way for further research on a larger scale regarding heart failure

GMA and 30-day hospital readmission rates. It will benefit the practice by improving access to

care for HF and allowing the researcher to see more patients in a timely, efficacious manner.

Design

The design of this study is intended to be a pilot study. The setting for the GMA is at a

private, outpatient cardiology practice in a conference room. The anticipated sample size is 15

patients. Inclusion criteria for the project is being18-89 years of age, and have a diagnosis of

heart failure and participants may be any gender or race. Patients will be excluded from the study

if they are not able to speak and understand English fluently because the researcher must be able

to educate patients and does not have translators available. Exclusion criteria also contain

patients who are on hospice or palliative care as these patients would not be readmitted to the

hospital for worsening symptoms.

Steps in the study are as follows:

1. Patients will be recruited for the study via personal invitation from the researcher, during

inpatient hospitalization for heart failure exacerbation. Recruitment will be verbal and the

researcher will use a recruitment script to recruit patients for the study. The informed

consent form will be provided at this time, the patient will be given time to read, and

consider the consent in a quiet, private room. After all questions are answered, the patient

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will sign the consent if he or she feels comfortable doing so. Signing of the consent will

be witnessed by the researcher and dated and timed. The current relationship that exists

between the researcher and potential participants is a NP-patient relationship. The

relationship will remain the same for the purpose of this research, as the NP will be

conducting the GMA. Since this GMA does not take the place of any usual hospital

follow-up care, subjects should not feel coerced to participate in the GMA, because they

will still be able to attend their usual hospital follow up appointment. The researcher will

prevent subjects from feeling coerced by verbally assuring them that deciding not to take

part in the study will not preclude them from usual hospital follow-up care.

2. Each GMA will last 30 minutes and must have at least two participants to be considered a

GMA. Each GMA will be an education-only session regarding HF: including but not

limited to diagnosis, importance of medication compliance, diet compliance, daily

weights, and purpose of medications and treatments.

3. Each patient will attend one GMA within 30-days after hospital discharge.

4. At the end of each patient’s 30-day post hospitalization period the researcher will make a

phone call to each patient to assess if they were readmitted to the hospital.

5. Once a minimum of 15-20 patients have attended a GMA, data will be analyzed using

statistics to compare patient’s re-hospitalization rates to rates of patient’s who received

standard care hospital follow-up.

Data Collection Instruments

Data collection on HF readmission rates of patients who receive standard hospital follow

up care will take place by running an analysis of heart failure readmission rates at the local

hospital. The researcher will call each patient who participated in a GMA at the end of their

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respective 30-day post hospitalization period to assess if they experienced a hospital

readmission.

Research data will be recorded in paper format, and there will be a key that connects data

to the subjects’ names, which will be stored separately from the data. Data will be stored in a

secure location at the researcher’s place of employment, on a password-protected computer,

behind two locks. The data collection document will include codes for subject identifiers, the key

to the code will be stored separately and only the researcher will have access to it.

Three years after the conclusion of the study, data and consent forms will destroyed by

shredding it. Data will be reported in an aggregated format to protect participants’

confidentiality. The results will be shared with other students and faculty in the DNP program,

may be published for public access and will be presented at a professional presentation as part of

the requirements for the DNP degree.

Analysis Plan

Descriptive statistics will be utilized to compare readmission rates of patients who

receive standard post hospital care after HF hospitalization versus patients who attend a GMA

post hospitalization. A statistician, provided by Maryville University, will be utilized to run the

statistics and help interpret the results.

Resources

Resources needed for the study are printing the informed consent and use of a projector

to show a PowerPoint presentation to the study participants during the GMA. The GMA will

transpire in the outpatient setting of Hagerstown Heart, that allows for use of a conference room

for each GMA.

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Budget

A budget of $100 allotted for printed consent forms.

Timeline

1. IRB board approval: March 2018

2. Recruitment of patients and conduction of GMAs: March 2018 to May 2018

3. Analyze Data: May to July 2018

4. Write final report and present research: July 2018 through August 26, 2018

Protection Human Subjects

Risks of the study include breach of confidentiality, which will be minimized by the fact

that the GMA is an educational appointment only and patient’s medical information is not

analyzed for the purpose of the study. There is a risk for patient’s feeling uncomfortable learning

in a group setting. This risk is minimized by including in the consent form that patients have the

right to leave the GMA at any time. A potential benefit of this pilot study is preparing the way

for future research regarding HF 30-day readmissions and GMA, and thus possibly improving

outcomes for future HF patients.

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Chapter IV

The overall goal of the scholarly project was to determine if using GMA education

sessions for HF patients would decrease HF 30-day hospital readmission rates. The project was

a quantitative study that aimed to answer the following research question: “In adult heart failure

(HF) patients are group medical appointments (GMA) in addition to standard hospital follow up

care more effective in reducing 30-day hospital readmission rates when compared to standard

individual standard provider medical appointments?”

Data Analysis

The study was conducted in the intended outpatient setting. Participants attended one

outpatient group medical appointment education session within 30 days after hospital discharge

as approved by the Maryville University Institutional Review Board (IRB) and Meritus Medical

Center IRB. The outpatient setting was chosen as the ideal setting for multiple patients to attend

the same group education session. At the end of 30 days, the researcher pulled data from the

electronic medical record regarding each participant and whether or not they were readmitted to

the hospital.

Sample

The Maryville University IRB was approved on March 19, 2018 , and the Meritus

Medical Center IRB granted study approval on March 13, 2018. The time frame of this study

was from March 26, 2018 to May 24, 2018 and data was collected during this time. Even though

the sample size was very small (n=2), the study concluded after two months due to difficulties

29


recruiting enough patients able to attend a group session at the same time and participants

backing out of their commitment to the group education session.

The researcher used an excel spreadsheet to collect data and extracted data from the

electronic medical record (EMR). The following information was collected from the electronic

medical record: Participant name, age, phone number and hospital readmission status. Collecting

the same information for every patient ensured that data was collected in a consistent manner.

The intended sample size for the study was 15 participants. Due to issues recruiting

participants and difficulties organizing group education sessions at a time where multiple

participants could attend, only two patients attended the group education seminar. One potential

barrier to organizing a time when multiple participants could attend was each participant had to

be within the first 30 days after hospital discharge in order to be eligible to attend. This left a

narrow time frame for when a participant could attend a group session.

Results

Data collected measured if participants who attended the group education session had

been readmitted to the hospital within 30-days from discharge. Data was also collected about the

control group, patients with heart failure who did not attend a group education session and their

30-day hospital readmission status. The research question entailed assessing if attending a group

education session would lower HF patient’s rates of readmission to the hospital, and the

collected data measured that intended concept. The researcher intended to a z-test to compare

readmission rates for participants in the study to people in the control group. However, due to the

small sample size, statistics would not have had a significant result.

30


There where no data collection instruments used. Data was collected directly from the

electronic medical record and transferred to a excel spreadsheet document. The study did not

require use of an instrument because it directly measured participant’s hospital readmission rates.

Validity

When research is conducted, there are always concerns related to the validity of the

study. Validity in a study examines if appropriate inferences are made and validity can be

threatened if the study’s conclusion is wrong or inaccurate (Polit and Beck, 2017). Statistical

conclusion validity is the validity that a relationship between two variables exists, for example a

cause and effect relationship (Polit and Beck, 2017).

In this scholarly project, there is a threat to statistical conclusion validity because there is

a low statistical power. The goal for the study was to have 15 participants, but due to recruitment

issues and patient’s unavailability or unwillingness to come to the group education session, the

researcher was only able to conduct one group education session with two participants. This

small sample size is not large enough to run a statistical analysis and would give skewed results.

Thus, there are threats to validity, specifically statistical conclusion validity in this scholarly

project.

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Chapter V

HF readmissions continue to be on the rise (Ross et al., 2009) and around 50% of people

in the United States (US) die within the first five years of diagnosis. Currently there are 5.7

million adults in the US who have HF and HF costs the US around 30.7 billion dollars annually

(Centers for Disease Control and Prevention, 2016). A solution is needed to this problem or HF

readmissions will continue to rise, as will mortality rates and cost of healthcare.

Discussion

After thorough literature review, there were no previous studies found that specifically

address using GMA to reduce HF 30-day hospital readmission rates. In preparation for this

study, the researcher thoroughly reviewed previous research regarding GMA and HF 30-day

readmission rates. There were some common themes including GMA reducing HF

hospitalization rates, improving patients’ satisfaction and self care skills.

The goal of this scholarly project was to investigate if using GMA for HF patients within

their first 30-days after discharge would help lower HF 30-day readmission rates. Unfortunately,

the goal was not met due to a small sample size (n=2) not being large enough to run statistical

tests or come to a statistically significant conclusion.

Strengths

The researcger was able to conduct one GMA with two participants. Both participants

verbally affirmed how much they had learned after the GMA concluded and they felt better

educated about their HF. Though the sample size was too small to run any statistical tests, this

verbal affirmation from participants coincided with what was found during the review of the

literature and provides positive verification regarding using GMA to educate patients. This small

32


pilot study helped the researcger learn the advantages and pitfalls of doing research regarding

GMA and HF 30-day readmission rates and will help pave the way for future research.

Limitations

The largest limitation to the study was the sample size (n=2), which was simply too small

to draw any statistically significant conclusions from. The researcher had a difficult time

recruiting participants for the study and analyzed that this was due to several barriers. These

barriers included participants backing out of the study, only one participant at a time being

available for GMA, thus being unable to use the participant before 30-day window expired and

participants being less willing to attend GMA within the first several weeks after hospital

discharge. Unfortunately, due to the small sample size the researcher was unable to run any

statistical tests, thus there is a threat to statistical conclusion validity because of the low

statistical power.

Reliability

Another important part of research is examining if it is reliable. Reliability in research is

the degree to which scores for variables are the same after repeated measurements, in different

situations, scenarios and even by different people (Polit and Beck, 2017). The reliability in this

project was questionable as the researcher found it difficult to find people who were interested in

participating in the project. Results could have varied greatly depending on how many

participants agreed to attend the GMA and how many actually followed through and attended a

session.

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Application to Research

Future research on this topic is important and in order to avoid the same barriers

experienced during this scholarly project, a longer time frame would be needed to recruit

patients. It would be ideal for future research to take place over the course of a whole year, to

thus allow for more opportunities to conduct GMAs. Future research regarding GMA and HF

might also be done to assess patient’s compliance with their medical regimen, their satisfaction

with care and if they felt the GMA also served as a support group. Thus there is implication for

both quantitative and qualitative further research related to this topic.

Application to Practice

Evidence based practice regarding utilization of GMA for HF patients should be

implemented into the researcher’s current place of practice and the researcher intends to present

the findings of this study, along with the findings of the literature review to the attending

Cardiologist. The researcger intends to propose that GMA be implemented for all HF patients at

the practice on a quarterly basis in order to improve patient outcomes, self-care skills and patient

satisfaction.

Application to DNP

The DNP-prepared nurse will be equipped to lead the process of translating research into

practice. The researcher, as a new DNP-prepared nurse will help to close the research-practice

gap at her current place of practice. The researcher found knowledge from previous studies and

did further research on that same topic, which she hopes will lead to an improvement in practice

and implementation of evidence-based practice.

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Conclusion

This doctoral scholarly project was a pilot study to assess the feasibility of utilizing GMA

to lower HF 30-day hospital readmission rates. Participants each attended one GMA educational

session within the first 30 days after their hospital discharge. The goal was to compare hospital

readmission rate from study participants to standard hospital follow up readmission rates. Due to

the small sample size of the project, the researcher was unable to run any statistical testing. It is

worthwhile mentioning that both of the study participants (n=2) verbally praised the GMA and

mentioned they felt better educated about their diagnosis and care.

Previous research has been done regarding GMA within the heart failure population.

Several overarching themes found in the existing literature are that GMA reduces HF

readmission rates, has higher patient and staff satisfaction rates than conventional one-on-one

appointments and can improve patient’s self care skills. Two additional themes found were

retrospective studies can help decrease HF readmissions and early follow-up can reduce HF

readmissions. Utilizing GMA to conduct outpatient HF appointments can help provide better

patient education and treatment in order to produce better patient outcomes. There is a gap in the

literature that does not address specifically if 30-day hospital readmission rates are reduced when

GMA is implemented for adult HF patients, and further research is needed on this topic. The

DNP prepared nurse will play a vital role in furthering research and also implementing evidence

based findings from previous literature into current practice.

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Appendix A

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Appendix B

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Appendix C

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GROUP MEDICAL APPOINTMENTS FOR HEART FAILURE 43


Appendix D

Data Collection Spreadsheet

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