1

April 2014:
Dear (Editor):

Registered dietitians (RDs) are the nutrition experts within the modern medical
profession; the knowledge and support they provide to patients and clients can often
make a pivotal difference in overall health. However, RDs often do not receive the credit
for that expertise which is deserved. As the healthcare industry and health insurance
have both been drastically changing over the past few years, preventative care has
become a more crucial part of the healthcare picture than ever before.
Post-inpatient education in an outpatient setting allows for patients to receive
more in-depth information than they are able to receive while admitted to the hospital,
for a much less-costly bill. The outpatient setting is, often, a less-stressful environment
for the patient to absorb that information as well. Some conditions, such a congestive
heart failure (CHF), can be greatly helped by making dietary changes; however, a
patient cannot make the correct changes for him or herself without the correct
knowledge to do so. Showing the correlation between receiving an outpatient RD
education session focused on a 2 gram sodium diet and lower readmission rates will
help raise awareness of the role RDs play in preventative outpatient care.
This study was conducted in fulfillment of requirements of the Aramark Distance
Learning Dietetic Internship. The study was conducted under the supervision of a
registered dietitian the hospital site as well as an Aramark Dietetic Internship Director.
The study was conducted with the hospitals permission. The information provided from
this study will help show that the hospital registered dietitian is making a difference by
helping lower inpatient CHF-related readmissions. Thank you for your consideration of
this manuscript.






Sincerely,

Brittany McCarel, BS, DTR (Corresponding Author)
Dietetic Intern
Aramark Healthcare Distance Learning Dietetic Internship
McCarel-Brittany@aramark.com

Michelle Schelling, RD, CD
Aramark Registered Dietitian

Allison Charny, MS, RD, CDE, CDN
Regional Director
Aramark Healthcare Distance Learning Dietetic Internship
Charny-Allison@aramark.com



2

Research Practice and Innovation
Congestive heart failure, registered dietitian, outpatient, readmission
Original Word Count: 2,544
(Note: This document has been edited to be posted on a public professional portfolio.)


Do participants in the multidisciplinary CHF Care Transitions Clinic who attend an
outpatient appointment with the registered dietitian experience fewer hospital
readmissions in comparison to non-attendees?
















Brittany McCarel, BS, DTR (Corresponding Author)
Dietetic Intern
Aramark Healthcare Distance Learning Dietetic Internship
McCarel-Brittany@aramark.com

Michelle Schelling, RD, CD
Aramark Registered Dietitian

Allison Charny, MS, RD, CDE, CDN
Regional Director
Aramark Healthcare Distance Learning Dietetic Internship
Charny-Allison@aramark.com


3

Do participants in the multidisciplinary CHF Care Transitions Clinic who attend an
outpatient appointment with the registered dietitian experience fewer hospital
readmissions in comparison to non-attendees?

Abstract:
The Affordable Care Act is changing todays healthcare climate by placing a high
priority on multidisciplinary outpatient services to lower costs by minimizing preventable
disease complications. The purpose of this study was to observe if attending a
scheduled appointment with a registered dietitian as a part of a congestive heart failure
focused outpatient clinic correlated with lower incidence of inpatient hospital
readmission. At my hospital site, 26 patients of both genders between the ages of 32-94
years of age were scheduled for an appointment with the clinics registered dietitian
between August 2013 and January 2014. Each patients appointment attendance was
noted, as was whether he or she readmitted to the hospital within 30 days of the
scheduled appointment.
While 13.6% of patients who did attend their appointments readmitted within the
allotted time window, 25% of patients who did not attend their appointments readmitted
within the time window. The results of this study show the possible impact of the
registered dietitians role in the multidisciplinary approach toward treating congestive
heart failure. Similar studies could be conducted to further assess the tangible impact of
registered dietitians on multidisciplinary outpatient chronic disease management and
inpatient readmission prevention.



4

Do participants in the multidisciplinary CHF Care Transitions Clinic who attend an
outpatient appointment with the registered dietitian experience fewer hospital
readmissions in comparison to non-attendees?

Introduction:
Providing patients with the best care and outcomes possible while working within
a financially sound business model has always been an integral component of
healthcare. However, this component has become an even more crucial focus over the
past few years. As stated by Orszag and Emanuel, the Affordable Care Act (ACA) was
signed into effect on March 23
rd
, 2010
1
; the authors explain that this bill is designed not
only to lower current costs in healthcare, but to slow the rate of healthcare cost inflation
for the future
1
.
Not surprisingly, Orszag and Emanuel inform that for current cost and future
inflation to change, the way that healthcare is administered will have to change as well
1
.
They reveal that health care costs are unevenly distributed: 10% of patients account for
64% of costs
1(pp 602)
. These high-cost patients often have chronic conditions, such as
congestive heart failure (CHF)
1
. Orszag and Emanuel elaborate that preventatively-
focused care will take a bigger role with the new system of healthcare; they state that,
by halting the chance for many preventative health issues to develop, healthcare costs
will drop as a result
1
.
My hospital site is a small hospital within a low income socioeconomic area.
Giving care to those who do not always have insurance coverage or the personal
finances to take care of themselves is very important to its healthcare providers. This is


5

an altruistic position to uphold; however, one large way this decision relates to hospital
operations is that the hospital has a tighter budget model than many of those either
within higher socioeconomic areas or with less charitable stances on providing care. In
addition, the hospital was number one for CHF-related hospital readmissions within the
state, according to information delivered during a hospital meeting in 2013. This is the
kind of statistic that calls for immediate action, even without the changing climate of
healthcare that the Affordable Care Act is initiating. To make matters even more
pressing, Orszag and Emanuel disclose that payment penalties on hospitals with high
risk-adjusted readmission rates will be instated
1(pp 603)
.
In light of this information, it comes as no surprise that a more proactive method
of managing CHF-diagnosed patients started at St. Margaret Hospital during the latter
half of 2013. When a CHF-diagnosed patient comes as an inpatient to the hospital, a
clinical dietitian recommends that the patient be placed on a 2 gram sodium diet
restriction, and then signs a sheet in the paper chart verifying that this recommendation
has been placed. Second, the patient is scheduled to see the clinical dietitian following
discharge (along with professionals of other healthcare disciplines) to help the patient
effectively manage his or her CHF. Following up with the dietitian (and other healthcare
professionals) in an outpatient setting post-discharge is theorized to prevent or
decrease further CHF-related readmissions. This research study will investigate if
patients who participate in their outpatient appointment with the registered dietitian, as a
part of the CHF Care Transitions Clinic (CTC), have fewer readmissions than those who
do not attend their scheduled appointment.


6

Several studies have been conducted in relation to congestive heart failure; this
suggests that the issue of CHF is pertinent not only at this hospital, but also nationwide.
The following six studies primarily focused on CHF in relation to hospital readmission,
but readmission was not the exclusive focus. Also, many of these studies focused on a
home-based intervention instead of one non-home based outpatient care. These
studies were similar enough to the research at this hospital to suggest an expected
result, but different enough that this study is still needed.
The first study reviewed was titled, A Multidisciplinary Intervention to Prevent the
Readmission of Elderly Patients with Congestive Heart Failure. Rich and colleagues
conducted research on a total of 99 patients who were 70+ years of age
2
. They were
first screened and confirmed as having a definite diagnosis of CHF with one risk factor
for early readmission to the hospital
2
. The intervention group received interdisciplinary
treatment based on education and follow-up; control group participants were eligible to
receive all standard treatments and services ordered by their primary physicians, Rich
and colleagues assured
2(pp 1190-1191)
. Patients were followed for 90 days after leaving the
hospital; reason for readmission was assessed for those who returned to the hospital
during this time frame
2
. At the end of the study, control group patients had more hospital
readmissions than intervention group patients, more control group hospitalizations were
related to CHF, and control group healthcare costs were higher
2
.
The second study reviewed was titled, Effects of a multidisciplinary, home-based
intervention on planned readmissions and survival among patients with chronic
congestive heart failure: a randomized controlled study. Like in the first study above,
Stewart and colleagues had one group that would receive a multi-disciplinary outpatient


7

approach, and the control would have access to usual care
3
. However, Stewart and
colleagues used a 6 month follow up time frame instead of a 90 day follow up time
frame
3
. Like in the first study, Stewart and colleagues intervention group also had fewer
readmissions and far lower healthcare costs than the corresponding control group
3
.
The third study, Differences in the Incidence of Congestive Heart Failure by
Ethnicity: The Multi-Ethnic Study of Atherosclerosis, took a different focus. Bahrami
and colleagues had 6814 participants from various ethnicities that did not have a history
of CVD at the studys start
4
. After an average of a 4 year timespan, the researchers
evaluated how many patients had developed CHF
4
. By CHF occurrence rate over that
time period, African Americans had the highest occurrence rate, with Hispanics in
second, Caucasians in third, and Chinese Americans with the lowest rate
4
.
The fourth study reviewed was titled, Decreased Readmissions and Improved
Quality of Care with the Use of an Inexpensive Checklist in Heart Failure. Basoor and
colleagues used a sample size of 96 randomly chosen patients to assess if physician
checklist utilization lowered CHF readmissions and increased the quality of care
5
.
Basoor and colleagues explained that the list was made to remind physicians of
documentation regarding medications and dose uptitration, relevant counseling, and
follow-up instructions at discharge
5(pp 200)
. The checklist was associated with lower 30
day and 6 month readmissions for the intervention group, along with better care quality
for intervention group patients
5
.
The fifth study reviewed was titled, Preventable Hospitalizations for Congestive
Heart Failure: Establishing a Baseline to Monitor Trends and Disparities. In this study,
Will and colleagues discussed race-related hospitalization trends over 15 years
6
. The


8

researchers found that roughly three of four hospital stays were by those of at least 65
years old, that blacks had far higher rates of preventable CHF hospitalizations than
Caucasians, and that preventable CHF hospitalization rates are declining in whites
more than blacks
6(pp E85)
.
The sixth and final study reviewed was titled, Early readmission of elderly
patients with congestive heart failure. Vinson and colleagues stated that while CHF is
one of the most common reasons for early hospital readmissions in the elderly,
variables identifying patients at increased risk and an analysis of potentially remediable
factors contributing to readmission (had) not previously been reported
7(pp 1290-1295)
.
Vinson and colleagues concluded that of the readmissions they studied, 38% may have
been preventable and 15% were likely preventable
7
. Factors the researchers found
which likely contributed to these readmissions included medication noncompliance, diet
noncompliance, poor discharge planning, poor discharge follow up, inadequate social
assistance, and not obtaining medical counsel in a timely manner following symptom
flare ups
7
.
Will and colleagues stated that preventable hospitalization for congestive heart
failure (CHF) is believed to capture the failure of the outpatient health care system to
properly manage and treat CHF
(pp E85)
. Between ACA-related payment penalties on
hospitals with high risk-adjusted readmission rates
1(pp 602)
foretold of by

Orszag and
Emanuel, the hospitals notable number of CHF-related readmissions, and the hospital
having a largely African American and Hispanic population (for whom CHF incidence is
higher than average
4
), the sites need for CHF-related research is justified. I expect that
the patients who do choose to attend their appointment with the CTC dietitian will


9

experience less CHF-related readmissions as a group than those who do not choose to
utilize this resource.
In conclusion, the research question for the study stands: Do participants in the
multidisciplinary CHF Care Transitions Clinic who attend an outpatient appointment with
the registered dietitian experience fewer hospital readmissions in comparison to non-
attendees?

Methodology:
The evaluation research design method was utilized for this research project.
The research evaluated patients who had their CTC appointment with the dietitian
scheduled within an approximate 5 month time window (August 28
th
through January
29
th
). The initial date was chosen because this date was when the CTC dietitian first
started seeing patients for the program. The end date was chosen to provide for
adequate time between the last patients scheduled appointment date, the subsequent
30 day window within which readmission could occur, time for dissemination of data,
and the ability to report results by the appropriate time. Percentages of readmission
were compared between the attendee group and non-attendee group. To assess
gathered data, a tool was utilized to track each patients sex, age, for which date a
patients CTC dietitian appointment was scheduled, and if a patient experienced a
hospitalization within 30 days of his or her scheduled CTC dietitian appointment. The
gathered data was analyzed using Microsoft Excel using descriptive statistics.
Candidates who met inclusion criteria were 18- to 99-year-old males and females
who had admitted to the hospital with a dx of CHF. Exclusion criteria included being an


10

age of below 18-years-old or over 99-years old, a patient having no CHF diagnosis, or a
patient having no admission to the chosen hospital site. Considering the relatively small
number of patients that the hospital serves at any given time, data was analyzed
utilizing the entire population of patients for whom a CTC dietitian appointment was
scheduled. No patients in the population violated the inclusion or exclusion criteria.
Resources that were needed to implement the project include the site, tools
which helped organize and assess data, a GANTT chart which aided with time-
management, the use of a facility computer on-site, and a letter granting permission to
conduct research on-site. No additional funding or resources were necessary.

Results:
A total of 26 patients were scheduled to see the CTC registered dietitian on dates
between August 2013 and January 2014. Of the patient population, 20 were male and 6
were female. The patients ages spanned between 32- 94 years (a range of 62 years),
and the mean age was 61.2-years-old (Note: Recorded patient ages were those as of
each patients scheduled appointment day.)
A total of 22 patients chose to attend their appointments, while 4 patients chose
not to attend their appointments. A total of 22 patients did not readmit from the hospital
within the 30 day window, while 4 patients did readmit to the hospital within the time
window. Only 13.6% of appointment attendees readmitted to the hospital within the
allotted time window, while for non-attendees, the percentage of readmission incidence
was nearly doubled at 25.0%.



11

Discussion:
The findings of the research supported the theory that attending a scheduled
appointment with the CTC registered dietitian correlated with being less likely to readmit
as an inpatient to the hospital within 30 days of the scheduled appointment. As stated
above, Rich and colleagues used a 90 day post-discharge evaluation period
2
and
Stewart and colleagues used a 6 month post-discharge period
3
; both observed the
effects of a multidisciplinary outpatient approach. Although the evaluation period used
here was far shorter and observed for readmission correspondence only in relation to
an RD outpatient education, screening only for participation alone in this one
educational facet shows a positive link.
Strengths of this study include the subject of the study (CHF-related
readmissions) being very pertinent to not only the selected research site but also the
current time period, excellent documentation by the CTC dietitian of attending and non-
attending patients, and efficient yet effective study design. Limitations include a small
population size, uneven distribution of the attending and non-attending groups, not
knowing whether or not non-readmitting patients expired during the 30 day window, not
knowing whether or not non-readmitting patients readmitted to a different hospital during
the 30 day window, and time limitations within which to observe available data. For
example, time constraints created an inability to observe most 90 day post-appointment
readmission rates, as well as an inability to observe nearly any 6 month post-
appointment readmission rates.
Although the CHF Care Transitions Clinic is still very new, the results of this
study are very promising. They provide the first glimpse into positive correlations


12

between attending a CTC dietitian appointment and a lower incidence of inpatient
readmission to the hospital within 30 days.

Conclusion:
In the midst of the new Affordable Care Act and the subsequent changing climate
of healthcare today, registered dietitians should be mindful of possible opportunities that
could develop in the outpatient setting focused on multidisciplinary disease
management. Recommendations for further related research could include comparing
readmission rates of clinics at different sites, studying optimal appointment length with
the registered dietitian in correlation with readmission rates, or studying if different
educational approaches to CHF-related teachings correlated to lower readmission rates
within at-risk populations (based on sex, age, race, or ethnicity). In conclusion, this data
points toward the registered dietitian being an important player within the
multidisciplinary approach toward disease management and inpatient readmission
prevention during this new era of healthcare.










13

Tables and Figures:






















Table 1.
Appointment Attendance relating to Readmission Rates
Number of
Patients who:
Did Attend
Appointment
with CTC RD:
Did Not Attend
Appointment
with CTC RD:
TOTAL:
Did Readmit
within 30 Days
Post-
Appointment:

3

1

4 (15.3%)
Did Not
Readmit
within 30 Days
Post -
Appointment:

19

3

22 (84.6%)

TOTAL:

22 (84.6%)

4 (15.3%)

26
Table 2.
Attendees: Readmission vs. No Readmission

Readmission

3

No Readmission

19

Total Attendees

22

Percent Incidence of
Readmission

13.6%
Table 3.
Non-Attendees: Readmission vs. No Readmission
Readmission 1
No Readmission 3
Total Attendees 4
Percent Incidence of
Readmission
25%


14
























Table 4.
Population: Male vs. Female
Male 20
Female 6
Total 26
Table 5.
Population: Patient Volume by Age Group
30-39 years 1
40-49 years 6
50-59 years 5
60-69 years 7
70-79 years 2
80-89 years 3
90-99 years 2


15

References:
1. Orszag PR, Emanuel EJ. Health Care Reform and Cost Control. New England
Journal of Medicine. 2010; 363:601-603.
2. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, and Carney RM. A
Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with
Congestive Heart Failure. New England Journal of Medicine. 1995; 333: 1190-1195.
3. Stewart S, Marley JE, Horowitz JD. Effects of a multidisciplinary, home-based
intervention on planned readmissions and survival among patients with chronic
congestive heart failure: a randomized controlled study. The Lancet. 1999; 354
(9184): 10771083.
4. Bahrami H, Kronmal R, Bluemke DA, Olson J, Shea S, Liu K, Burke GL, Lima JAC.
Differences in the Incidence of Congestive Heart Failure by Ethnicity: The Multi-
Ethnic Study of Atherosclerosis. Archives of Internal Medicine. 2008; 168(19): 2138-
2145.
5. Basoor A, Doshi NC, Cotant JF, Saleh T, Todorov M, Choksi N, Patel KC,
DeGregorio M, Mehta, RH, and Halabi AR. Decreased Readmissions and Improved
Quality of Care With the Use of an Inexpensive Checklist in Heart Failure.
Congestive Heart Failure. 2013; 19: 200206.
6. Will JC, Valderrama AL, Yoon PW. Preventable Hospitalizations for Congestive
Heart Failure: Establishing a Baseline to Monitor Trends and Disparities.
Preventative Chronic Disease. 2012; 9: E85.


16

7. Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of
elderly patient with congestive heart failure. Journal of the American Geriatrics
Society. 1990; 38(12):1290-1295.