By Howard Rodenberg, MD, MPH, CCDS for CDI Blog
I just finished reading a book by the historian H.W Brands called The General and the President. It’s a tale of conflict between President Harry S. Truman and Douglas MacArthur, the American commander-in-chief during the Korean War. As you may recall, Truman fired the general after the latter had overstepped his bounds. While history has more than vindicated Truman, the contemporary reaction was strongly in favor of the general. MacArthur returned to a hero’s welcome. And in a valedictory address to a joint session of Congress, he ended by citing lines from an old Army ballad: “Old soldiers never die; they just fade away.”
In a similar fashion, there are a number of medical terms that have overstepped their bounds and should just fade away. One of these is “congestive heart failure.”
(Yes, I get that it might be a poor analogy, that medical terminology did not help win the War in the Pacific, nor threaten to bomb the living daylights out of China. But I’m trying to be erudite here, to show that I occasionally read something other than Facebook posts, comic books, and the ICD-10-CM Official Guidelines for Coding and Reporting. Throw me a bone.)
Let’s start by breaking the phrase down into pieces. Heart failure (HF) can be defined as “a syndrome caused by cardiac dysfunction, generally resulting from myocardial muscle dysfunction or loss and characterized by either left ventricular dilation or hypertrophy or both.” (That’s the fancy, doctor-cocktail-party way of saying the heart doesn’t pump very well).
HF may be further subdivided by time into acute and chronic HF. Chronic HF has been subject to a multiplicity of definitions and classifications, including Killip Classes and the New York Heart Association (NYHA) system. In contrast, the definition of acute HF is more elusive, and might best be categorized simply as a state of “decompensation” that presumes the prior presence of chronic HF.
HF may also be categorized by the left ventricular ejection fraction. Patients may exhibit HF with reduced election fraction (HFrEF) or with preserved ejection fraction (HFpEF). HFrEF and HFpEF correlate to the older terms of systolic and diastolic failure, respectively.
“Congestive” is more problematic. In this context, “congestion” refers to a constellation of signs and symptoms resulting from volume overload and relative stasis within the vascular tree. Fluid backup in the pulmonary system produces dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND), tachypnea, and pulmonary rales on physical exam. Volume excess within the hepatic system results in elevated liver function tests and ascites; the extremities show edema and long-term skin changes consistent with venous stasis.
This would not be an issue in and of itself if the term “congestion” had not become irrevocably stapled to the words “heart failure.” In fact, there are any number of clinical conditions that can lead to congestive symptoms in the absence of heart failure. To label these patients with “CHF” is to establish an inappropriate diagnosis.
To simplify my thinking, I tend to think of “congestive” symptoms as being intrinsic or extrinsic to the heart. Intrinsic causes are those which truly lie within the heart itself, such as a worsening of chronic HF or HF prompted by myocardial infarction or hemodynamically significant valve disease. Extrinsic causes of congestive symptoms can include volume overload from missed dialysis, medical non-compliance, dietary indiscretions, pulmonary embolism, or tachycardic states such as dysrhythmias, sepsis, or profound anemia where ventricular filling time is impaired, resulting in volume backup within the vascular tree.
Noting the presence of “congestion” does describe a clinical picture of volume overload but adds nothing in terms of knowledge of the underling pathology, functional status of the heart, or a clear path of care. It’s critical not to simply paste the term “CHF” on a case based on the symptom complex and not the underlying cause of the problem. When a CDI specialist finds “CHF” used in a scenario that might suggest an alternate diagnosis, a query would be a reasonable approach. It’s important that there also be an educational effort directed at hospital-based physicians to redirect their terminology to more clinically appropriate labels.
(In my experience, this is one of those times our cardiology colleagues have taken the lead, as only rarely do I find the term “CHF” in their notes. Within hospitalist documentation, “CHF” is as ubiquitous as commercials for injury attorneys and male enhancers on sports radio.)
Identifying a specific etiology of heart failure symptomatology is important clinically, but it’s also a significant driver of institutional performance. The CMS Hospital Readmission Reduction Program looks at 30-day all-cause readmissions for patients with selected principal diagnoses. Heart failure is one of these indexed conditions, with inclusion in the cohort based on a list of HF-related ICD-10 codes. Excessive readmissions within a selected cohort triggers a readmission penalty. When a patient whose principal diagnosis is represented by one of these codes is readmitted within 30 days of discharge, the readmission is counted towards the penalty.
Hospitals may also participate in bundled payment models. The CMS Bundled Payment Care Initiative-Advanced (BPCI-A) establishes a fixed sum to pay for the care of patients with specified clinical conditions within a 90-day window following an index admission. If the total costs of care (including inpatient, outpatient, home health, and skilled nursing services) during that period are less than the specified price point, the participant health system receives the additional revenue; if costs exceed the designated values, the health system must pay the excess as a penalty. It’s clear that for different measures and models, securing an appropriate principal diagnosis on patients with congestive symptoms is key.
A final thought: While some medical terms may need to be revised, that doesn’t mean I’ll always favor their replacements. The latest fad in this category is the phrase “short of air,” which I understand is new-fangled, whipper-snapper way to say what used to be called “short of breath.” I don’t know for sure, but I think the reason for the change is that in the era of open medical records, the average patient has no idea what SOA means, while everyone’s pretty sure about SOB. As a literalist and grammar nerd the term drives me nuts. Unless you’re in outer space, there’s plenty of air. It’s just a matter if you can breathe it or not.