Coordination (or Bust) for HF Readmission Reduction

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 - Going over Record

Acute decompensated heart failure (HF) is a complex disease state with multiple comorbidities contributing to cardiac dysfunction and poor outcomes. Due to its high prevalence and complexity, HF is the most common reason for rehospitalizations in the U.S., leading to hefty expenses for private payors and the overall healthcare system. Therefore, providers and payors are seeking better management strategies for these patients to reduce preventable readmissions and mortality through improved, protocol-driven coordinated care throughput inpatient and outpatient settings.

The problem

More than one million people are admitted to the inpatient setting for HF annually, according to Centers for Disease Control and Prevention 2006 statistics, and HF is the leading cause of hospitalization for people 65 years and older. Approximately 25 percent of Medicare patients with HF are readmitted within 30 days (N Engl J Med 2009;360[14]:1418-1428), and the rates of hospital readmission within six months range from 25 to 50 percent (J Am Coll Cardiol 2001;38:2101-2113). Despite efforts on the part of healthcare facilities to reduce rehospitalizations, unplanned readmissions cost Medicare $17.4 billion a year (N Engl J Med 2009;360[14]:1418-1428). As problematic, the 60- to 90-day post-discharge mortality rate remains as high as 15 percent (JAMA 2006;296[18]2217-2226).

These statistics are leading many to question how to better manage the HF patient population, including federal government agencies that have placed greater emphasis on transparency. Specifically, CMS and the Joint Commission have started publicly reporting patient satisfaction, mortality rates and readmission rates, as well as quality measures.

The government has been looking for additional ways to drive down readmissions. As early as 2012, CMS is putting into effect a new readmission policy, where hospitals with a higher rate of risk-adjusted, all-cause rehospitalizations will receive lower reimbursement. Thus, hospitals with low rates of rehospitalizations will receive greater reimbursements and there will be penalties for hospitals with overall higher readmission rates.

"Establishing a policy that would simply not reimburse for HF readmissions within the first 30 days would falsely convey that every rehospitalization for HF is preventable, which is wrong," explains Gregg C. Fonarow, MD, director of Ahmanson-University of California, Los Angeles (UCLA) Cardiomyopathy Center. "Even with the most intensive care and newest therapies, treating heart failure is still challenging, as complications will ensue and gaps can occur. Nevertheless, many HF hospitalizations are preventable and there are substantial opportunities to improve care and outcomes for HF."

Additional national drivers may alter how providers deal with HF readmissions, including the Recovery Audit Contractor programs, bundled payments, care management models, patient-centered medical homes and accountable care organizations (ACOs).

Treating the whole patient

Acute decompensated HF is "a manifestation of diverse and complex cardiac and noncardiac conditions," leading Gheorghiade and Peterson to classify the disease as "acute HF syndromes," as opposed to a single syndrome (JAMA 2011;305[23]2456-2457).

Observed Hospital-specific 30-Day All-Cause Readmission Rates
for Fee-for-service Medicare Beneficiary Discharges After HF Hospitalization
Observed Readmission Rate Overall 2004 2005 2006
Mean 23.1% 23% 23.3% 22.9%
Median (50th percentile) 23.1% 23.1% 23.3% 22.9%
25th percentile 18.6% 18.7% 18.8% 18.2%
75th percentile 27.5% 27.3% 27.8% 27.3%
Source: Circulation: Heart Failure 2010; 3:97-103

"Terminology is one of the biggest problems in this specialty because heart failure does not directly address the patient's clinical problem," says Mihai Gheorghiade, MD, director of experimental therapeutics at the Center for Cardiovascular Innovation at Northwestern University Feinberg School of Medicine in Chicago. "Therefore, physicians attempt to treat the failure, and do not assess the heart holistically." HF can result from a weak heart muscle itself, but also from abnormal valves or blockages of the coronary arteries that supply the heart muscle with oxygen, he adds, which need to be identified and treated uniquely based on each patient's needs.

For patients hospitalized for HF, Gheorghiade recommends identifying three components: the cause of the HF (i.e., weak heart muscle or