Readmissions & reassessing PCI practices

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Candace Stuart, Editor

Earlier this month, analysts at Fitch Ratings shared information that informed their outlook on the fiscal health of nonprofit hospitals and health systems in 2013. They foresaw a stable year, barring deep cuts in Medicare and Medicaid.

They described penalties for preventable readmissions for heart failure (HF) and acute MI as “fairly small in 2013 and are not expected to have a material impact on the sector’s financial performance.” I am not sure hospitals are as confident. While Medicare will withhold only 1 percent of reimbursement to underperformers in 2013, the penalty will grow to 2 percent and 3 percent in 2014 and 2015. Future penalties likely will target CABG, too. And even 1 percent will pinch. 

However, penalties for HF readmissions may be misplaced. A study based on Veterans Affairs data found that hospitals could simultaneously improve hospital length of stay and readmissions for HF and acute MI, but there appeared to be a sweet spot for achieving both efficiency and quality. Hospitals with a mean risk-adjusted length of stay that was a day lower than the average had a 6 percent higher readmission rate compared with hospitals with an average length of stay. Patients with longer than average lengths of stay had higher readmission rates.

In an interview with Cardiovascular Business, lead author Peter J. Kaboli, MD, of the Iowa City Veterans Affairs Healthcare System in Iowa City, Iowa, said that the relationship between longer initial hospitalizations and a higher likelihood of readmissions made sense: the patient were sicker. What may appear to be excessive stays and preventable readmissions may actually be the physician understanding what is best for his or her patient.

In his view, hospital readmissions “are a poor marker of quality” because they fail to account for many factors involved in caring for patients. “Just focusing on readmissions is probably not a very efficient use of our resources,” he said.

An unrelated study also questioned whether HF readmissions should be seen as a marker of poor quality. The study was designed to tease out which interventions in heart failure clinics improve outcomes, based on real world data that encompassed the heterogeneity of clinics and interventions. They found that treatment at clinics was associated with a small reduction in mortality, and that greater involvement of caregivers and more comprehensive self-care education programs were associated with increased hospitalization.

The authors suggested that these interventions helped to screen patients in need of care early, which led to more readmissions. “In this setting, one can argue that these hospitalizations are not avoidable, but may be an important mediator of improved survival,” they wrote.

On another note, please be sure to read the meta-analysis on clopidogrel and PCI, which reinforced that patients pretreated with clopidogrel before PCI experienced fewer major cardiac events although there appeared to be no increased mortality benefit. Their findings may prove relevant in clinical practice; they determined that the primary benefit was to the sickest patient, and questioned if systematic clopidogrel pretreatment was needed in low-risk patients.

We will conclude this year’s newsletters with a Top 10 list of stories from our magazine and website. Look for our e-newsletter on Friday.

We’re looking forward to 2013 and the opportunity to provide you with information that will help you better manage patients and practices throughout the year.

Candace Stuart

Cardiovascular Business, editor