Since CMS began publicly reporting hospital readmission rates for heart failure in 2009, a greater emphasis has been placed on quality initiatives that can help curb them. But are readmission rates the best metric by which to judge hospital quality?
When to follow-up?
Heart failure (HF) is the No. 1 readmission diagnosis, which is related to a strong disconnect between hospitals and private practice settings, ultimately resulting in a lack of coordinated care, says Adrian Hernandez, MD, of the Duke University School of Medicine in Durham, N.C. “There is no systematic protocol for early follow-up of heart failure patients. But it’s sometimes as simple as making a phone call when a patient misses an appointment,” he says.
Early follow-up is integral to decreasing readmissions, says Hernandez. He and colleagues found that patients were readmitted less often if they were followed up within seven days by any type of physician—primary care, general internist or cardiologist. Interestingly, those patients followed up by cardiologists had a lower 30-day mortality rate (JAMA 2010;303(17):1716-1722). “The ideal follow-up is within one week from discharge,” says Hernandez. “We saw an association with fewer readmissions at 14-day follow-up, which became weaker the further out from discharge.”
Hernandez calls the first week of discharge “crucial” for evaluating patient status. “Patients are no longer under 24-hour hospital supervision. They may not have picked up their medications or they may not have followed up on a test. Early evaluation should include a review of therapeutic changes and a thorough assessment of the patient’s clinical status outside of the highly structured hospital setting.”
While HF readmissions can be dangerous and costly—soaking up an estimated $17.4 billion, or 5 percent of total Medicare spending—a majority of them are preventable. Practitioners are now emphasizing a multidisciplinary approach, comprising cardiologists and other physicians, nurse practitioners, nutritionists/dieticians and pharmacists, among others. “Disease management programs are so effective because they are not focused on a one-size-fits-all solution. Instead, the team works to individualize a patient’s problems and examine why they lead to readmissions, along with how they can be alleviated,” says Barbara Riegel, MD, a professor at University of Pennsylvania School of Nursing in Philadelphia.
Patient education also is key to preventing rehospitalization, says Riegel. “We need to change behavior. We need to urge patients to follow a strict low-salt diet and guide them to take medications properly, in addition to using a team-based approach to care.”
In a 2009 meta-analysis published in Health Affairs, Riegel and colleagues found that patients in a disease management program had 25 percent less all-cause readmissions and 30 percent less readmission days. The team-based approach reduced HF readmissions specifically by 2.9 percent and readmission days by 6.4 percent per month. Riegel estimated that the 2.9 percent reduction per month in HF readmissions could lead to 14,700 to 29,140 fewer hospital stays per year.
A BOOST from Michigan
In May, the University of Michigan in Ann Arbor, Blue Cross Blue Shield of Michigan and the Society of Hospital Medicine (SHM) announced the Michigan Transitions of Care Collaborative, or MTC2, a training and mentoring program where physician groups and hospitals share best practices in an effort to reduce hospital readmissions and ER visits.
The initiative, based on SHM’s Project BOOST (Better Outcomes for Older Adults through Safer Transitions), involves 15 physician organizations working with 14 hospitals across the state. “The idea is to help patients get better prepared to move from the closely observed setting of the hospital back to their home,” says Christopher Kim, MD, an assistant professor of internal medicine and pediatrics at the University of Michigan and the program director of MTC2.
Project BOOST reports 30-day readmission rates, patient satisfaction, length of stay and other process metrics on a quarterly or monthly basis to help identify specific trends and provide transparency within hospitals.
Other strategies/programs utilized include:
- Teach Back, which involves getting patients to describe important steps they need to take to ensure a smooth transition from hospital to home;
- Preparations to Address Situations (after discharge) Successfully, or PASS, which helps patients understand