Strategies to reduce 30-day HF readmission largely ineffective

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A telephone survey of participants in the Get With the Guidelines-Heart Failure Registry (GWTG-HF) found no correspondence between the improvement processes the hospitals implemented and rates of unplanned readmission for heart failure (HF) within 30 days post-discharge.

Hospital readmission rates for HF patients remain high, despite an overall decline of HF hospitalizations over the past decade. Noting that reducing expensive, preventable unplanned readmissions is a focus of national quality improvement efforts, the authors attempted to identify a link between improvement processes hospitals commonly employ and a reduction in unplanned readmissions. 

Robb D. Kociol, MD, of Beth Israel Deaconess Medical Center in Boston, and colleagues conducted a focus group to explore potential care process variables to survey. On the basis of the comments of the focus group, they selected inpatient care and education, discharge and transitional care and general quality improvement efforts as the domains that would be the focus of the survey. A draft survey was circulated among eight providers that included clinicians, clinical investigators, outcomes researchers and nursing experts.

With input from the group, the researchers further refined the survey, and questions were selected by an HF physician investigator and reviewed by two other physician investigators.

The study group comprised 100 facilities nationwide that were participating in the federal Get with the Guidelines Program, a quality improvement initiative focused on identifying and implementing care processes to reduce unplanned readmissions for HF patients. The participating facilities were randomly selected from those that had reported at least 40 HF admissions to GWTG-HF. Of the participating hospitals, 28 were academic medical centers, 64 were community hospitals, three were private tertiary care centers and five were other hospital types.

Using the GWTG-HF list of institutional contacts, trained interviewers conducted the survey over the telephone between March and October 2010 regarding care processes. The participants were questioned about:

  • Who was responsible for providing inpatient care to HF patients;
  • What sort of information is included in inpatient education efforts;
  • How is such information conveyed;
  • Discharge process and education;
  • Who is responsible for providing discharge instructions;
  • Post-discharge follow-up practices; and
  • Description of general quality improvement efforts.

Respondents were scored within each of the three domains, receiving points for each initiative within the domain that their facility employed. Physicians reviewed the recorded text responses to ensure accuracy in scoring.

The hospitals surveyed reported an average 24.2 percent rate of readmission within 30 days for HF patients. According to the authors, “We found no significant associations between individual processes and short-term readmission rates. Among the three domains (i.e., inpatient processes, discharge and transitional care processes and general quality improvement) only processes in the discharge and transitional care domain had even a modest association with lower readmission rate.” 

The authors noted that their study, published online in Circulation: Heart Failure on Aug. 28, had limitations. Among them: the relatively small sample size, respondents who may not have had full knowledge of all their institutions' quality improvement efforts and the fact that the survey was administered in 2010 and the readmission data was from 2005-2008.  

At least one larger recent study, published online in The Cochrane Review Sept. 12, found some interventions effective at reducing unscheduled readmissions of HF patients. Based on a database review of 25 trials (5,942 patients), the researchers found that nurse-led case management type interventions lead to decreased unscheduled HF readmission at six months and 12 months post-discharge. This study did not analyze 30-day readmission rates.

Beginning in October, Medicare will begin efforts that tie payments to 30-day HF and acute MI readmission rates. The October issue of Cardiovascular Business reviews programs that aim to improve outcomes and lower readmissions rates. To learn more, go here.