Six strategies may nip at heart failure readmissions

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 - Emergency

Hospitals potentially could lower their 30-day heart failure readmissions rate by two percentage points by following six strategies. “That may not seem like a lot,” the lead researcher told Cardiovascular Business, but applied to the costs of readmissions annually “you are looking at a fair amount of money and a significant clinical change.”

Preventable 30-day readmission for heart failure is one of three penalties now in place under Medicare’s Hospital Readmissions Reduction Program. Beginning in October, Medicare will increase the penalty for higher-than-expected readmission rates for heart failure, acute MI and pneumonia from 1 percent to 2 percent. The program was designed to rein in costs for these conditions.

Elizabeth H. Bradley, PhD, of the Yale School of Public Health in New Haven, Conn., and colleagues have been studying strategies that help to nudge down 30-day readmission rates for heart failure, which nationally hovers between 20 percent and 25 percent. In the July issue of Circulation: Cardiovascular Quality and Outcomes, the team reported results from a national survey of hospitals that explored the association between strategies and lower readmission rates.

Bradley et al contacted hospitals enrolled in the Hospital to Home National Quality Improvement Initiative and the State Action on Avoidable Rehospitalizations Initiative to participate in a web-based survey listing approximately 30 measures that fell into one of three domains: efforts to improve quality and monitor performance; medication management; and discharge and follow-up procedures. They used Centers for Medicare & Medicaid Services data to determine 30-day risk-standardized readmission rates (RSRRs).  

Between November 2010 and May 2011, 585 hospitals completed the survey. Their mean RSRR for heart failure was 24.7 percent, which matches the national average reported by Medicare. After adjusting for hospital characteristics and region, the researchers identified six strategies associated with lower readmission rates:

  • Partnering with community physicians or physician groups to reduce readmissions, for a 0.33 percentage point reduction in RSRR;
  • Partnering with local hospitals to reduce readmissions (0.34 reduction);
  • Making nurses responsible for medication reconciliation (0.18 reduction);
  • Arranging a follow-up appointment before discharge (0.19 reduction);
  • Having a process to send discharge summaries directly to the patient’s primary physician (0.21 reduction); and
  • Having staff assigned to follow up on results from tests returned after the patient is discharged (0.26 reduction).

Bradley said the results underscore the need to develop partnerships with other hospitals and medical groups involved in the patient’s care. “This is a systems issue,” she said. “We cannot just pin this on the hospital.” That requires better connections and communication with primary care providers and ensuring sufficient numbers and access to primary care services “so they actually can absorb patients leaving hospitals,” she added.

Only 7 percent of hospitals used all six strategies and less than 30 percent incorporated most of the six strategies. Researchers also noted some strategies associated with higher RSRRs:

  • Higher frequency of electronic linkages between outpatient and inpatient prescription records (0.18 percentage point increase);
  • Giving patients and their caregivers a written emergency plan at discharge (0.38 increase);
  • A reliable process for alerting outpatient physicians of the patient’s discharge within 48 hours (0.42 increase); and
  • Regular follow-up calls to the patient after discharge (0.34 increase).

Bradley said the team was surprised by what they described in the study as “this paradoxical finding.” They offered several possible explanations, including unintended consequences, reverse causation and flawed implementation or measurement of a strategy. Another possibility is that the strategies, which have been associated in other research with reductions, facilitated readmission by lowering barriers.

“We would never recommend that we do not do these [strategies] because they are good, but we must have a robust primary care system,” Bradley said. With a strong primary care component, a patient would contact his or her primary care physician rather than fall back on the hospital emergency department.

Bradley cautioned that their research is still in its early stage. She pointed to the need to have longitudinal studies that tracked not just strategies