Hospitals implement only half of key AMI, HF practices
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On average, hospitals implement only five of the 10 recommended practices for reducing 30-day readmission rates for patients with acute MI (AMI) or heart failure (HF), according to a study published online July 18 in the Journal of the American College of Cardiology. Researchers plan to build from this baseline paper to identify which practices help reduce rates, the lead author told Cardiovascular Business.

“What our next paper will do is correlate statistically these practices with risk standardized readmission rates to try to identify what are the core practices,” said lead author Elizabeth H. Bradley, PhD, director of the Global Health Leadership Institute and a professor at Yale School of Public Health in New Haven, Conn. “Right now we know what is recommended. As we look at those recommendations, it looks like hospitals are doing about half of them.”

The approach of a pay-for-performance reimbursement system by the Centers for Medicare & Medicaid Services (CMS) has made hospitals keenly aware of the need to track and improve their readmission rates. Motivated by the high costs of readmissions, CMS will begin financially penalizing hospitals with higher than expected readmission rates for AMI and HF in fiscal year 2013.

Bradley and colleagues have designed a series of studies to better understand modifiable practices in hospitals that may affect the quality of care for AMI and HF patients. Their goal is to provide guidance to hospitals on practices that impact care, which can be gauged through measures such as 30-day readmission and mortality rates.

“Despite the national focus on readmission rates, contemporary data on the hospital practices aimed at reducing readmissions are lacking,” the authors wrote.

In the current descriptive study, they wanted to define the range and prevalence of key practices implemented by hospitals to reduce 30-day readmissions of patients with AMI or HF. To do so, they surveyed 537 hospitals enrolled in the American College of Cardiology and the Institute of Healthcare Improvement’s quality initiative, Hospital-to-Home. The survey included 10 specific recommended practices that covered quality improvement resources and performance monitoring, medication management, as well as discharge and follow-up procedures.

Almost 90 percent of the hospitals responded that they had a written objective to reduce preventable AMI and HF readmissions. Most also described having a reliable system for identifying HF patients at the time of admission and having a quality improvement team assembled to reduce preventable readmissions of HF patients. But only 54 percent reported having a similar team in place for AMI.  Almost all tracked their 30-day readmission rates and two-thirds had a designated person or group of people to review unplanned readmissions.

Medication management practices were spotty, though, with 14 percent reporting that the responsibility for medication reconciliation was not formally assigned to someone. About half of the hospitals did not involve a pharmacist or pharmacy staff in obtaining medical histories.

Most hospitals reported giving patients or their caregivers discharge instructions and using “teach-back” techniques. But fewer hospitals reported having a process to alert the patient’s primary care physician of a discharge within 48 hours, and about 30 percent said they failed to make discharge summaries available for viewing within seven days of discharge.   

On average, hospitals had 4.8 of the 10 recommended practices in place. Only 12 percent had implemented eight or more practices while another 12 percent implemented two or less.

“We are finding tremendous variations in the practices implemented,” Bradley said.

The authors suggested time constraints may hinder some practices, such as providing timely discharge summaries or patient education, and the lack of standardized systems for coordinating care among groups of physicians, pharmacists and nurses may be particularly challenging.  

“Lastly, clinicians and administrators might be uncertain about the efficacy of various strategies as we lack definitive studies demonstrating their impact on readmission,” Bradley and colleagues wrote. “As a result, adoption of these strategies might be slower, particularly in the absence of definitive evidence supporting their effectiveness for reducing readmission rates.”

The authors cautioned that their study was descriptive only and could not evaluate the effect of practices on outcomes. As member hospitals of a quality care initiative, respondents were motivated to reduce readmission rates and may not be representative of hospitals as a whole.

“Given the diversity of efforts to reduce readmission rates, establishing more definitive evidence about the effective hospital practices in this area is warranted,” they concluded. “Nevertheless, our findings suggest opportunities for continued improvement in communication and care coordination, which may assist in hospital efforts to reduce readmission rates.”