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Reducing Hospital Readmissions for Cardiovascular Disease: Is it Feasible?

      On October 1, 2012, the federal government launched the Hospital Readmissions Program, a quality improvement initiative designed to impose financial penalties on those hospitals whose Medicare readmission rates are higher than the national average.
      • McKinney M.
      Preparing for impact. Many hospitals will struggle to escape or absorb penalty for readmissions.
      This program was mandated by the Patient Protection and Affordable Care Act to improve both the quality and the continuity of care beyond those acute conditions that lead to hospital admissions.
      • McKinney M.
      Preparing for impact. Many hospitals will struggle to escape or absorb penalty for readmissions.
      As a hospital quality assurance measure, the hospital readmission rate has been thought to mirror aspects of patient care that include patient education, discharge assessment, and post-discharge 30-day follow-up.
      • Berenson RA
      • Paulus RA
      • Kalman NS
      Medicare's readmissions-reduction program—a positive alternative.
      Currently, the United States has the highest rate of post-myocardial infarction readmissions.
      • Moon M.A.
      U.S. tops 16 nations in STEMI readmissions.
      Medicare is now using data to apply reimbursement penalties to hospitals on the basis of rates of 30-day readmissions for congestive heart failure, myocardial infarction, and pneumonia, using hospital records from July 2008 to June 2011.

      Rau J. Hospitals face pressure to avert readmissions. New York Times/Science Times. November 27, 2012:D1, D6.

      The program penalties for hospitals below the readmission standard range from 0.01% to 1% of base operating Diagnosis Related Grouping payments. The maximum penalty for 2013 will be 1%, and that number will increase to 2% in 2014 and 3% in 2015.

      Rau J. Hospitals face pressure to avert readmissions. New York Times/Science Times. November 27, 2012:D1, D6.

      Currently, approximately 20% of Medicare recipients have experienced readmission within 30 days after discharge.

      Rau J. Hospitals face pressure to avert readmissions. New York Times/Science Times. November 27, 2012:D1, D6.

      Although some readmissions are inevitable and staged, there are a number of studies that have concluded that a significant percentage of these readmissions are potentially preventable.
      • Berenson RA
      • Paulus RA
      • Kalman NS
      Medicare's readmissions-reduction program—a positive alternative.
      • Kaboli P.J.
      • Go J.T.
      • Hockenberry J.
      • et al.
      Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals.
      • Bernheim S.M.
      • Grady J.N.
      • Lin Z.
      • et al.
      National patterns of risk-standardized mortality and readmission for acute myocardial infarction and heart failure. Update on publicly reported outcomes measures based on the 2010 release.
      Although some readmissions are caused by hospital system problems, patient and community system issues also can influence the rate of readmissions.
      Patient characteristics that also are thought to influence an increase in readmission rate include female gender, living alone, increased age, advanced stage of disease, a greater length of stay during the initial hospitalization, emergency department use, and the acuity of the illness.
      • Au A.G.
      • McAlister F.A.
      • Bakal J.A.
      • et al.
      Predicting the risk of unplanned readmission or death within 30 days of discharge after a heart failure hospitalization.
      • Bradley E.H.
      • Curry L.
      • Horwitz L.I.
      • et al.
      Contemporary evidence about hospital strategies for reducing 30-day readmissions.
      • Bettger J.P.
      • Alexander K.P.
      • Dolor R.J.
      • et al.
      Transitional care after hospitalization for acute stroke or myocardial infarction.
      Socioeconomic factors and individual educational levels undoubtedly also play a role.
      Heart failure is the leading cause of hospitalization among adults aged more than 65 years and a leading cause for readmissions.
      • Desai A.S.
      • Stevenson L.W.
      Rehospitalization for heart failure. Predict or prevent?.
      The readmission rate within 30 days for a heart failure diagnosis is approximately 25%, whether the ventricular ejection fraction is preserved or depressed.
      • Desai A.S.
      • Stevenson L.W.
      Rehospitalization for heart failure. Predict or prevent?.
      There are reliable risk models for predicting readmission for heart failure, despite the use of biomarkers, echocardiographic data, and clinical symptoms.
      • Desai A.S.
      • Stevenson L.W.
      Rehospitalization for heart failure. Predict or prevent?.
      More often, readmissions occur when psychosocial and socioeconomic factors limit adherence and compliance to recommended treatment.
      • Desai A.S.
      • Stevenson L.W.
      Rehospitalization for heart failure. Predict or prevent?.
      Safety-net hospitals and rural hospitals may have higher rates of readmissions because of a paucity of community support systems.
      • McKinney M.
      Preparing for impact. Many hospitals will struggle to escape or absorb penalty for readmissions.
      Back so soon? Hospital readmission and the impact on quality of care.
      Readmission rates for heart failure also may not be the best marker of quality, because there seems to be an inverse relationship between readmission rates and mortality.
      • Heidenreich P.A.
      • Sahay A.
      • Kapoor J.R.
      • et al.
      Divergent trends in survival and readmission following a hospitalization for heart failure in the Veterans Affairs health care system 2002 to 2006.
      Patients who are severely ill may be denied readmission to keep the readmission rate down, putting them at greater risk.
      Clearly, there are hospital readmissions that can be avoided. As long-time practitioners, we have appreciated that certain strategies can reduce heart failure and post-myocardial infarction readmissions, with better outcomes. While one of us (WF) was serving in 1976 as Chief of Cardiology in the US Army Medical Corps at US Walson Army Hospital in Fort Dix, NJ, we established a home visit program for patients post myocardial infarction. This program used a health care worker who would visit the home to determine whether the patient was adherent to the prescribed drug and exercise regimens. Readmission to the hospital decreased, and overall outcomes improved. In recognition of this original effort in home visitation which was subsequently carried out by other military hospitals, Dr Frishman received the US Army Commendation Medal for Meritorious Service. Subsequently, as an academic practitioner with a large clinical following, Dr Frishman continues to make home visits after hospital discharge to all patients with heart failure and patients post-myocardial infarction to ensure adherence to therapy. Dr Frishman also is available by telephone and closely monitors patient weights. With the use of this system, there have been few inappropriate readmissions even in patients with end-stage disease. Dr Frishman works closely with the patient and family to provide a realistic prediction of the future to reduce inappropriate readmissions. Other groups have promoted similar strategies in an attempt to improve the quality of care while reducing readmissions.
      • Desai A.S.
      • Stevenson L.W.
      Rehospitalization for heart failure. Predict or prevent?.
      The approach to reducing hospital readmission rates in cardiology must be a multifactorial one, and certain strategies are presented in Table 1.
      • Chen J.
      • Ross J.S.
      • Carlson M.D.
      • et al.
      Skilled nursing facility referral and hospital readmission rates after heart failure or myocardial infarction.
      • Frishman W.
      • DeSilvey D.
      • Mayberry J.
      • et al.
      Continued coronary care: multidisciplinary approach to cardiac rehabilitation in the military community (abstr).
      • Kangovi S.
      • Long J.A.
      • Emanuel E.
      Community health workers combat readmission.
      • Evans M.
      Residential therapy.
      • Palaniswamy C.
      • Mishkin A.
      • Aronow W.S.
      • et al.
      Remote patient monitoring in chronic heart failure.
      • Collins S.P.
      • Pang P.S.
      • Fonarow G.C.
      • et al.
      Is hospital admission for heart failure really necessary? The role of the emergency department and observation unit in preventing hospitalization and rehospitalization.
      During the initial hospitalization for cardiac diagnosis, the patient and his/her family must be educated about the disease and its treatment. Discharge planning and instruction must be thorough. Plans must be made for close follow-up and home visits. The burden and penalties for readmission should not just be placed on the hospital, especially those that have a major safety-net responsibility.
      • Nasir K.
      • Lin Z.
      • Bueno H.
      • et al.
      Is same-hospital readmission rate a good surrogate for all-hospital readmission rate?.
      Community, outpatient, social, and financial support need to be provided for the underserved so that recommended treatments are adhered to by the patient.
      Table 1Strategies to Reduce Cardiovascular Hospital Readmissions
      • 1.
        Detailed discharge instructions (medications/diet) communicated to patient/family/other significant caregivers.
      • 2.
        During admission/transitions of care during hospitalization, patient/family should be informed about ultimate post-discharge treatment plans.
      • 3.
        Make sure patient has follow-up medical appointments and outpatient care at the time of discharge, including prescriptions/plan to visit the pharmacy.
      • 4.
        Post-discharge phone calls (within 1 wk) to make sure patient is adhering to the prescribed discharge regimen, with follow-up 2 to 4 wks thereafter.
      • 5.
        A home visit from the physician or nurse to make sure treatment and recommendations are followed.
      • 6.
        Strenuous efforts to ensure patient has adequate housing after discharge.
      • 7.
        Telemonitoring (patients with heart failure) when available.
      • 8.
        Simple procedures such as daily weights (heart failure).
      • 9.
        Observation units at a hospital's outpatient facility where patients can be watched short-term and not readmitted.
      • 10.
        Transition of care—transfer to skilled nursing facility before discharge home.
      • 11.
        Educational materials regarding disease/treatment for home use by patient/family, including, if possible, instructional videotape made by physician.
      The readmission process is a complex one, involving the characteristics of patients, the type of hospitals and their missions, outpatient practices, community support, and early warning systems that can bring a patient to early attention (as simple as an inappropriate weight gain for patients with heart failure).
      • Dharmarajan K.
      • Hsieh A.F.
      • Lin Z.
      • et al.
      Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
      • Dunlay S.M.
      • Weston S.A.
      • Killian J.M.
      • et al.
      Thirty-day rehospitalizations after acute myocardial infarction.
      The burden for readmission should not be placed on the hospital alone, and the financial burdens and penalties should be shared by other players in the readmission process (eg, unreliable patients).
      Clearly, there are readmissions to the hospital and revisits to the emergency department that are preventable and inappropriate, and these can be reduced, but it will involve the efforts of patients, their support systems, and the entire health care system to achieve an appropriate fix.
      • Bradley E.H.
      • Curry L.
      • Horwitz L.I.
      • et al.
      Contemporary evidence about hospital strategies for reducing 30-day readmissions.
      • Dunlay S.M.
      • Weston S.A.
      • Killian J.M.
      • et al.
      Thirty-day rehospitalizations after acute myocardial infarction.

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