Six Strategies to Reduce 30-Day HF Readmissions
Combining several strategies may be the key to lower risk-standardized 30-day readmission rates (RSRRs) for patients with HF. Elizabeth H. Bradley, PhD, Yale School of Public Health, and colleagues conducted a survey of almost 600 hospitals participating in national quality initiatives to reduce readmission and then constructed a multivariable linear regression model to determine strategies independently associated with 30-day RSRRs.
Six strategies were associated with significantly lower RSRRs: 1. Partnering with community physicians or physician groups to reduce readmission 2. Partnering with local hospitals to reduce readmissions 3. Having nurses responsible for medication reconciliation 4. Arranging a follow-up appointment before discharge 5. Having a process in place to send all discharge paper or electronic summaries directly to the patient’s primary physician 6. Assigning staff to follow up on test results that return after the patient is discharged Many of these strategies were implemented by less than two-thirds of the hospitals.
Source: Bradley EH, Curry L, Horwitz LI, et al. Circ Cardiovasc Qual Outcomes. 2013;6:444-50.
Where’s the Data?
The idea that 30-day readmission rates may be a lousy quality metric for HF is no surprise to Javed Butler, MD, MPH and Andreas Kalogeropoulos, MD, PhD (both from Emory University School of Medicine), who wrote the aforementioned commentary3 to the JACC paper by Dr. Bradley and colleagues. They wrote that the overarching question is not what the hospitals are doing to prevent HF readmission, but why are they doing it and what is the evidence that these interventions are effective and cost-effective? The answer to why is simple: because hospitals are compelled to do so. The evidence to support these measures, on the other hand, is just not there. Unlike acute MI, where the evidence base in support of the 30-day readmit metric is strong, Drs. Butler and Kalogeropoulos note that HF is a complex disease, and what should work logically does not always work in practice. As for many of the efforts to reduce readmissions (spawned by the CMS decision to not pay for early readmissions), Drs. Butler and Kalogeropoulos wrote, “Many of these activities are neither proven nor primarily based on the motivation to improve patient outcomes, but rather on the fear of punitive financial disincentives.” Dr. Yancy and others also have expressed concern that the CMS penalties are unfair because hospitals that treat the poorest patients are getting hit harder than others. Penalties can be a drain on safety net hospitals, many of which operate on slim profits or at a loss. “The idea is right, but the implementation has been greatly flawed by penalizing hospitals that take care of the most vulnerable patients,” said Atul Grover, MD, PhD, chief public policy officer at the Association of American Medical Colleges. Low-income patients are more likely to have trouble following hospital instructions for taking care of themselves after discharge. They don’t always have easy access to doctors to monitor their recuperations and sometimes can’t afford needed medications.
Medicare has disagreed that the readmissions penalty program needs revisions, but in a June 2013 report to Congress, the Medicare Payment Advisory Commission, or MedPAC, agreed with critics that there are “shortcomings” that “can work at cross purposes to the policy’s intent.” The criticisms carry extra weight because MedPAC helped devise the readmission penalties, calling for them back in 2008. “Income is still an important variable in explaining variation in readmissions,” the commission said. It recommended that in future years, when determining penalties, Medicare should compare a hospital’s readmission rates to those of hospitals with c ??&&?R?V?&W'2?b??"F?V?G2???&R?W2???&R???66?&F??rF??&?????'V?????B?&?fW76?"?b6&F????w??B?V?F???7?B??RV??fW'6?G??B??R??Wr?fV???7?F????R?bF?R6??Vb&6??FV7G2?bF?Rv?fW&??V?N( ?2?Wr?V??F?fR??7?F?&VF?76????V7W&W2???F?R&??#2?77VR?bF?F?( ?2??7?F?7B??R?ffW&VBF??266V?&????b6??V??R7&6?W2??26"?W72F?????F?gFW"&V??rF?66?&vVBg&??F?R??7?F?v?F??WV?????????v?B6?F?R&VF?76???&W7V?F??rg&??F?R66?FV?B?B??F???rF?F?v?F?F?R???F????7?F??F?????V?6R?F?R&V6????rv?V?Bv??F?R?Wr??7?F??F???6??V?F?( ?B6?V?Bv??7BF?R??7?F?2&WfV?F&?R&VF?76????'WB??R6?B?v?B?bV??R&R( ?BV?WfFVB&?6??b66?FV?G>( ?&V6W6RF?W?vW&R&V6V?F???7?F??VC?F?V???R7W&?6VB??B?2&V?FVB????W76???F?R??V'?F??77VR?bF?R?WrV?v??B??W&???b?VF?6??R?G"??'V???7VvvW7FVBF?BF?R???VF?FR?7B??7?F??F???W&??B???VVBF?&R&R??v??VB2( ??6R.( ??b?????W72?W&??B?&?VB'??V?v?FV?VB( ?vV?W&??VB&?6?( ?f?"???6??F?F???2?( ?6???B( ??7B??7?F?7??G&??^( ?&V6W6R?&V?vWG2F?RGFV?F????bF?7F?'2?( ?G"??'V???W????2?( ?BvWG2??RF????rF?BF??26?V?B7GV??&R6??W&V?B7??G&??RF?B?27V?&VB?G&?6?V?B?B6??WF???rF?V?G2F?F?( ?B?fR&Vf?&RF?W?6?RF?F?R??7?F??( ?v???R&WfV?F&?R&VF?76???26??V?B&RF&vWB?G"???7?6?B?( ?N( ?2?&BF?V?'&6R3?F?&VF?76???v??F?r2?&?&?FRV?G??V7W&Rv?V?F?R6V?FW'2B&?6?&RF?R6V?FW'2F?B?VVBF?R&W6?W&6W2F?R??7B??B?B?2WfV???&RF?7V?WF??rF?BF?R??7?F?2F?B&R7V66W76gV???&VGV6??r3?F?&VF?76???&FW2??&RF???rF??2BF?RW?V?6R?b3?F???'F?G?&FW2?( ?G"???7?FFVB?( ?v^( ?&RV?FW&??rfW'?F?ffW&V?B?V?F?6&R76R?BvR?VVBF?&R?V?B66?V?F&?Rf?"V?G????VW7F???&?WBF?B??BvR6??V?B&RW?V7FVBF?f????r&W7B&7F?6W2F?Bv?????B&?GV6R?VVF?W72W?V?F?GW&W2?'WB???W"?V?F???R???bF?W6RF???w2?V?6??7W'&V?F??BV?6???vR6?( ?B??6R6?v?B?bF?R???'F?6R?b&W7BF?V?B?WF6??W2?( ?)j ??D$?R"v??F?F?V?G2&?V?6R&6?????N( ?2??B?v?2f?"F?R?&?v???F?66?&vRF?v??6?0???7B??7?F?7??G&??P???F?W"v??b??????rBF?R&?&?V?6??W2g&??W"'?7FW?V?b??V?6?2??B?????B6???VwVW2??F?R?WrV?v??B??W&???b?VF?6??RF?Bf?V?B?V&?Gv??F??&G2?b??7?F?&VF?76???2&R??Bf?"F?R?&?v???6??F?F???6?FVBB???F??F?66?&vR?D$?R"??b?b?????WF??&B?b&VF?76???2&Rf?"F?R6?R6??F?F???2F?R&V6V?B??7?F??F????v?N( ?2F?R&?&?V???'f??W6??&VF?76????2??77VR?'WBv????F?RV??6?2??&WfV?F??r&VF?76???2v?V?6?V&???7B&VF?76???2&Rf?"6??WF???rV?6R?B??B???VBF?F?R??7?F??F??????&VfW&V?6W0??6?W&6S??V?6?24b?v????2?b?6??V??T??V?v???VB?#??3c?C??#????'&F?W?T??7W''?????'v?G???WB????6???6&F????##?c?cr?B??GG???6??FV?B?????V?62??&r?'F?6?R?7??'F?6?V?C?##Cs2"??vW&?&GBr??V??R???6????WB???VF?6&R?VF?6?B&W2&Wb?#3?2?"???GG???wwr?6?2?v?b???'"?'&?Vg2?##2???'"?#2?2?"?#??F??2??'WF?W"?????vW&??V??2???6???6&F????##?c?cR?r??GG???6??FV?B?????V?62??&r?'F?6?R?7??'F?6?V?C?##Cs"B????6???$B???r???W&??FW?b?WB????V'B??#3?cS???r?B?S?R???V?FV?&V?6???W&??FW?b???7?5r?WB??6?&26&F??f62V??WF6??W2?##?S?3r?C2?b???V?6?24b?v????2?b?6??V??T??V?v???VB?#??3c?C??#??r???'V???????V?v???VB?#3?3c???"?6&F??6?W&6R??&r?55t?6&F??6?W&6Rv?&?D?Ww0??3??55t??52?3?F???s2???FB3??????2S????