Readmission rates after percutaneous coronary intervention (PCI) at some US hospitals will soon become public knowledge thanks to a collaborative effort initiated by the Centers for Medicare and Medicaid Services (CMS). Details of the effort were outlined in a press statement released by the American College of Cardiology (ACC) on July 18, 2013.
More than 300 of the nearly 1,200 hospitals participating in the ACC’s National Cardiovascular Data Registry (NCDR) CathPCI Registry have elected to release their 30-day readmission rates for Medicare Fee for Service patients treated from January 2010 to November 2011. Hospitals are assigned to categories by how they fare compared with the nationwide registry’s overall readmission rate of 11.9%—better, similar, or worse. Importantly, rates are adjusted for baseline patient risk factors such as sex and age.
The exact approach to measuring 30-day readmission rates was developed through a partnership with the Yale-New Haven Health Services Corporation/Center for Outcomes Research and Evaluation.
Individual hospital data are available on a special section of the Hospital Compare Web site run by CMS, while more general information for patients can be found on CardioSmart, a Web site operated by the ACC.
Patients Want Information
Gregory J. Dehmer, MD, of Texas A&M University Health Science Center College of Medicine (Temple, TX), who serves as chair of the ACC Public Reporting Advisory Group, told TCTMD in a telephone interview that the effort has been approved by the National Quality Forum. “That’s a very rigorous evaluation,” he said, adding that readmission rates will be updated over time as newer CMS data become available. Using the NCDR Cath PCI data, the ACC will release several additional measures by 2014.
“Part of the Affordable Care Act mandates . . . more public reporting to keep consumers informed so that they can make better health care decisions,” Dr. Dehmer noted, although he acknowledged that this benefit has not yet been convincingly proven.
“A long time ago, if you wanted to buy a refrigerator, you went to the appliance store and the guy said, ‘This is really the best one,’ and there you go,” Dr. Dehmer related. “Now, if you’re going to buy a refrigerator, you look on the internet and see all the reviews by customers and professional organizations. The public has become accustomed to being more and more informed when making decisions. They look for this information.”
Dr. Dehmer did not predict any negative fallout from public reporting of 30-day readmissions, in part because rates are so consistent across the NCDR CathPCI database. For patients, this information is still valuable, he explained. “At least if [a hospital] is the same as everybody else, you have some level of confidence that [if you go there], they’re doing what they need to do. They’re not an outlier.”
Consequences Still Unclear
In a telephone interview with TCTMD, Véronique L. Roger, MD, MPH, of the Mayo Clinic (Rochester, MN), was hesitant to speculate about any consequences or benefits of releasing readmission rates.
“In an era of increasing transparency . . . and public reporting, we need to gain some insight into how patients actually react to this. The way patients make decisions about their care is a complex process. There are components that we don’t fully grasp,” she said, stressing that better understanding of this process is a valid goal in and of itself.
Dr. Roger cautioned that “[t]here are always unintended consequences when you start something new.” Several caveats must be kept in mind, she said. To begin with, this is a pilot program. It is voluntary and, thus, participating hospitals may represent ‘best-case scenarios.’ PCI also stands apart from other public reporting of readmission rates by being a procedure rather than a disease like heart failure; for example, staged PCI involves an inherent readmission.
Hospitals that choose not to report data “hopefully will be looking at this,” she said. “It may change practices for the good even without [all centers] contributing data.”
Transparency in health care “is critically important to foster, develop, and amplify. Regardless, the concept of transparency is not one that you can argue with. Whatever consequences come out of that will have to be understood and managed, but increased transparency is always a good thing,” Dr. Roger concluded.
Robert W. Yeh, MD, MSc, of Massachusetts General Hospital (Boston, MA), commented in an e-mail communication with TCTMD that “the jury is still out as to whether readmission rates judge hospitals ‘fairly.’
“There are undoubtedly a large number of factors that influence readmission rates that are beyond the control of most hospitals, but we don't know what all of those factors are and whether or not they affect hospitals differently,” he continued. “We still don’t have a good sense of what proportion of PCI readmissions are actually preventable and how they could have been prevented.”
Even so, the quality metric could still be useful, Dr. Yeh emphasized. “Readmissions after PCI are common, and they are a problem for the health system. The combined efforts of the ACC and CMS to bring this measure to life are raising institutional awareness of the importance of this issue across the country—this can only help in the quest to find innovative ways to reduce readmissions.”
However, Dr. Yeh also noted that, based on his own experience, he expects payers and hospital administrators to focus more than patients on these numbers.
He predicted that hospitals will use the measure “to benchmark their performance against their peers, develop innovative ways to reduce readmissions to improve their numbers, and disseminate best practices so that all hospitals might benefit. Over time, perhaps we learn more about the strengths and weaknesses of the measure and work to improve it.”
Also possible, Dr. Yeh said, is that “good performing hospitals rest on their laurels, bad performing hospitals ignore the measure because they believe they are being judged unfairly, and payers begin to reduce payments based on the metric in a manner that preferentially harms those hospitals that are already potentially the most poorly resourced.
“I truly believe that the best-case scenario is more likely than the worst,” he commented. “There clearly is the potential for the measure to reduce readmission rates, and I have confidence in our medical community that it will not result in adverse effects on patient care.”