Few Hospitals Go the Distance to Reduce Readmissions for Heart Failure, AMI Patients

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Though most hospital administrators claim their institutions seek to reduce preventable readmissions for patients with heart failure or acute myocardial infarction (MI), implementation of strategies to achieve this goal varies widely. The findings, from a survey of participants in a nationwide quality improvement initiative, were published online July 18, 2012, ahead of print in the Journal of the American College of Cardiology.

Elizabeth H. Bradley, PhD, of the Global Health Leadership Institute at Yale University (New Haven, CT), and colleagues contacted all 594 hospitals enrolled as of July 2010 in the Hospital to Home program, which aims to reduce readmission rates by 20% for patients with heart failure or acute MI by the end of 2012. Among them, 537 (90.4%) completed a Web-based survey on hospital practices in 3 areas: quality improvement efforts and performance monitoring related to readmission, medication management, and discharge and follow-up procedures.

Disconnect Between Intent, Practice

The vast majority of respondents (89.9%) said their hospital agreed or strongly agreed that they had a written objective of reducing preventable readmissions for patients with heart failure or acute MI. Yet only half of hospitals (56.5%) had a multidisciplinary team set up to manage the care of patients at high risk of readmission. Most claimed to have members of quality improvement teams who focus specifically on readmission for heart failure patients (87.0%); the proportion with members devoted to acute MI was much smaller (53.5%).

While many hospitals had paired with community home care agencies and/or skilled nursing facilities to reduce readmissions (67.9%), far fewer had joined forces with community physicians or physician groups (49.3%) or other local hospitals (23.5%).

In terms of keeping tabs on specific efforts, hospitals were most likely to track 30-day readmission rates (94.6%), accuracy of medication reconciliation (73.2%), and timeliness of discharge summary (70.2%). Only 11.4%, meanwhile, reported being aware when patients were readmitted to another hospital.

Nearly three-quarters of hospitals said they had some electronic medical record or Web-based form to facilitate medication reconciliation (73.7%). But only 9.8% said they always linked outpatient and inpatient prescription records electronically, and 13.9% reported always making contact with the primary physician over medication.

Upon discharge, a minority of hospitals (25.5%) said they always sent the discharge summary to the patient’s primary medical doctor.

Fewer than 3% responded that they implemented each of 10 processes identified by researchers as key to reducing readmissions:

• Having at least 1 quality improvement team for reducing readmissions for heart failure, acute MI, or both
• Monitoring proportion of discharged patients with follow-up appointment within 7 days
• Monitoring 30-day readmission rates
• Providing information to all patients about medications
• Having a pharmacist responsible for conducting medication reconciliation at discharge
• Having a pharmacy technician primarily responsible for obtaining medication history as part of medication reconciliation process
• Providing patients or their caregivers direct contact information for a specific physician in case of emergency and/or other emergency plan
• Arranging an outpatient follow-up appointment before patients leave the hospital
• Ensuring the outpatient physicians are alerted to a patients discharge within 48 hours
• Calling patients regularly after discharge to either follow-up on post-discharge needs or provide additional education

Adoption of such practices varied widely, with 12% implementing 2 or fewer, and another 12% implementing at least 8 practices. Medication management practices were particularly heterogeneous.

Uncertain Efficacy

As to why practices might be lacking in so many hospitals, “[o]ne reason might be because they require added resources. . . . Perhaps a more important [obstacle], however, is the management challenge of coordinating efforts to ensure timely and proper discharge,” the researchers suggest. “Lastly, clinicians and administrators might be uncertain about the efficacy of various strategies as we lack definitive studies demonstrating their impact on readmission.”

Robert W. Yeh, MD, MSc, of Massachusetts General Hospital (Boston, MA), agreed with Dr. Bradley et al that there are multiple reasons why such strategies are not used more often. “Second, although many of these practices would seem on face value to be helpful, . . . it's not entirely clear that these specific interventions and practices should be the ones that are adopted by any one hospital,” he wrote in an e-mail communication with TCTMD. “The specific challenges related to readmissions faced by hospitals may require more individualized solutions which are of course harder to study.”

In an editorial accompanying the paper, Javed Butler, MD, MPH, and Andreas Kalogeropoulos, MD, PhD, both of the Emory Clinical Cardiovascular Research Institute (Atlanta, GA), note that hospitals appear strongly motivated to cut readmission rates.

“The overarching question, however, is not what the hospitals are doing to prevent [heart failure] readmission,” they point out, “but why are they doing it and what is the evidence that these interventions are effective and cost effective?”

The simple answer is “because they are compelled to do so. The perspective of pay-for-performance is a strong incentive for action,” Drs. Butler and Kalogeropoulos assert. But they suggest the underlying logic of quality improvement programs relies on several untested assumptions: that implementation will change actual practice, that interventions will be effective no matter how they are implemented, and that a short-term reduction in readmissions would improve life expectancy and quality of life for patients while reducing costs.

In a telephone interview with TCTMD, Dr. Bradley agreed that such assumptions must be questioned, adding that the research group’s next study will be an attempt to correlate specific practices with readmission rates.

Why Interventionalists Matter

According to Dr. Bradley, the literature has shown that “interventional cardiologists really make a huge difference [in efforts to reduce readmission] because they are perceived as—and really are—leaders on the clinical team of a patient undergoing PCI or [having acute] MI.”

Interventionalists play a key role in cooperating with nursing and social work staff, she continued. “Their communication with the team and with the family ultimately makes a very big difference,” Dr. Bradley observed. “I think it’s very hard because it’s beyond their technical work and what they’re necessarily trained to do, and they’re not really paid to do it.”

Asked whether he considers readmission in his regular practice, Jeffrey W. Moses, MD, of Columbia University Medical Center/Weill Cornell Medical Center (New York, NY), replied, “Everyone’s thinking about it, because the government has forced everyone to think about it, because of their ‘pay-for-performance’ initiative.”

Much of the research on this topic is driven by epidemiologists, Dr. Moses said. In general, he added,“[t]hey’re the ones making pronouncements about the efficacy of various interventions. But when you read the accompanying editorial it’s clear that . . . there’s no uniform consensus about which interventions work.” It is crucial to tease out how much of readmission is due to the disease process itself rather than uncoordinated care, Dr. Moses noted, acknowledging that “obviously coordinated care is a noble objective.”

In thinking of how clinicians can play an active part, Dr. Yeh stressed that “it’s worth restating that PCI is associated with very high rates of 30-day readmission in its own right.” Modifiable factors like procedural complications and not prescribing beta blockers at discharge, for example, are associated with higher rates of readmission, he added.

However, “Many of the strongest predictors of readmission,” Dr. Yeh continued, “are not things that proceduralists can affect—things like age, whether patients are nursing home patients, a history of chronic kidney disease. Until we have better data showing that there are specific strategies that reduce readmission, we’re left with doing things that interventionalists should and are doing already—minimizing contrast exposure, paying careful attention to vascular access, considering transradial approaches, etc.”

Study Details

For the survey, letters of invitation were sent to the contact person registered with the Home to Hospital program. Roles of respondents varied; nearly 60% were from quality management departments, 25% from cardiology departments, 25% from other clinical departments, and 16% from case management or care coordination. Another 8% reported working in nonclinical roles.

 

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Sources:
1. Bradley EH, Curry L, Horwitz LI, et al. Contemporary evidence about hospital strategies for reducing 30-day readmissions: A national study. J Am Coll Cardiol. 2012;Epub ahead of print.

2. Butler J, Kalogeropoulos A. Hospital strategies to reduce heart failure readmissions: Where is the evidence? J Am Coll Cardiol. 2012;Epub ahead of print.

 

 

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