Opportunities Exist for Hospitals, Interventionalists to Stave Off Unnecessary Readmissions

Facing financial penalties for above-average readmission rates by the Centers for Medicare & Medicaid Services (CMS), healthcare professionals and researchers are looking more intently at how to prevent patients from unnecessarily returning to the hospital after their initial discharge.

In a 2-part series, TCTMD is taking on the issue of hospital readmission. Part 1 looked at the CMS-inspired effort to identify preventable readmissions after PCI. Today, part 2 covers attempts to improve key hospital processes and explores their impact on readmission.

Gatekeepers Needed in the ED

A major contributor to post-PCI readmissions—and thus a prime target for quality improvement—is the cascade of events set off when anxious patients who have previously had an MI then return to the emergency department (ED).

In fact, a study on rehospitalization after PCI found that by far the largest proportion of readmissions (38.1%) involved patients who went to the ED with chest pain or other symptoms they suspected might be recurrent angina. The majority received at least 1 diagnostic test, typically angiography, yet only 6.2% had evidence of a new MI. Overall, 15.8% received repeat PCI, but only 2.6% underwent TLR during readmission.

Amy Boutwell, MD, MPP, founder of Collaborative Healthcare Strategies (Boston, MA), described a common scenario to TCTMD in a telephone interview: A few days after PCI for an acute MI, a patient feels a sensation in his chest and—especially if his cardiologist is unavailable—heads for the ED. There he is seen by physicians who almost reflexively admit him for a workup.

To short-circuit this pathway, some hospitals ensure that a cardiologist is available in the ED, noted Jason H. Wasfy, MD, MPhil, of Massachusetts General Hospital (Boston, MA) in a telephone interview. After troponin testing, the cardiologist makes the call as to whether a patient can safely be sent home and perhaps return the next day for a stress test. “As specialists, cardiologists are more able to reassure both patients and ED doctors that symptoms are not angina,” he noted.

Other approaches use algorithms to allow diversion of appropriate patients to chest pain units. Patients can remain in the hospital for up to “2 midnights” before they are charged as inpatients.

According to Sorin J. Brener, MD, of New York Methodist Hospital (Brooklyn, NY), interventionalists can help by explaining to patients what to expect after they are released: “We stretched your arteries, so you may feel a twinge here and there for the next 3 or 4 days. Don’t be alarmed. Call,” he told TCTMD in a telephone interview.  These telephone calls can potentially be fielded by experienced physician assistants, who decide when a cardiologist needs to be alerted, he noted.

Such strategies not only conserve hospital resources but also empower patients, Dr. Wasfy stressed.In particular, if it is their first cardiac event, patients may “just need counseling to understand their disease and how to interpret symptoms,” he said. “It helps people live with their condition. They don’t want to be in the hospital if they don’t have to be.” 

Other process changes can also be effective, Dr. Wasfy said. For example, to ensure specialist input early on, his hospital has instituted a system whereby cardiologists are immediately notified when their patients are in the ED. In addition, he said, “we [cardiologists] need to make sure that our patients know how to get us on the phone and that we are available to see them in the ED when needed. That is as much a part of quality care as the technical aspects of PCI.”

Another approach being tested in some EDs, said Dr. Boutwell, is directed at patients with stable recurrent symptoms—the so-called frequent flyers, who show up at the slightest discomfort. Specific care plans for such patients, supported by a multidisciplinary team including a psychologist or sociologist, can help guide ED physicians in deciding whether they need to be readmitted, she said.

Prime Target: Transition of Care

The period surrounding discharge is a time when patients are especially vulnerable and care may be fragmented, observed Dr. Boutwell. Growing recognition by hospitals of the need to focus on the transition to home or a rehabilitation center has elicited many recommendations.

Central to any such program should be a plan to proactively meet patients’ needs when they are leaving the hospital and beyond, Dr. Boutwell said. To be comprehensive, that effort requires the expertise and cooperation of a variety of hospital staff, often including a discharge or care coordinator. Key areas include:

• Managing medications. Many PCI patients will be on new drugs, including dual antiplatelet therapy and secondary prevention medications. The importance of adhering to the new regimen should be stressed to those who are already taking a different dosage of a drug and may be reluctant to pay for a new prescription, Dr. Boutwell noted. Hospital pharmacists also play an important role by ensuring that all medications, including preexisting ones, have been reconciled, she added.
• Educating patients and engaging family/caregivers. Patients are more likely to understand complicated instructions if they hear them from multiple sources and can “teach them back,” experts have found. Moreover, Dr. Boutwell continued, the hospital team should try to identify a “care partner” who will make sure a plan is followed. Often that is not the spouse at the bedside—who may be older and somewhat impaired—but another family member or friend, and it requires extra effort to identify them, she cautioned.
• Following up. Nurses or care coordinators can follow up to ensure that scheduled appointments with the cardiologist or primary care doctor are kept. Smartphone apps that provide a dynamic interface with patients may help, said Dr. Boutwell, though the efficacy of high-tech tools like remote telemonitoring has not been proven except in cases of heart failure.

Another tool to curb readmissions is communication among the team of physicians involved in a patient’s care, said Dr. Boutwell. Not uncommonly, patients return to the hospital on the advice of their primary care physician, who was not informed of the details of a procedure or the reason for a prescription, she said. But, she added, if that doctor has direct access to all pertinent information—as well as an opportunity for real-time “curbside” consultations with specialists—patients’ questions are more likely to be answered at the primary-care level, obviating unnecessary readmissions.

Posthospital Syndrome

Patients’ susceptibility to readmission may also stem from a more general source—namely, the stress of hospitalization, commented John A. Spertus, MD, MPH, of St. Luke’s Mid America Heart Institute (Kansas City, MO), in a telephone interview. Triggered by interrupted sleep, undertreated pain, inactivity, and poor nutrition, “posthospital syndrome” can leave patients weak and/or cognitively impaired when they return home, making them more prone to medication errors, missed appointments, and falls. 

The impact of this phenomenon on readmissions has yet to be confirmed, Dr. Spertus acknowledged. But, he added, the “physician-centered hospital”—where, for example, labs are drawn at 3 AM so they will be available for the doctor at 6 AM—should be rethought.

The push to improve posthospital continuity of care has spawned a host of programs, some of them aggressively marketed, Dr. Spertus added. One of the more successful of these is the RARE (Reducing Avoidable Readmissions Effectively) campaign, which offers “learning collaboratives” to hospitals in Minnesota, Dr. Boutwell reported. Other programs are Project Re-engineered Discharge (RED) and the CMS-sponsored Hospital Engagement Networks. The latter work at the regional, state, or hospital-system level to identify and disseminate proven solutions.

Although some programs are free and others carry varying price tags, all entail substantial investments in time, training, and other resources, noted Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. “Not everything has worked as well as one might hypothesize in every setting,” she told TCTMD in a telephone interview.

Dr. Spertus was blunter, saying: “It’s easy to spend a lot of money on snake oil.” According to Dr. Boutwell, hospitals must set goals for readmission reduction and use analytics to determine both the efficacy and cost-effectiveness of individual measures.

Does CMS Risk Adjustment Need Adjusting?

From the outset, the CMS campaign’s method for risk-adjustment of readmission rates to assess penalties has come under fire, as has the validity of readmission as a quality metric.

In a commentary in the Archives of Internal Medicine, Adrian F. Hernandez, MD, MHS, and Christopher B. Granger, MD, of Duke University Medical Center (Durham, NC), point out that readmission rates may not be tightly tied to overall quality of care. For example, they suggest, good 30-day mortality rates may be associated with more readmissions when very sick patients survive and need further hospitalization. “[I]t is unclear how much of the variability in readmission relates to quality of care and how much is due to unmeasured confounding factors,” they write.

Early concerns about the distorting influence of staged PCI were eased when CMS decided not to count planned readmissions in assessing penalties.

Moreover, though the readmission rates are “risk standardized,” the models are built largely on administrative data and thus fail to include important clinical variables, Dr. Spertus said. For example, Seattle Angina Questionnaire data that can predict recurrent angina and readmission are not taken into account, he noted.

Dr. Wasfy acknowledged that readmission rates are subject to both unmeasured confounders and potential manipulation. “[But] ultimately, if we’re going to improve care, we have to act on them,” he asserted. Both physicians agreed that risk-adjustment models are likely to improve over time.

A more controversial issue, Dr. Spertus observed, is whether CMS should adjust for socioeconomic factors so that hospitals serving disadvantaged populations are on a level playing field with others.

A recent Perspective in the New England Journal of Medicine declared: “A growing body of evidence suggests that the primary drivers of variability in 30-day readmission rates are the composition of a hospital’s patient population and the resources of the community in which it is located—factors that are difficult for hospitals to change.” Additionally, an article in Annals of Internal Medicine pointed out that penalties for hospitals in disadvantaged communities could unintentionally exacerbate disparities between rich and poor.

But opponents argue that such adjustments could mask differences in hospital performance and actually serve to perpetuate disparities in care, Dr. Boutwell said. “If we adjust for socioeconomic status, that sends a message to these hospitals that they don’t have to address the issue of transitional care as aggressively.”

Meanwhile, the Medicare Payment Advisory Commission (MedPac) has recommended that CMS account for socioeconomic factors in calculating its penalties while continuing to report unadjusted readmission rates in order to preserve data on potential disparities. The American Hospital Association strongly favors socioeconomic adjustment, Ms. Foster said.

Dr. Spertus counts himself a supporter of socioeconomic adjustment, but he noted that hospitals can influence readmission rates through the culture of their EDs. “Some EDs are very risk averse and just admit all patients, while others are more willing to risk stratify and have a higher threshold for admission,” he said. The latter approach is encouraged when hospitals create an infrastructure that enables ED physicians to refer lower-risk patients to an outpatient clinic, he added.

In addition, Dr. Spertus said, it is important that the imposition of financial penalties be seen as both fair and “ungameable.” After all, he noted, the CMS penalties are “creating multimillion-dollar incentives to come up with ways to avoid looking bad.”

Also somewhat problematic is the often-assumed link between reducing readmissions and improving patient outcomes. “I strongly believe that work to reduce readmission is a stepping stone to a larger system transformation,” Dr. Boutwell said. “In my mind, this is about taking the long, more comprehensive view of the patient and putting aside the more episodic way we have practiced medicine.”

Dr. Spertus found the connection less clear. CMS-inspired hospital policies are “focused on reducing costs and increasing value, not necessarily meaningfully improving patient outcomes,” he said. “I think that’s reasonable, and I don’t want to minimize the [impact on patients] of being readmitted.” But, he stressed, reducing readmissions is not the same as reducing mortality.  

Hopeful Signs

Readmission rates have trended downward since the start of the CMS campaign, Dr. Boutwell reported. The most recent Department of Health & Human Services figures show a decline in Medicare fee-for-service 30-day readmissions from about 19% over the preceding 5 years to 17.5% in 2013, which it says translates to an estimated 150,000 fewer readmissions. This trend likely stems from implementation of the known strategies for improving patient care, said the AHA’s Ms. Foster, adding that future declines will probably be more challenging.

Interestingly, a recent study suggests readmission rates may not be central to improving PCI value. Investigators led by Steven M. Bradley, MD, found little correlation between post-PCI readmission rates and overall cost, with the second hospitalization accounting for less than 6% percent of the expense over 30 days—mainly because PCI readmissions are uncommon.

“As we continue to move toward a system that provides reimbursement for an entire cycle of care under a value framework, we will have increasing opportunity to look at how we provide the best care longitudinally,” Dr. Bradley told TCTMD in a telephone interview. “Our study suggests that when it comes to [paring costs], there may be lower hanging fruit during the expensive index procedure.”

Dr. Wasfy made the same overall point. In the current healthcare environment, “hospitals are becoming increasingly dependent on contracts that pay better for more efficient care, such as bundled payments for given diagnoses, value-based purchasing, and now Medicare penalties,” he said. “And all these things incentivize them to think more about readmissions.”

But in the end, he concluded, “it’s not just about reducing costs; it’s fundamentally about improving the patient experience and improving safety.”

Disclosures:

• Drs. Boutwell, Bradley, Brener, and Wasfy and Ms. Foster report no relevant conflicts of interest.
• Dr. Spertus reports being the founder of Health Outcomes Sciences.

Related Stories:

• CMS Penalties Spur Efforts to Reduce 30-Day Hospital Readmissions
• Risk Model Predicts 30-Day Readmissions After PCI
• Hospital Readmission Post-PCI Linked to Increased Mortality