The Case for Reviving PCI Readmission Metrics: A Holistic Approach Could Improve Both Quality, Value

Two years after the halt of a pilot program to measure national rates of hospital readmission after PCI, authors of a new paper argue that the controversial metric should be rejuvenated.

“Quality metrics offer an enormous opportunity to improve both the quality of care given to American cardiology patients and the value of care. We think that the PCI readmission metric is one of those metrics,” co-author Jason H. Wasfy, MD, MPhil, of Massachusetts General Hospital (Boston, MA), told TCTMD.

An unpopular nationwide pilot program that mandated PCI readmission reporting, sponsored by the Centers for Medicare & Medicaid Services (CMS) and American College of Cardiology (ACC) was scrapped in 2013. However, as Wasfy and co-author Robert W. Yeh, MD, MSc, of Beth Israel Deaconess Medical Center (Boston, MA), point out, the Affordable Care Act has since authorized CMS to charge penalties of hospitals with high risk-standardized readmission rates as part of the Hospital Readmission Reduction Program.

Since the pilot phase ended, “it’s unclear what’s going to happen going forward,” Wasfy said. “We think that that initial experience could be expanded with benefits for American cardiology patients.”

The commentary was published online ahead of the March 2016 print issue of Circulation: Cardiovascular Quality and Outcomes.

Problems With Reporting

Critics of PCI readmission reporting have pointed out that the metric makes physicians feel over-scrutinized for circumstances they cannot always control. As Wasfy and Yeh note, PCI readmission “does not appear to relate closely to procedural complications.” Instead, patient characteristics such as mental illness, poor social support, and poverty strongly influence the odds of being readmitted.

As such, penalizing hospitals on readmission rates alone could potentially “unfairly punish hospitals that care for socioeconomically vulnerable populations,” potentially further degrading the quality of care in these patients, they say.

Additionally, emergency departments can often be “admission sieves” for patients presenting with chest pain after PCI, according to Stephen G. Ellis, MD, of the Cleveland Clinic in Ohio, who commented on the paper for TCTMD. “There’s a large number of low-risk patients in this situation that get admitted, probably unnecessarily,” he said. “[ED physicians] don’t want the patient to have a heart attack, and they certainly don’t want to be sued if the patient had a heart attack.”

Outside of the ED, Ellis said, “what tends to happen is the physician will focus on [readmission metrics], and other things that are equally important may be getting less resources.” He estimated that his institution spent “well over a million dollars basically filling out forms” as of a few years ago.

Other metrics make more sense for judging whether standards or care are being met, Ellis argued, including quality of life, mortality, and costs. “I would far rather be measured on outcomes than processes because life is complex,” he said.  

Path Toward a ‘More Holistic Solution’

Both Ellis and John A. Spertus, MD, MPH, of St. Luke’s Mid America Heart Institute (Kansas City, MO), who also spoke to TCTMD about the commentary, criticized it for not proposing solutions as to how PCI readmissions reporting could effectively be done in practice. Organizations like the ACC and Society for Cardiovascular Angiography and Interventions should “logically” be responsible, Ellis suggested, but “having said that, I think sometimes the agencies that make up these rules are not terribly responsive to physician opinion.”

What Wasfy and Yeh have articulated well, according to Spertus, is that using readmissions as a reliable metric “is really an opportunity to think about a more holistic solution to minimizing patient inconvenience and resource utilization.”

Among all of the “very talented people” working in hospitals across the country, exist “a myriad of ideas about how care can be improved, how it can be more patient-centered, [and] how it could be more efficient,” Spertus said. “What doesn’t exist now is an incentive for the hospitals to invest in those individuals to bring forth new strategies for delivering care.”

Reintroducing accountability for PCI readmissions would create “an economic incentive for hospitals to think of strategies that work” within their patient population, region of the country, and staff, he said. “And that’s what I think we really want to see.”

The fact that “we’ve [currently] got a foot in the fee-for-service world and a foot in value-based care” affects how much change can be made in the near future, Spertus commented. “Until we jump in with both feet, we’re always going to be a little bit across purposes.”

Empowering Patients Through Education

Wasfy does not deny the possibilities of “gaming or unintended consequences” that might potentially follow implementation of the readmissions metric in the future. “We need to look at that very closely,” he said to TCTMD.

Ellis agreed, saying hospitals can game the system by using “observational status” as the reason for readmission. “Hopefully, most of us are putting our patients ahead of ourselves, and I think we are, but nobody likes to be singled out for penalties or to have implied that you are a bad hospital or bad physician because you don’t meet some of these metrics—the validity of which may not be terribly great,” he said.

The best solutions to reducing readmissions include better coordinated care, improved triage mechanisms, and patient education, Wasfy and Yeh write. The education component is especially important as many patients leave the hospital after a PCI not understanding the differences between angina and symptoms of an MI, they say.

“They’re scared, they’re nervous, and they are not empowered to deal with the disease,” Wasfy stressed. “We need to make sure fundamentally that not only is our procedural care good, but that we also create a healthcare system that’s responsive to the whole patient—that we’re dealing with anxiety, that we’re making sure patients know when to call us and how to get in touch with us quickly.”

Source: 
Wasfy JH, Yeh RW. Future of the PCI readmission metric [policy commentary]. Circ Cardiovasc Qual Outcomes. 2016;Epub ahead of print.

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