Six strategies to reduce HF readmission rates

Yael Waknine

July 31, 2013

Dallas, TX - Six accountable-care strategies may help reduce 30-day readmission rates in patients with heart failure, according to a study published in the July 2013 issue of Circulation: Cardiovascular Quality and Outcomes[1]. At least one expert, however, thinks the new analysis shows better measures are needed.

Although each individual step reduced 30-day readmission rates by less than 0.5% (range 0.18%-0.34%), using all six steps in a large patient population could yield significant cost savings, write Dr Elizabeth H Bradley (Yale University in New Haven, CT) and colleagues.

"A million people are hospitalized with heart failure each year, and about 250 000 will be back in the hospital within a month," Bradley said in an American Heart Association news release. "If we could keep even 2% of them from coming back to the hospital, that could equal a saving of more than $100 million a year."

Dr Akshay Suvas Desai (Brigham and Women's Hospital, Boston, MA), who was not involved in the study, was less enthusiastic, saying in an interview that the findings were "quite discouraging" in light of the considerable resources that have been allocated to strategy design and implementation.

"The most striking feature of this analysis is not the association between specific strategies and variation in readmission rates but the small magnitude of the apparent effects. Even hospitals implementing several 'effective' strategies had only marginally lower rates of heart-failure readmission," Desai pointed out. The study revealed an absolute incremental effect of only -0.34% (p<0.001) for each additional strategy.

"These data underscore the point that a large proportion of readmissions at 30 days may be outside the reach of efforts focused on early postdischarge care transitions. Longitudinal support through comprehensive disease management with attention to specific cardiovascular, noncardiovascular, and psychosocial drivers of heart-failure readmission may be even more important than standardization of the care processes examined here," Desai said.

Six positive alliance-vetted strategies

Collecting data from a web-based survey of 585 hospitals participating in one or two national quality initiatives, researchers analyzed the effects of 30 vetted strategies in a model that controlled for the number of staffed beds, teaching status, and census region.

They found that coordination of care between hospitals (-0.34%; p=0.020) and partnering with community physicians/physician groups (-0.33%; p=0.017) were associated with the greatest effect on reducing 30-day readmission rates.

Other helpful strategies included assigning staff to follow up on postdischarge test results (-0.26%; p=0.049), sending discharge summaries directly to primary-care physicians (-0.21%; p=0.004), scheduling follow-up appointments before discharge (-0.19%; p=0.037), and giving nurses the responsibility of medication reconciliation (-0.18%; p=0.002).

Many of these strategies were being implemented by a minority of hospitals (<30%), and only 7% of the hospitals used all six, highlighting opportunities for improvement.

Four strategies increased readmission rates

Surprisingly, four of the strategies were associated with increased 30-day readmission rates, including electronic linking of inpatient and outpatient prescription records (0.18%; p=0.003), providing a written emergency plan on discharge (0.38%; p=0.004), alerting outpatient physicians of discharges within 48 hours (0.42%; p=0.003), and providing follow-up calls with additional education for discharged patients (0.34%; p=0.010).

The authors attribute the effect to inadvertent lowering of the readmission threshold, variations in strategy implementation, and imperfect methods of measurement.

"It is not possible to conclude that hospitals should selectively implement those strategies that were 'helpful' to the exclusion of those that were 'harmful' based purely on the directional association in this sample," Desai said, noting the "considerable" overlap between the helpful and harmful strategies and cautioning that some of the observed associations may merely reflect residual confounding or the play of chance.

Moreover, some interventions, such as increased surveillance intensity to facilitate early detection of deterioration, may be valuable despite their association with higher readmission rates.

"Indeed, secular trends suggest that rates of readmission tend to vary inversely with mortality rates after discharge," Desai said. "Hospitals must take caution not to develop excessive aversion to appropriate hospital admissions in their zeal to meet performance metrics."

The study was funded by the Commonwealth Fund ; the Center for Cardiovascular Outcomes Research at Yale University; the National Heart, Lung, and Blood Institute ; the National Institute on Aging ; the American Federation for Aging Research ; and the Claude D Pepper Older Americans Independence Center at Yale University School of Medicine. Bradley reported no conflicts of interest. Disclosures for the coauthors are listed in the paper. Desai have disclosed no relevant financial relationships.

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