Ileana L. Piña, MD, MPH


April 29, 2015

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Hello. I'm Ileana Piña from Montefiore Medical Center in the Bronx, New York. This is my blog. I am thrilled to be here at the American College of Cardiology (ACC) National Meeting in San Diego, where we have traded the bad weather of New York for this beautiful San Diego weather.

It's been a very interesting meeting. The ACC is trying very hard to get audiences and presenters closer together, to have a better educational interaction. This was demonstrated to me yesterday, when I moderated a poster session where we had probably between 50 and 70 people waiting for the discussions to happen in a very small booth.

I want to talk about the papers that I heard about. This was all about my favorite topic of the 30-day readmission rate. I think all of us, and I'm sure my audience here, continues to think about this unacceptably high 30-day readmission rate that we have for heart failure patients.

Multiple Comorbidities

We keep thinking that the second admission must be for heart failure because we left something out. In fact, it isn't. The return admissions are for a multitude of comorbidities, and there may be such things as electrolyte disturbances, or renal dysfunction, or even a pulmonary infection. Questions have arisen: Were these problems already there when the heart failure presentation happened and they weren't addressed appropriately, and now they come back literally to bite us? Or is it that these patients are so complex that we're dealing with the overwhelming problem during the first admission, which really is heart failure and trying to get them decongested? That was one poster.[1]

Timing of Readmission

There was a second very interesting observation in this poster about the timing of that readmission. Now we have heard—and I've done other blogs about this, and in Get With the Guidelines we had some data[2]—that if follow-up happened somewhere around 7 days, which only about 34% of hospitals were doing, then we could effectively reduce the readmission rate.

Well guess what? Twelve days is about the mean that patients are coming back. It doesn't take all 30 days. Whatever intervention we do, we must do it early. We must do it within the first 2 weeks, because whether it's an electrolyte disturbance, a return of the heart failure symptoms, or an infection—and did the patient get the infection while in the hospital, such as Clostridium difficile?—then we need to address it early.

Accountable Care Organizations

The other poster[3] that was presented was from the Yale Center for Outcomes Research & Evaluation, which is run by Dr Harlan Krumholz and is a very successful center. They have been putting together comorbidity "big data" comprising Medicare populations, and trying to compare the Medicare non-heart failure population with the Medicare heart failure population to see how have our accountable care organizations (ACOs) been doing. The ACO is one of Medicare's pathways to improve quality and to reduce cost.

Even with the onset of the big ACOs—and some of them have been highly successful—it's really a regular distribution curve. A small percentage of them have made improvements in the 30-day readmission rate, and a small percentage have gotten worse. The rest are kind of in the middle.

So what is happening out there between accomplishing our goals and making this reduction in 30-day readmission for which we are getting penalized? I truly believe that the social determinants of care are very much at play here. Until we address this, we're not going to put our hands around the problem.

Thank you for your attention today. Ileana Piña signing off.


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