Melissa Walton-Shirley, MD


November 16, 2016

If there was ever an ideal first job for our president-elect Donald J Trump, it would be to repeal the Heart Failure Readmission Reduction Program (HRRP) of the Centers for Medicare & Medicaid Services (CMS).

With it should come a directive to pour all the money "stolen" from hospitals over the past few years into programs that actually work.

And don't tell me he can't do it. It should be infinitely easier than "building a wall" between the US and Mexico, or "rounding up and deporting" all undocumented immigrants.

Despite the lamenting over the election results by the "liberal media," of which many at the American Heart Association 2016 Scientific Sessions are a collective part, we should recognize that as a unit we could implore our new president to act as the impermeable pit bull that he is.

By all accounts, he does listen to the media, and he has Ben Carson in his camp to advise him—who is both intelligent and a physician. Trump is in a position to do something good for medicine. It's not just a passing thought or a hapless lark of a notion. The request is based on evidence and common sense.

Going for the throat of what drives the cost of healthcare by starting with our country's most expensive DRG would seem to be right down his ally. Today, we saw more on the specifics of why a repeal is necessary.

The simple poster session, Hospitalization and readmission for heart failure: Rethinking current events, was buried at the back of the science and technology hall—and that was a mistake. As you can see from the photo, it would have packed a room, and then some. And the photos does not capture the attendees who just kept walking or gave up and left because they couldn't see or hear.

Anyone perusing the program for interesting and practical presentations would earmark this as a "must see" if they ran across it. As clinicians and researchers, we fully recognize that congestive heart failure (CHF) is a cardiovascular cancer that is killing our nation.

Furthermore we acknowledge that all of its drivers—coronary heart disease, diabetes, hypertension, smoking, and obesity—hold a firm second place as coconspirators. CHF is the hub of many spokes that should be systematically addressed.

As a result, the merry-go-round of readmission rates for heart failure across the board are 20% and have been accurately described as deplorable long before politics morphed that definition forever.

Dr Ambarish Pandey (University of Texas Southwestern Medical Center, Dallas) gave a most salient talk on the topic[1].

The proof in Dr Pandey's talk is here:

  • ERR (excess readmission rates)=Risk-adjusted observed readmission/Risk-adjusted expected readmissions.

  • ERR >1 indicated higher than expected readmission rates and contributes toward readmission penalty.

The sample size of 44,143 that Dr Pandey reported on included heart-failure patients at 175 participating centers. He found that centers with higher ERR ratios had lower mortality, but based on the current rules of the CMS game, unfortunately they also incurred more penalties.

These succinct sound bytes require no description:

Dr Pandey: "Thirty-day readmission is essentially inversely related to mortality because the tertiary centers treat patients who are sicker and die; therefore, some don't get readmitted. They are willing to take care of sicker patients who have higher readmission rates, but it makes them live longer and the mortality lower.

"This has been shown in short-term mortality, but also we saw this at 1-year follow-up with lower mortality in centers with higher readmission. It's not that the admissions were unjustified."

Dr Eiran Gorodeski (Cleveland Clinic, OH), moderator: "As a follow-up question, this is controversial and puts this metric into question. So what would your message be to CMS and hospitals dealing with this issue?"

Dr Pandey: "The burden-of-admission penalty has been increasing and is now at 4% in the most recent fiscal year. And while focusing on readmission rates, it has diverted our attention from other quality metrics and management of the patient.

"The metric should be modified to account for differences in ethnic distribution. This and the severity of disease burden have not been accounted for in a fair manner."

Dr Pandey: "Each year there is a new penalty, and not the same hospitals get penalized every year. It's hard to tease out the differences between the first and second years. ERR stratification in MI outcomes has produced the same results.

"Improving the quality metrics includes the need to focus on mortality rates and socioeconomic status. It's unfair, for instance, to compare a county hospital with a tertiary center because they are probably taking care of sicker patients."

We then heard from Dr Ahmad Masri (University of Pittsburgh Medical Center, PA). His presentation examined the impact of the ridiculous label shuffling between the terms "admission" and "observation" that the CMS has forced hospitals to participate in to avoid penalties[2]. He studied a large sample size of 21,339 unique patients with 52,493 hospital admissions in 18 systems with a primary diagnosis of heart failure. The end points included heart-failure readmission, cardiac readmission, all-cause readmission, and all-cause mortality.

Outcomes were adjusted for age, gender, left ventricular ejection fraction (LVEF), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), pneumonia, renal failure, and liver disease. He found there was "no mortality difference and higher readmission rates in heart-failure patients placed under observation as compared with those admitted under short inpatient stays . . . suggesting the difference is more administrative designation than a true reflection of patient status." His conclusion? "There is a need for a patient-centered streamlined approach in evaluating and treating patient with heart failure with a revised treatment-based algorithm and admission rules that guide physician and shape healthcare policy."

Now, why did I kept hearing Joe South's 1970 Grammy-winning song "The games people play" over and over in my head after this talk? There is probably no better theme song for what the CMS is doing to our heart-failure patients and to us. Adding another twist of irony, Mr South died of heart failure in 2012. Sadly, I wonder how many times he was an "observation" or an "admission" in the latter weeks of his life?

So how could we implement the monies that CMS has "stolen" to actually help CHF patients? What follows are a few cursory suggestions.

  1. Reward hospitals that put a Dietary Approaches to Stop Hypertension (DASH) diet and Mediterranean diet in the hands of every CHF patient and compensate them if they are visited by a nutritionist at every single hospital admission to explain it.

  2. Employ teams to make certain that medication reconciliations are accurate. We've all seen patients who have been readmitted back on all the same meds they were failing on at first admission for reasons unclear. I have a feeling it's because we don't have dedicated discharge pharmacologists and follow-up. Empower pharmacists!

  3. Employ nurses to call back patients to remind them to take their meds and weight.

  4. Fund glucose-tolerance testing in those with an elevated body-mass index (BMI), not just "abnormal blood sugars." The burden of the inflammatory milieu that continues to fibrose the ventricles of HFpEF (heart failure with preserved ejection fraction) sufferers is no doubt tremendous, and many of them don't even have a diagnosis of diabetes. It's like putting a blindfold on these patients and then telling them to go fight their biggest enemy.

  5. Pay for smoking-cessation counseling. This is a really big "duh." I'm tempted to say a "tremendous duh."

  6. Encourage studies to separate out the "why" of heart-failure admissions instead of lumping them all together. Is it valvular heart disease? Pump failure? Poorly controlled atrial-fibrillation rates that hint at noncompliance? Sodium loading? Renal failure or something else like thromboembolic disease that's masquerading as CHF? The way we now study the readmission patterns of this disease by lumping all CHF patients together would be equivalent to treating all cancers the same.

  7. Teach patients how to weigh themselves and give all of them an algorithm for a sliding scale of diuretic. This seems trite to many of us that often deal with CHF, but I find that patients have never been told to stop "flushing their kidneys" by overdrinking or to avoid salt and weigh themselves daily.

  8. Make certain we've accurately assessed for valvular heart disease, coronary heart disease, and ischemia.

CHF is a bipartisan disease, affecting both Democrats and Republicans, conservatives and liberals, and does not respect gender. Although most patients are older, it cuts across all ages. There are plenty of young people, including children, who find themselves in need of therapies, including advanced transplantation and assist devices.

One of the first and best ways we could come together after the most divisive election in our nation's history would be to extend an olive branch and helping hand to hospitals, who treat the cross-section of the country that is dying and draining our resources.

Encouraging the assessment, treatment, and compliance with CHF therapies combined with an immediate halt to penalties being imposed on our nation's most excellent heart-failure centers are paramount to our future success. It's then important that we divert the resources "stolen" by CMS to the above eight tenets to get at the drivers of CHF readmission.

Now that would be a beautiful thing.

A beautiful thing, indeed.


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