John Mandrola, MD

Disclosures

November 17, 2016

Taking care of people with heart failure is hard enough. Policy makers should stop making it harder.

The idea that reducing 30-day readmissions for heart failure would predict good care made sense. In the practice of medicine, however, ideas that make sense don't always deliver benefit. Witness hormone-replacement therapy in postmenopausal women and treating premature ventricular contractions (PVCs) with antiarrhythmic drugs after MI.

Evidence guides those of us who deliver care at the bedside. Evidence should also guide those making policy from cubicles.

New research[1] presented at the American Heart Association (AHA) 2016 Scientific Sessions and simultaneously published in JACC: Heart Failure provides further evidence that quality measures may actually reduce quality­­­.

A group of American researchers used data from the Get the Guidelines-Heart Failure to assess the value of lowering 30-day readmissions for heart failure. They separated two groups of hospitals—those with higher-than-expected earlier readmissions and those with normal rates of readmissions.

They included 171 centers with more than 43,000 patients. End points measured were adherence to performance measures during the hospital stay and 1-year clinical outcomes. (Focus on the latter.)

  • No differences were observed between the low and high 30-day heart-failure readmission groups in adherence rate to all performance measures (95.7% vs 96.5%, P=0.37) or percentage of defect-free care (90.0% vs 91.1%; P=0.47).

  • Composite 1-year outcome of death or all-cause readmission rates was not different between the two groups: 62.9% in hospitals with normal readmission rates vs 65.3% in hospitals with high rates of readmissions (P=0.10).

  • In all-cause readmissions, hospitals with low 30-day HF readmission rates outperformed high-readmission hospitals by 4% (P=0.01).

  • Researchers noted a strong trend (P=0.07) toward higher mortality in hospitals with lower readmissions. (Read that result again.)

The authors concluded that these findings raise questions about the validity of using readmissions as a means of identifying and penalizing hospitals.

Comments

It's little surprise that performance measures were similar among the two groups of hospitals. Performance measures such as the use of ACE inhibitors/ARBs and beta-blockers are easy to comply with. Box checking and protocol following can be taught and enforced.

The main finding of this study was the lack of benefit—and possible harm—in clinical outcomes seen in hospitals that had low 30-day HF readmissions.

This policy reversal should have been expected. Previous studies have shown no signal of benefit from lowering 30-day HF readmissions.[2,3] You could argue, then, that this most recent study confirmed previous studies—which strengthens our trust in the results.

Thirty-day readmission rates have become a benchmark of hospital performance, one that is enforced by financial penalties. In the first year the penalty went into effect, the Centers for Medicare and Medicaid Services penalized 64% of hospitals, totaling $290 million in fines.

Anyone who works in a hospital knows the result of penalties: administrators will furiously spend time, mental energy, and dollars to reduce short-term readmissions. They may even form an ad hoc committee—or hire another coordinator.

In my experience, people rarely question policy. Penalties and public reporting of data seem to stifle critical appraisal. Yet well-meaning but poor policy can affect millions. For instance, I'm not an infectious-disease expert, but I suspect the quality measure of time to antibiotics for pneumonia did little to improve our antibiotic-resistance problem.

In the discussion section of the JACC: Heart Failure paper, the authors explain the failure of 30-day HF readmissions as a surrogate for quality by noting "hospital-level" factors such as the proportion of vulnerable patients served and socioeconomic status of the hospital community and "patient-level factors" such as history of mental illness, social and home support, and baseline disease severity.

Anyone who cares for patients with heart failure knows these factors as givens. Robotic titration of guideline-directed medications works well for the 55-year-old man with an isolated cardiomyopathy, high blood pressure, and a large family support system. But that same robotic titration of meds in an elderly woman with heart failure and Parkinson's disease, sarcopenia, chronic kidney disease, no transportation to the clinic, and no cell phone is almost guaranteed to do harm. This latter patient would do far better with less of anything called a "quality measure" or "guideline-directed."

Another harm from adherence to bad policy is that it worsens what I consider the biggest patient safety issue of our time—distraction. If hospital people are focused on readmissions, they aren't focused on other important things—relief of symptoms, for example.

Finally, the authors call for "broadening the focus of hospital quality assessment and improvement programs from short-term readmission rates to more comprehensive measures of care quality and clinical outcomes."

The problem with that lofty statement is that one of the measures they called for is to address relevant social issues that may influence long-term clinical outcomes.

How, exactly, does a hospital improve "social issues?"

If hospitals could improve social issues, or even health for that matter, Philadelphia County in Pennsylvania—home of five major medical centers—would not rank last in the state for health measures.

I think the best way for health policy makers to improve social issues is for them to let hospitals focus on caring for the ill and leave the well alone. Second, evidence should guide policy as much as it does bedside care. Finally, clinicians need veto power of cubicle decisions.

The money saved could then be redirected into social issues: parks, walkable neighborhoods, good schools, and stores to buy decent food.

Asking less of hospitals and our health policies might just deliver more health.

JMM

PS. My colleague Dr Melissa Walton Shirley also chose to wrote about this major policy reversal. Her take on this topic is worth a look.

Comments

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