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  • Six-Step Plan May Cut HF Readmissions

    Posted on July 30, 2013 by in Heath Care News, News

    By Chris Kaiser, Cardiology Editor, MedPage Today

    Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

    Hundreds of millions of dollars could be saved if hospitals implemented six strategies aimed at reducing heart failure readmissions, a large national sample of hospitals revealed.

    Individually, the six strategies had a modest but still significant size effect ranging from 0.34 to 0.18 percentage points change in risk-standardized 30-day readmission rate (RSRR), wrote Elizabeth Bradley, PhD, of Yale University, and colleagues in the study published online inCirculation: Cardiovascular Quality and Outcomes.

    “But if all six strategies are followed, readmissions would drop by about 2%, which would result in a savings of more than $100 million,” Bradley told MedPage Today.

    However, Clyde Yancy, MD, from Northwestern University Feinberg School of Medicine in Chicago, said he is “concerned that hospitals will immediately launch resources towards one or more of these meager six steps, with at best the hope for a modest impact. The larger message of a dysfunctional system cannot be ignored.”

    Yancy, who is chief of the division of cardiology, said the Medicare Physician Advisory Committee recently endorsed the possibility of changing the Hospitals Readmission Reduction Program.

    “The change would eliminate the current disease-specific model and focus on all readmissions. Hospitals could then use more resources on process issues and fewer futile efforts on already overburdened heart failure patients,” said Yancy, who was not involved in the study.

    Bradley expressed a similar sentiment. She told MedPage Today that she hoped the study would help people realize that reducing readmission rates is a systems problem.

    “It is not something one physician or one nurse can do. It requires engagement of a full clinical discharge team, excellent practices of follow-up, and full engagement with the patient and family,” she said.

    The six strategies identified by Bradley and colleagues that were associated with reducing heart failure readmissions are:

    • Having nurses supervise medication plans
    • Scheduling follow-up appointments before patients leave the hospital
    • Collaborating with other hospitals to develop consistent strategies for reducing readmission
    • Developing systems to forward discharge information to the patient’s primary care doctor
    • Contacting patients on all test results received after they are discharged
    • Forming partnerships with community physicians or physician groups

     

    One of the problems, researchers discovered, was that fewer than 30% of the hospitals surveyed followed most of the steps, and only 7% used all six.

    To identify the six strategies, Bradley and colleagues sent a web-based survey between November 2010 and May 2011 to 658 hospitals that were enrolled in one or both of two national quality initiatives to reduce heart failure readmissions. A total of 599 hospitals completed the survey, and 14 hospitals were excluded for missing RSRR data.

    The remaining 585 hospitals comprised the cross-sectional study. Investigators found a mean readmission rate of 24.7%. In the multivariable analysis, they adjusted for the number of staffed beds, teaching status, and census region.

    Unexpectedly, researchers also found some strategies associated with an increase in RSRR, even though they have been recommended by quality alliances. They include:

    • More frequent electronic linking of outpatient and inpatient prescription records
    • Providing all patients or their caregivers with a written emergency plan upon discharge
    • Having a reliable process to ensure outpatient physicians were alerted about the patient’s discharge within 48 hours after discharge

     

    A number of reasons could explain this increase in RSRR including variable quality of implementation or a measurement of the strategy that is imperfect, Bradley and colleagues said.

    There may be some strategies that were not significant in this national sample, but may be effective in individual hospitals and “tailoring strategies to fit local circumstances should be encouraged,” researchers noted.

    The study was limited by its cross-sectional design, the lack of data on how hospitals implemented the strategies, no data on patient socioeconomic status, self-selection bias, and no information on organizational culture, according to the researchers.

    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. One co-author reported a research grant from Medtronic through Yale University and serving as chair of a cardiac scientific advisory board for United Health. Another co-author reported serving as a consultant to United Health Care and Eli Lilly. Other authors reported no conflicts of interest.

    From the American Heart Association:

     

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