Most U.S. hospitals are scrambling to reduce readmissions for heart failure and heart attack as financial disincentives go into effect this fall, but efforts aren’t always targeting recommended methods, a survey found.
Almost 90% of the 537 centers surveyed said they had a written objective of reducing preventable readmissions for heart failure and acute myocardial infarction (MI), according to Elizabeth H. Bradley, PhD, of Yale, and colleagues.
But, on average, the hospitals had tried only half of the strategies recommended to tackle the readmission problem, the group reported online in the Journal of the American College of Cardiology.
The Centers for Medicare and Medicaid Services already tracks 30-day readmission rates for heart failure and acute MI, which it publicly reports on its Hospital Compare website.
Under the Affordable Care Act, the agency will begin docking Medicare payments to centers with high 30-day readmission and pneumonia in October. By 2014, hospitals with high rates could lose up to 3% of regular reimbursement as a penalty.
This escalation of pay-for-performance is a strong motivator and has hospitals worried, Javed Butler, MD, MPH, and Andreas Kalogeropoulos, MD, PhD, both of the Emory Clinical Cardiovascular Research Institute in Atlanta, noted in an editorial accompanying the paper.
But that doesn’t mean it’s going to actually end up improving outcomes, they argued, pointing to many efforts at heart failure quality of care improvement that haven’t shown hard endpoint or cost-savings benefits.
“Unfortunately, many of these activities are neither proven nor primarily based on the motivation to improve patient outcomes, but rather on the fear of punitive financial disincentives,” the editorialists wrote.
The enormous resources being spent by hospitals to randomly implement unproven interventions might be better spent nailing down effective interventions and how they must be implemented, they suggested.
Bradley’s group found wide variation in efforts under way at hospitals enrolled in the Hospital to Home campaign that aims to reduce readmission rates by 20% by the end of the year.
Most of the hospitals (88%) had implemented at least a couple of the 10 key practices recommended to reduce preventable readmissions in heart failure and acute MI, but only 12% used eight or more and just 3% used all 10. The overall average was 4.8.
The most universal was tracking 30-day readmission rates at their center (95%).
Close behind was setting up quality improvement teams to tackle preventable readmissions, more often related to heart failure than acute MI (87% versus 54%).
Rates of the other recommended key practices were more variable:
- 77% always included medication management efforts at discharge, including providing patient education about the purpose of each medication and any changes to their medication list
- 65% had discharge processes in which patients or their caregivers receive an emergency plan
- 63% regularly called patients after discharge to follow-up on post-discharge needs or to provide additional patient education
- 54% at least usually had patients leave the hospital with an outpatient follow-up appointment already arranged
- 32% monitored the percent of patients with follow-up appointments within 7 days of discharge
- 26% always sent a discharge summary directly to the patient’s primary medical doctor within 48 hours
- 23% had a pharmacy technician primarily responsible for obtaining medication history as part of medication reconciliation process
- 10% had a pharmacist usually or always responsible for conducting medication reconciliation at discharge
“Why might these practices be lacking in so many hospitals?” the researchers asked. “One reason might be because they require added resources.”
Another problem is lack of definitive evidence supporting efficacy of these strategies for reducing readmission rates, they added.
The group cautioned about the self-reported nature of the results, inability to assess impact on outcomes, and evaluation of practices within a group of hospitals enrolled in the quality improvement program that may not be representative of the nation as a whole.