Follow-Up Lowers 30-Day CHF Readmissions

ATLANTA — Ensuring that patients hospitalized for heart failure are evaluated by a physician within 7 days after discharge is emerging as a potential new target for hospital quality improvement.

Data from the American Heart Association's Get With The Guidelines–Heart Failure (GWTG–HF) Registry linked to Medicare billing records indicate that patients discharged from hospitals with higher rates of early physician evaluation have lower 30-day readmission rates, even after adjustment for covariates, Dr. Adrian F. Hernandez reported at the annual scientific session of the American College of Cardiology.

Unplanned early readmissions is a hot button issue that has drawn considerable attention from health policy makers. Roughly 20% of Medicare beneficiaries are readmitted within 30 days of hospitalization. Nearly 90% of readmissions are unplanned and potentially preventable. These readmissions account for $20 billion annually in Medicare hospital payments. Heart failure is the No. 1 cause of readmission within 30 days, noted Dr. Hernandez of the Duke Clinical Research Institute, Durham, N.C.

Dr. Hernandez and coinvestigators studied 30,136 patients hospitalized for heart failure during 2003–2006 in 225 U.S. hospitals participating in the GWTG–HF quality improvement program.

Rates of physician follow-up within 7 days post discharge were generally low but varied from hospital to hospital. In the lowest quartile of hospitals, less than 32.4% of patients had an outpatient evaluation and management visit within a week billed by a physician; in the fourth quartile, more than 44.5% did.

The unadjusted 30-day readmission rate at first-quartile hospitals was 23.3%, significantly higher than the 20.5% readmission rate at second- and third-quartile hospitals and the 20.9% rate at hospitals in the top quartile for early outpatient physician evaluation.

Thirty-day mortality was 5% for patients at first-quartile hospitals and 4.5% at top-quartile hospitals, a nonsignificant difference.

After adjustment for potential confounders, including patient age, gender, race, illness severity, and comorbidities, early rehospitalization was 9% less at fourth-quartile hospitals than at those in the bottom quartile in terms of early physician evaluation. That difference was statistically significant, as were the 13% and 15% cuts in readmission at third- and second-quartile hospitals, respectively.

One audience member serving on a panel advising the Center for Medicare and Medicaid Services said “these are just the kind of data we've been looking for” in order to advise the agency regarding new hospital performance standards. But she questioned whether a physician was necessarily the right person to do the early follow-up evaluation. Fine-tuning of outpatient heart failure management might be better done by a dedicated nurse practitioner or physician assistant.

Dr. Hernandez said that a limitation of the Medicare billing data is that it does not specify whether a physician-billed visit was performed by the physician who signed off or by a physician extender.

However, he was able to look at the specialties of physicians who billed for the early evaluations and found it had no bearing on the 30-day readmission rate.

Also, whether a patient was seen by the same or different physicians for the early outpatient and inpatient care had no bearing on the 30-day readmission rate.

These results were published subsequent to their presentation at the ACC meeting (JAMA 2010;303:1716–22).

Disclosures: Dr. Hernandez reported having financial relationships with Johnson & Johnson, Medtronic, Merck, Novartis, and AstraZeneca.

In the lowest quartile, 32% of patients had an outpatient visit within a week; in the fourth quartile, 45% did.

Source DR. HERNANDEZ