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Heart failure readmission metric not linked to care quality

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Metric flaws should raise alarm

These authors add to a chorus of voices expressing concern regarding the appropriateness and validity of the 30-day readmission metric. Arguably, this metric has driven our entire provider workforce to construct machinery designed to reduce short-term posthospitalization utilization, while doing little to improve quality for the 5.7 million (and counting) Americans with heart failure.

Dr. Marvin A. Konstam

Dr. Marvin A. Konstam

The 30-day readmission metric, with its many flaws and clear direction to reduce utilization and cost but without focus on patient well-being, should serve as an alarm that we are heading in the wrong direction of allowing government policy makers, rather than patients, to drive the design of clinical care metrics. Alternatively, the government can and should play an important role in facilitating an environment of integrated health care systems and market-based competition, within which consumers can drive the advancement of their own health.

Marvin A. Konstam, MD, of Tufts University, Boston, made these comments in an accompanying editorial (JACC: Heart Fail. 2016 Nov 15. doi: 10.1016/j.jchf.2016.10.004). He reported no relevant disclosures.



Metrics used by the Centers for Medicare & Medicaid Services to determine penalties for heart failure hospital readmissions are not associated with quality of care or overall clinical outcomes, according to data presented at the annual scientific sessions of the American Heart Association.

Ambarish Pandey, MD, of the University of Texas Southwestern Medical Center in Dallas, and his colleagues analyzed data from centers participating in the American Heart Association’s Get With The Guidelines-Heart Failure (GWTG-HF) registry linked to Medicare claims from July 2008 to June 2011. Centers were stratified as having low risk-adjusted readmission rates and high risk-adjusted readmission rates based on publicly available data from 2013.

The study included 171 centers with 43,143 patients. Centers were almost evenly split between low- and high-risk–adjusted 30-day readmission rates, with just a few more (51%) falling in the low-risk–adjusted category.

Performance was nearly equal (95.7% for centers with a low risk-adjusted readmission rate vs. 96.5% for those with high risk-adjusted rate) for median adherence to all performance measures, as was the case for median percentage of defect-free care (90.0% vs. 91.1%, respectively) and composite 1-year outcome of death or all-cause readmission rates (median 62.9% vs. 65.3%, respectively). The higher readmission group had higher 1-year all-cause readmission rates (median, 59.1% vs. 54.7%), Dr. Pandey and his colleagues reported in the study that was published simultaneously in JACC: Heart Failure (2016 Nov 15. doi. org/10.1016/j.jchf.2016). One-year mortality rates were lower in the higher readmission group with a trend toward statistical significance (median, 28.2% vs. 31.7%; P = 0.07).

Taken together, the findings suggest the 30-day readmission metrics currently used by CMS to determine readmission penalties are not associated with quality of care or overall clinical outcomes, Dr. Pandey and his colleagues wrote. Results showing higher 30-day readmissions do not necessarily reflect poor quality of care and may be related to other factors.

“These findings question the usefulness of the [hospital readmission reduction program] metric in identifying and penalizing hospitals with low quality of care,” Dr. Pandey wrote, adding that the findings were consistent with previous studies that have demonstrated a lack of association between in-hospital quality of care and 30-day readmission rates.

CMS implemented the federal Hospital Readmissions Reduction Program (HRRP) in 2012 to provide financial incentives for hospitals to reduce readmissions. Under the program, CMS uses claims data to determine whether readmission rates for heart failure, acute myocardial infarction, and pneumonia at eligible hospitals are higher than would be predicted by CMS models. Centers with higher than expected readmission rates face up to a 3% reimbursement penalty.

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