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Reducing Heart Failure Readmission Rates with an Emergency Department Early Readmission Alert
CLINICAL EFFECTIVENESS Kim A. Eagle, MD, and Elizabeth A. Jackson, MD, MPH, Section Editors
Reducing Heart Failure Readmission Rates with an Emergency Department Early Readmission Alert Azam Hadi, MD,a Yaron Hellman, MD,a Adnan S. Malik, MD,a Marco Caccamo, DO,a Irmina Gradus-Pizlo, MD,a Joanna Kingery, PharmDb a
Krannert Institute of Cardiology, IU School of Medicine, Indianapolis, Ind; bIU Health, Indianapolis, Ind.
Among Medicare beneficiaries, readmission within 30 days after hospitalization for heart failure approaches 25% even after accounting for hospital profiles and case mix.1 These readmissions have a direct impact on patient prognosis, patient satisfaction, and costs.2 According to the Patient Protection Affordable Care Act of 2010, hospitals with high readmission rates can lose up to 3% of their Medicare reimbursement by 2015.3 Early follow-up after discharge may decrease readmissions,4 but approximately half of heart failure readmissions occur before the first scheduled ambulatory visit.5 Bradley et al6 constructed a multivariable linear regression model from multiple hospitals, weighted by hospital volume, to determine whether multiple systematic established interventions (ie, partnering with local hospitals, medication reconciliation, follow-up appointments) are independently associated with riskstandardized 30-day readmission rates and found that although statistically significant, the magnitude of the effects was modest, with individual strategies associated with less than half a percentage point reduction in readmission rates; however, hospitals that implemented more strategies had significantly lower readmission rates. Our institution had implemented multiple strategies already: establishing a dedicated quality assurance program, early discharge scheduling and follow-up,
Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Azam Hadi, MD, Director of Heart Transplant, Krannert Institute of Cardiology, Indiana University School of Medicine, 1801 N. Senate Blvd, MPC-II Suite 2000, Indianapolis, IN 46202. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.07.025
early assignment of “heart coaches,” and predischarge medication reconciliation to reduce readmissions. Despite diligent efforts toward these interventions, readmission rates remained high and essentially unchanged after a period of predictable mild improvement. Our heart failure quality assurance program suggested a novel “reverse” approach, which targets the last step toward readmission: the emergency department. This intervention includes 2 stages: generating an emergency department early readmission alert and appropriately responding to the alert.
METHODS Generating the Emergency Department Early Readmission Alert The electronic medical record system was programmed to tag all patients discharged from a heart failure hospitalization. This link allowed the electronic medical record system to immediately identify the patient as a readmission during registration in the emergency department within 30 days and generate a page and e-mail alert to the heart failure team.
Response to the Early Readmission Alert Our protocol consisted of dispatching an advanced provider to the emergency department to initiate aggressive diagnostics and therapy geared toward avoidance of readmission. The 3 main options included (1) discharge the patient from the emergency department for a heart failure clinic visit within 72 hours; (2) admit the patient to an observation unit designated for approximately 24 to 48 hours of heart failure therapy; if the readmission is unrelated to heart failure, the patient will receive targeted initial therapy (eg, infection, chronic obstructive pulmonary disease, anemia) and referral to
Hadi et al Table 1
Emergency Department Readmission Alert Reduces Heart Failure Readmissions
1061
Heart Failure Readmissions for 12-Month Periods Before Versus After Early Readmission Alert Intervention
Total HF admissions 30-d readmissions (rate%) Admissions to observation unit (rate %)
Before ERA Intervention (12 mo)
After ERA Intervention (12 mo)
P Value
Odds Ratio (95% CI)
838 194 (23.2%) 19 (2.3%)
827 143 (17.3%) 34 (4.1%)
.003 .045
0.69 (0.55-0.88) 1.85 (1.04-3.27)
CI ¼ confidence interval; ERA ¼ early readmission alert; HF ¼ heart failure.
the appropriate outpatient subspecialty; and (3) admit the patient as an inpatient.
Statistical Methods This was a retrospective cohort study of patients who were admitted to Indiana University Health Methodist Hospital with a diagnosis of heart failure between February 2011 and January 2013. We compared patients before and after implementation of the early readmission alert intervention. The preintervention group consisted of patients with heart failure who were admitted between February 2011 and January 2012, and the postintervention group consisted of patients with heart failure who were admitted between February 2012 and January 2013. A chi-square test was used to discern the categoric differences between the 2 groups. A P value < .05 was considered significant. This study was approved by the institutional review board as an exempt study.
RESULTS There were approximately equivalent numbers of total hospital admissions for heart failure labeled as index heart failure admissions during the comparable time periods.
We observed a significant decrease in the 30-day heart failure readmission rate in the early readmission alert intervention group when compared with previous patients without this intervention (17.3% vs 23.2%, respectively). As expected, there was an increase in admissions to the observation unit in the intervention group (Table 1). The decrease in the monthly percentage of heart failure readmissions out of all hospital readmissions is also evident when plotted over time (Figure 1).
DISCUSSION Strategies to reduce heart failure readmissions have mainly focused on the predischarge and early postdischarge periods. To our knowledge, there have been no studies addressing the problem of readmissions at the emergency department “gatekeeper” level. The advantage of this approach is the use of minimal resources for the first stage—programming the electronic medical record to identify readmissions and automatically alert the team. The second step uses available resources. This intervention also intercepts patients who evaded all other heart failure readmission reduction strategies.
Figure 1 Thirty-day readmission rates before and after implementing emergency department early readmission alert. Note the rates of readmissions (blue line) dramatically decrease on implementation of the early readmission alert to levels that are predominantly lower than the goal 30-day readmission rate (orange line). ED ¼ emergency department; ERA ¼ early readmission alert.
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The American Journal of Medicine, Vol 127, No 11, November 2014
CONCLUSIONS
References
Our single-center study is limited with selection and time bias inherent to the retrospective design. However, the results were significant with a clinically meaningful reduction in heart failure readmission rates. The emergency department early readmission alert is comparable to other strategies of decreasing heart failure readmissions and may be evaluated in larger trials and quality improvement programs.
1. Keenan PS, Normand SL, Krumholz HM. An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2008;1:29-37. 2. Chun S, Tu JV, Wijeysundera HC, et al. Lifetime analysis of hospitalizations and survival of patients newly admitted with heart failure. Circ Heart Fail. 2012;5:414-421. 3. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §2702, 124 Stat. 119, 318-319. 2010. 4. Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303:1716-1722. 5. Desai AS. The three-phase terrain of heart failure readmissions. Circ Heart Fail. 2012;5:398-400. 6. Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6:444-450.
ACKNOWLEDGMENTS The authors thank Scott Keller, MS, and Robert Parr, BA, of the IU Health Information Technology Department. This publication was made possible by the Indiana University Health e Indiana University School of Medicine Strategic Research Initiative.
Reducing Heart Failure Readmission Rates with an Emergency Department Early Readmission Alert Azam Hadi, MD,a Yaron Hellman, MD,a Adnan S. Malik, MD,a Marco Caccamo, DO,a Irmina Gradus-Pizlo, MD,a Joanna Kingery, PharmDb a
Krannert Institute of Cardiology, IU School of Medicine, Indianapolis, Ind; bIU Health, Indianapolis, Ind.
Among Medicare beneficiaries, readmission within 30 days after hospitalization for heart failure approaches 25% even after accounting for hospital profiles and case mix.1 These readmissions have a direct impact on patient prognosis, patient satisfaction, and costs.2 According to the Patient Protection Affordable Care Act of 2010, hospitals with high readmission rates can lose up to 3% of their Medicare reimbursement by 2015.3 Early follow-up after discharge may decrease readmissions,4 but approximately half of heart failure readmissions occur before the first scheduled ambulatory visit.5 Bradley et al6 constructed a multivariable linear regression model from multiple hospitals, weighted by hospital volume, to determine whether multiple systematic established interventions (ie, partnering with local hospitals, medication reconciliation, follow-up appointments) are independently associated with riskstandardized 30-day readmission rates and found that although statistically significant, the magnitude of the effects was modest, with individual strategies associated with less than half a percentage point reduction in readmission rates; however, hospitals that implemented more strategies had significantly lower readmission rates. Our institution had implemented multiple strategies already: establishing a dedicated quality assurance program, early discharge scheduling and follow-up,
Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Azam Hadi, MD, Director of Heart Transplant, Krannert Institute of Cardiology, Indiana University School of Medicine, 1801 N. Senate Blvd, MPC-II Suite 2000, Indianapolis, IN 46202. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.07.025
early assignment of “heart coaches,” and predischarge medication reconciliation to reduce readmissions. Despite diligent efforts toward these interventions, readmission rates remained high and essentially unchanged after a period of predictable mild improvement. Our heart failure quality assurance program suggested a novel “reverse” approach, which targets the last step toward readmission: the emergency department. This intervention includes 2 stages: generating an emergency department early readmission alert and appropriately responding to the alert.
METHODS Generating the Emergency Department Early Readmission Alert The electronic medical record system was programmed to tag all patients discharged from a heart failure hospitalization. This link allowed the electronic medical record system to immediately identify the patient as a readmission during registration in the emergency department within 30 days and generate a page and e-mail alert to the heart failure team.
Response to the Early Readmission Alert Our protocol consisted of dispatching an advanced provider to the emergency department to initiate aggressive diagnostics and therapy geared toward avoidance of readmission. The 3 main options included (1) discharge the patient from the emergency department for a heart failure clinic visit within 72 hours; (2) admit the patient to an observation unit designated for approximately 24 to 48 hours of heart failure therapy; if the readmission is unrelated to heart failure, the patient will receive targeted initial therapy (eg, infection, chronic obstructive pulmonary disease, anemia) and referral to
Hadi et al Table 1
Emergency Department Readmission Alert Reduces Heart Failure Readmissions
1061
Heart Failure Readmissions for 12-Month Periods Before Versus After Early Readmission Alert Intervention
Total HF admissions 30-d readmissions (rate%) Admissions to observation unit (rate %)
Before ERA Intervention (12 mo)
After ERA Intervention (12 mo)
P Value
Odds Ratio (95% CI)
838 194 (23.2%) 19 (2.3%)
827 143 (17.3%) 34 (4.1%)
.003 .045
0.69 (0.55-0.88) 1.85 (1.04-3.27)
CI ¼ confidence interval; ERA ¼ early readmission alert; HF ¼ heart failure.
the appropriate outpatient subspecialty; and (3) admit the patient as an inpatient.
Statistical Methods This was a retrospective cohort study of patients who were admitted to Indiana University Health Methodist Hospital with a diagnosis of heart failure between February 2011 and January 2013. We compared patients before and after implementation of the early readmission alert intervention. The preintervention group consisted of patients with heart failure who were admitted between February 2011 and January 2012, and the postintervention group consisted of patients with heart failure who were admitted between February 2012 and January 2013. A chi-square test was used to discern the categoric differences between the 2 groups. A P value < .05 was considered significant. This study was approved by the institutional review board as an exempt study.
RESULTS There were approximately equivalent numbers of total hospital admissions for heart failure labeled as index heart failure admissions during the comparable time periods.
We observed a significant decrease in the 30-day heart failure readmission rate in the early readmission alert intervention group when compared with previous patients without this intervention (17.3% vs 23.2%, respectively). As expected, there was an increase in admissions to the observation unit in the intervention group (Table 1). The decrease in the monthly percentage of heart failure readmissions out of all hospital readmissions is also evident when plotted over time (Figure 1).
DISCUSSION Strategies to reduce heart failure readmissions have mainly focused on the predischarge and early postdischarge periods. To our knowledge, there have been no studies addressing the problem of readmissions at the emergency department “gatekeeper” level. The advantage of this approach is the use of minimal resources for the first stage—programming the electronic medical record to identify readmissions and automatically alert the team. The second step uses available resources. This intervention also intercepts patients who evaded all other heart failure readmission reduction strategies.
Figure 1 Thirty-day readmission rates before and after implementing emergency department early readmission alert. Note the rates of readmissions (blue line) dramatically decrease on implementation of the early readmission alert to levels that are predominantly lower than the goal 30-day readmission rate (orange line). ED ¼ emergency department; ERA ¼ early readmission alert.
1062
The American Journal of Medicine, Vol 127, No 11, November 2014
CONCLUSIONS
References
Our single-center study is limited with selection and time bias inherent to the retrospective design. However, the results were significant with a clinically meaningful reduction in heart failure readmission rates. The emergency department early readmission alert is comparable to other strategies of decreasing heart failure readmissions and may be evaluated in larger trials and quality improvement programs.
1. Keenan PS, Normand SL, Krumholz HM. An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2008;1:29-37. 2. Chun S, Tu JV, Wijeysundera HC, et al. Lifetime analysis of hospitalizations and survival of patients newly admitted with heart failure. Circ Heart Fail. 2012;5:414-421. 3. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §2702, 124 Stat. 119, 318-319. 2010. 4. Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303:1716-1722. 5. Desai AS. The three-phase terrain of heart failure readmissions. Circ Heart Fail. 2012;5:398-400. 6. Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6:444-450.
ACKNOWLEDGMENTS The authors thank Scott Keller, MS, and Robert Parr, BA, of the IU Health Information Technology Department. This publication was made possible by the Indiana University Health e Indiana University School of Medicine Strategic Research Initiative.