Is this really important? Yes, it is. Hospitals are now seeing their precious profit margins decimated by penalties up to 1%, soon to be 2% and then 3%. The Centers for Medicare and Medicaid services, in its wisdom, has decided that heart failure readmissions are largely preventable and that all a hospital has to do is institute some form of improved discharge planning, telemanagement, visiting nursing, disease management, home weight scales, iPhone or iPad or email or other electronic communication, and – poof! – the problem dissipates.
I wish it were so simple.
Multiple intervention trials, including a high-visibility effort at telemanagement (N. Engl. J. Med. 2010;363:2301-9), have failed, perhaps because patients are readmitted for a variety of causes. Surely some are directly preventable. Back in 1990, Vinson and associates (J. Am. Geriatr. Soc. 1990;38:1290-5), listed the top causes of readmission (which included noncompliance with medications, 15%; noncompliance with diet, 18%; inadequate follow-up, 20%; and lack of social support, 21%).
From personal experience, the noncompliance part seems to have magnified. Take a look at a study by Dr. Ruben Amarasingham and colleagues (Med. Care 2010;48:981-8). His group found that important predictors included the number of home address changes, a history of cocaine use, depression or anxiety, and a history of a missed clinic visit. Noteworthy in the analysis is the absence of all those physiological parameters we seem to discuss at national meetings. No surprise there. The biomarkers, echo parameters, and hemodynamics all count, but the devastating effect of dietary and medication nonadherence seems to trump all.
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Recently, at the annual meeting of the Heart Failure Society of America, Narendra Bhalodkar of Bronx-Lebanon Medical Center, New York, described the efforts at his hospital (in, of all places, the South Bronx) to decrease readmissions in a talk entitled "Can Horse Drink the Water Please?" It was a remarkable presentation of the tribulations that his program has experienced in its futile attempt to act not just as a provider of heart failure care but as social worker, psychologist, nurse, dietician, and community organizer ... all for naught.
I plan to discuss this more in later columns, but let me add just a few interesting tidbits.
First, in Europe, lengths of stay for heart failure are longer but readmission rates are lower.
Second, an admission with heart failure is not an admission for heart failure. Maybe we should be less aggressive in our coding!
Third, the readmission debate has not included frank discussions about patient responsibility.
Finally, expect some form of regression to the mean. Programs spared in the first round will undoubtedly find themselves dinged in the second.
Mark my words, this will happen. In the meantime, a lot of money and a lot of effort will be expended in pursuit of an ill-defined goal line.
Good luck to all of us.