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HEALTH SCENARIO

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Mrs. E., a 69-year-old, Spanish-only-speaking Hispanic woman with a history of congestive heart failure (CHF), is admitted to Hospital A complaining of shortness of breath and difficulty breathing when lying down. During her stay, she is not evaluated for left ventricular systolic dysfunction (LVSD); as a result, she does not receive a prescription for an angiotensin- converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for LVSD despite having no contraindications. She receives postdischarge instructions verbally and in writing but only in English because Hospital A does not have onsite translators or a translation service. Two days after discharge, she is readmitted through the emergency department (ED) with an ejection fraction of 15% and severe pulmonary edema. Despite treatment, she dies.

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Hospital A starts looking closely at its delivery of heart failure care when it receives the maximum 1% reimbursement penalty under the Medicare Readmissions Reduction program based on higher-than-expected 30-day readmission rates in the Medicare patients it treats for heart failure, pneumonia, and acute myocardial infarction (AMI) and a 1.1% penalty under Medicare’s Hospital Value-Based Purchasing Program based on its below average compliance with publicly reported, evidence-based practices in heart failure, pneumonia, AMI, and surgical care and on patients’ experience of care in fiscal year 2013. Hospital A finds that there are significant opportunities for improvement, and it seeks to address these issues to improve its patients’ experience and outcomes, and to avoid further financial penalties.

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CLINICAL BACKGROUND

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More than 5 million adults in the United States have heart failure, and more than 500,000 new cases are diagnosed each year. Approximately 275,000 deaths and more than 1 million hospitalizations are attributable to heart failure annually in the United States; it is the most common discharge diagnosis in persons older than 65 years, and nearly 25% of patients require rehospitalization within 30 days. The total cost of care for heart failure in 2013 was estimated at $32 billion; this number is expected to rise to $72 billion by 2020.

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Clinical practice guidelines strongly recommend the evidence-based practices of left ventricular function assessment, ACEI and ARB prescription for left ventricular systolic dysfunction, smoking cessation counseling, and discharge instructions as part of standard care for heart failure, yet they remain underutilized: fewer than 60% of heart failure patients receive all recommended evidence-based diagnostic and therapeutic measures for which they are eligible.

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The high prevalence and incidence of heart failure, together with its high burdens of mortality and morbidity and the availability of easily measurable, evidence-based treatments that reduce these burdens, makes it a high-priority target for quality improvement. It is one of the four conditions and categories for which Medicare has required hospitals to publicly report compliance with certain evidence-based recommendations since 2005 and performance on 30-day readmission and mortality rates since 2009. Most recently, Medicare has linked hospital reimbursement to these performance measures through its Readmissions ...

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