Hospital A from the Health Scenario described in Chapter 15 is pleased with the progress it has made in improving performance on the publicly reported Heart Failure Core Measures but is concerned that the improved delivery of these processes of care does not seem to be reducing the 30-day readmission rate for heart failure patients. Hospital A is concerned about the high readmission rate because it suggests there is substantial room for further improvement in the care provided to heart failure patients and because currently the hospital is paying a penalty under the Medicare Readmissions Reduction Program. To learn more about heart failure readmissions and identify effective strategies to reduce them, Hospital A’s clinical and quality leaders turn to the published research literature. They learn that there is substantial variation in risk-adjusted heart failure readmission rates among hospitals across the United States, which suggests that the hospitals with higher rates can likely achieve performances closer to those demonstrated by the hospitals with lower rates if they can identify the ways in which their practices, communities, and patient populations differ, enabling revision of the former and appropriate risk adjustment for the latter.
Data released by the Centers for Medicare and Medicaid Services (CMS) in 2013 show a median national risk-standardized 30-day unplanned heart failure readmission rate of 22.9% (95% confidence interval [CI], 17.1, 30.7) for Medicare patients. Risk-standardized heart failure readmission rates show distinct geographic patterns: areas with the highest rates are located almost exclusively in Eastern, Southeastern, and Midwestern states, and the majority of areas with rates in the lowest quintile are found in Western states (Figure 16-1). Almost 60% of the national variation in publicly reported risk-standardized 30-day readmission rates (i.e., for heart failure, acute myocardial infarction, and pneumonia) is at the county level, and approximately half of that 60% is explained by county characteristics, including demographic and socioeconomic factors, access to care factors, and nursing home quality factors. County characteristics associated with lower readmission rates include greater numbers of primary care physicians and nursing homes per capita and classification of the county as a rural or retirement area. Characteristics associated with higher readmission rates include greater numbers of specialists and hospital beds per capita and higher proportions of the population that never married, are Medicare beneficiaries, or have low education status and higher percentages of long-stay nursing home patients with pressure ulcers or with an increased need for help. Other research shows higher heart failure readmission rates among patients discharged from public (vs. private nonprofit) hospitals, hospitals without cardiovascular services, hospitals with low levels of nurse staffing, and small hospitals. However, hospitals that partner with community physicians or local hospitals to decrease readmission, that have processes in place to ensure patients’ discharge summaries are sent to their primary care physicians, and that assign staff to follow up on test results after discharge have been found to ...