The ultimate guidebook on everything you need to know about reducing hospital readmissions-the most common risk factors, the reimbursement issues, and how real-world hospitals are solving the problem.
Reducing preventable readmissions among Medicare patients has become an important national priority for healthcare policy makers.
Last month, Managed Healthcare Executive brought you what you need to know about reducing heart failure readmissions. This month, in part 2 of our ongoing series, we’re taking a look at three other conditions tracked by the Hospital Readmissions Reduction Program (HRRP): acute myocardial infarction (AMI, or heart attack), coronary artery bypass grafting (CABG), and chronic obstructive pulmonary disease (COPD).
The final part will examine hospital readmissions caused by Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA) and pneumonia.
Patients who experience both heart attacks and COPD have a high cost of care, but there are multiple strategies to limit readmissions. The same holds true for those dealing with CABG.
Main causes of heart attack hospital readmissions
Andrew D. Boyd, MD, associate professor in the department of biomedical and health information sciences college at the University of Illinois at Chicago, led a recent study that looked at readmission trends for six diseases, including heart attacks, CABG, and COPD.
By examining data from 14,307 hospital reports from the HRRP from 2012–2015, the authors found that readmission rates for Medicare patients with these diseases were statistically higher among for-profit hospitals compared with nonprofit or government hospitals.
In fact, the findings showed that those with heart attacks and COPD have the highest readmission rate, at 23% to 26%.
Stephen Sinatra, MD, a cardiologist in Manchester, Connecticut, notes the primary causes of re-hospitalization following heart attacks continues to be researched, but in his experience, top causes for re-admission include recurrent angina, cardiac arrhythmia, age, and being a female with smaller blood vessels, congestive heart failure, compromised renal function, and diabetes mellitus (which is a risk factor for coronary artery disease).
“For CABG, the main causes of hospital readmissions are complications such as wound infections, and pulmonary compromise like pleural effusions,” he says. “The method with which a CABG/CABS is performed is also important. When arteries are hooked up artery-to-artery, the prognosis is much better. Use of the internal mammary is superior to venous bypass grafts when the vessel is local to the artery needing bypassing, such as the left anterior descending artery (LAD).”
Still, he explains, a lot of these surgical outcomes depend on the individual (patient dependent) as well the experience of the surgeon, technical difficulty, what the surgeon finds once the heart is open, and operative time on bypass pump.
“When a surgeon bypasses vessels with major obstructions but leaves vessels that are only mildly ‘clogged,’ those un-bypassed vessels may still be prone to plaque rupture,” Sinatra says. “Bypassing more vessels, even those that are mildly obstructed, may help to reduce hospital readmissions.”
Main causes of COPD hospital readmissions
The major cause of hospital readmission is COPD because it’s a chronic illness.
“Pneumonia and other infections can also precipitate readmission, which is why antibiotics are used frequently to prevent infections and readmissions,” Sinatra says. “Unfortunately, that’s probably one of the many reasons we have antibiotic resistance today.”
Stephen Schimpff, MD, MACP, an internist in Baltimore, Maryland, and former CEO of the University of Maryland Medical Center, says the primary reason for unexpected 30-day readmission return is communication between hospitalist and primary care physicians.
“In times past, the PCP admitted their patients to the hospital, took care of them in the hospital and discharged them so that the PCP had a clear understanding of the patient’s needs,” he says. “Today two things have changed. PCPs rarely see their patients in the hospital and frequently don’t even know the patient has been admitted. The patient is cared for by hospitalist and at discharge, although a written record is sent to the PCP that may not arrive until sometime much later, there is rarely any verbal communication between the two at the time of discharge.”
Furthermore, the patient is not instructed to obtain an appointment with the PCP or cardiologist within 48-72 hours, so the medications often aren’t reviewed in the context of the patient’s other issues and adjustments. The result is the patient has an exacerbation, goes to the ER, and is readmitted with recurrent heart failure.
For example, at the Charlestown Retirement Community in Catonsville, Maryland, a facility with 2,000 individuals with an average age of 82, the readmission rate has been brought down from the national average of over 25% to just under 10%.
“When a patient is admitted to the hospital, the PCP is aware and receives notification when the patient returns to the community and an appointment is set within 48 hours,” Schimpff says. “If the patient is sent back to the rehab unit, the doctor visits within the same time frame. That simple attention to communication and seeing the patient immediately is the key.”
Related article: Nine Ways to Reduce Hospital Readmissions from Hospital Executives
In a recent study conducted by Beth Israel Deaconess Medical and Harvard Medical School, which looked at heart attack readmissions, the findings revealed that although reductions in readmissions have been attributed to improvements in discharge planning and care transitions, these declines may instead be due to hospitals and clinicians intensifying efforts to treat patients who return to a hospital within 30 days of discharge in emergency departments and as observation stays.
The study suggested that financial penalties imposed by HRRP may have inadvertently pushed some physicians to avoid readmitting patients who needed hospital care, or potentially diverted hospital resources and efforts away from other quality improvement initiatives.
Based on the results of Boyd’s study, the authors recommend that policy makers may want to consider if readmission penalties are sufficient, examine how patient care can be improved, and make sure that type of ownership does not impact care quality.
Chetan Khamare, MD, cardiologist at the Premier Heart and Vascular Center in Zephyrhills, Florida, says the center is seeing a 2.9% net increase in 2019, compared to 2018, for heart attack and CABG. However, for readmissions there is a 3% penalty for excess readmissions for CHF, acute MI, and CABG.
Managing risk factors to drive down 30-Day readmissions
To drive down 30-day readmissions, the Premier Heart and Vascular Center has: increased education around the importance of diet, exercise, and medication compliance at discharge; schedules a follow-up appointment in the office prior to discharge; provides a home health RN to visit the patient after discharge; and calls patients after discharge to ensure they have answers to any questions about medications and symptoms.
“We also assign a nurse navigator to follow up with the patient,” Khamare says. “And we have implemented immediate physician specialty consultation in the emergency department to determine if readmission is necessary.”
This strategy has helped drive down readmissions by as much as 5% this year.
“We have been effective in decreasing readmissions rates; however, more work needs to be done,” he says. “This is a work in progress.”
Sinatra’s biggest personal successes with patients with all these heart issues came with pairing conventional treatments with a “metabolic cardiology” protocol: CoQ10, D-ribose, L-carnitine, and magnesium, as well as omega-3s (fish oils). This combination of nutrients was instrumental in helping to prevent arterial reclosure and plaque rupture in his patients.
In an August 2019 study published in the Annals of Internal Medicine, researchers looked at 41 studies with a total of 134,034 participants to evaluate the effectiveness of omega-3 supplements. What they found is that omega-3 supplement use was correlated with an 8% reduction in heart attack risk and a 7% reduction in coronary artery disease when compared with the non-supplement group.
Another study conducted at Carnegie Mellon University showed that optimism is an extremely important healer. In their conclusion, they found that “Optimism predicts a lower rate of rehospitalization after coronary artery bypass graft surgery [and] fostering positive expectations may promote better recovery.”
“An often hidden risk factor in hospital readmissions is emotions-which can put patients into fight-or-flight mode and precipitate a cardiac event,” Sinatra says. “A lot of my patients needed to be counseled. I would tell them they needed to let the situation go-it’s not worth dying for.”
Related article: How Health Systems Use Pharmacists to Reduce Readmissions
Nicholas Hamm is an editor with Managed Healthcare Executive. Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.