Heart failure patients discharged from hospitals with high levels of early physician evaluation are less likely to be readmitted to the hospital within 30 days, according to an analysis of records on more than 30,000 heart failure patients from 225 hospitals.
However, most heart failure patients do not visit a physician within 7 days of discharge.
The analysis of data from the American Heart Association's Get With The Guidelines–Heart Failure (GWTG–HF) Registry linked to Medicare billing records, which looked at hospital-level rates of early outpatient follow-up after discharge during 2003–2006, found that the median rate of follow-up within 7 days of discharge was 38%.
“For patients with heart failure, the transition from inpatient to outpatient care can be an especially vulnerable period because of the age of the patients, complex medical regimens, the large number of comorbid conditions, and the multiple clinicians who may be involved,” wrote Dr. Adrian F. Hernandez of Duke University, Durham, N.C., and his coauthors. “Our findings highlight a need for improvement and greater uniformity in coordination of care from inpatient to outpatient settings.”
Overall, about 21% of heart failure patients were readmitted to the hospital within 30 days of discharge. Patients in hospitals with higher rates of early follow-up had a lower risk of readmission, the study found (JAMA 2010;303:1716–22).
After adjustment for case mix, admission laboratory results, provision of discharge instructions, and length of stay, the risk-adjusted hazard of 30-day readmission was 15% lower in the hospitals with higher rates of early follow-up, the study found. Whereas 20% of patients whose initial hospital stay took place in a hospital with the highest rates of early follow-up were readmitted, 23% of patients in the hospitals with the lowest follow-up rates were readmitted, a significant difference.
Still, the authors only found differences in rehospitalization rates in the hospitals that ranked in the lowest quartile of posthospitalization follow-up; rates at the other 75% of hospitals were similar. They also found some racial differences: The proportion of black patients was “markedly higher” among hospitals with the lowest rates of early follow-up.
They also found that patients discharged from hospitals with the highest rates of early follow-up by a cardiologist had lower risk of 30-day mortality, which they noted is consistent with other studies of cardiology care for heart failure.
Most follow-up during the transitional period, especially during the first week, is handled by general internists, the study authors found. More than two-thirds of patients hospitalized for heart failure are evaluated by a cardiologist during their inpatient stays, but fewer than 10% see a cardiologist within 7 days of hospital discharge. By 21 days post discharge, 76% of patients had been seen by any physician, and 25% by a cardiologist.
However, neither early follow-up with a cardiologist nor continuity of care from the same physician seen during the hospitalization was a significant predictor of 30-day readmission, they wrote.
Documentation of discharge instructions, which many physicians presume helps to ensure early follow-up and better outcomes, also was not associated with lower readmission rates. “This finding raises the possibility that discharge instructions are becoming rote processes that do not adequately address elements of care that ensure a safe transition,” the authors wrote.
The study provides evidence in support of guidelines recommending the use of postdischarge systems of care, the authors said. “Achieving early follow-up may be difficult for some physician practices, but models of care that include nurse practitioners or physician assistants under physician supervision may result in increased access to and timeliness of care.”
Reporting the results at the annual scientific session of the American College of Cardiology in Atlanta in March, Dr. Hernandez said that ensuring that patients hospitalized for heart failure are evaluated by a physician within 7 days after discharge is emerging as a potential new target for hospital quality improvement.
The problem of unplanned early readmissions is a hot button issue that has drawn considerable attention from health policy makers. Roughly 20% of Medicare beneficiaries are readmitted within 30 days of hospitalization. Nearly 90% of these readmissions are unplanned and potentially preventable. These readmissions account for $20 billion annually in Medicare hospital payments. And heart failure is the No. 1 cause of readmission within 30 days, noted Dr. Hernandez of the Duke Clinical Research Institute, Durham, N.C.
One audience member serving on a panel advising the Center for Medicare and Medicaid Services said “these are just the kind of data we've been looking for” in order to make recommendations to the agency regarding new hospital performance standards. However, she questioned whether a physician was necessarily the right person to do the early follow-up evaluation. Fine-tuning of outpatient heart failure management might be better done by a dedicated nurse practitioner or physician assistant.