hernandez et al. jama, may 5, 2010 – vol. 303, no. 17 relationship between early physician...

Hernandez et al. JAMA , May 5, 2010 – Vol. 303, No. 17

Relationship Between Early Physician Follow-up and 30-day Readmission Among

Medicare Beneficiaries Hospitalized for Heart Failure

Adrian F. Hernandez, MD, MHS, Mellissa A. Greiner, MS, Gregg C. Fonarow, MD, Bradley C. Hammill,

MS, Paul A. Heidenreich, MD, Clyde W. Yancy, MD, Eric D. Peterson, MD, MPH, Lesley H. Curtis, PhD


DisclosuresThe Get With The Guidelines– HF (GWTG-HF) program is provided by the American Heart Association/American Stroke Association. The data analyzed in this manuscript were collected while the GWTG program was supported in part through an unrestricted educational grant from GlaxoSmithKline.

The individual author disclosures are listed in the manuscript.


Background• Hospital readmission rates are being targeted as an area

to promote efficiency and quality in health care.

• 1/5 of Medicare patients are rehospitalized within 30 days and more than 1/3 are rehospitalized within 90 days.

• The most common readmission diagnosis is Heart Failure.


IntroductionReadmission after hospitalization for Heart Failure is common. Early outpatient follow-up after hospitalization has been proposed as a means of reducing readmission rates. There is little data describing patterns of follow-up after Heart Failure hospitalization and its association with readmission rates.


To examine associations between outpatient follow-up within 7 days post discharge from a Heart Failure hospitalizations and readmission within 30 days.

Objective


Study PopulationInclusions:

• Hospitals fully participating from 2003-2006

• Heart failure patients 65 years and older who were

• Enrolled in fee-for service Medicare for at least 30 days after the index hospitalization

• Discharged to home

•If patient had multiple hospitalizations, we selected the first as the index hospitalization.

Exclusions:

•Discharged to SNF or Hospice, and hospitals with fewer than 25 patients after prior exclusions.


• Study population: 41,496 GWTG-HF/OPTIMIZE CMS

• Excluded:

• Skilled nursing facility discharges: 9166

• Hospice care: 804

• Low volume hospitals (<25): 1390

• Final study population of 225 hospitals and 30,136 patients.

Study Population (cont.)


Patient CharacteristicsCharacteristic Quartile 1

(<32.4%)Quartile 2(32.4-37.9)

Quartile 3(38.3-44.5)

Quartile 4(>44.5)

P Value

Median Age 78.0 79.0 79.0 80.0 <.001Female Sex 54.3 52.8 52.9 53.4 .24African American 18.9 8.3 9.9 5.9 <.001Past Med HxAtrial arrhythmia 35.0 37.4 34.2 35.0 <.001COPD 28.6 29.9 25.9 24.9 <.001CAD 54.2 55.5 51.6 52.1 <.001Chronic kidney dz 19.1 19.1 17.6 16.2 <.001Diabetes 41.0 39.8 39.9 36.9 <.001PVD 13.8 16.4 13.0 11.6 <.001Prior CVA/TIA 15.5 17.2 15.2 15.5 .002Smoker 9.7 10.9 9.9 7.8 <.001


Data Source•Included patients in GWTG-HF & its predecessor OPTIMIZE-HF:

• Episode of worsening Heart Failure• Development of significant Heart Failure symptoms during a hospitalization for which Heart Failure was the primary discharge diagnosis.

•HF case-ascertainment methods similar to those used by the Joint Commission were used by Hospital Teams.


• GWTG HF and OPTIMIZE-HF were linked to Medicare claims (Part A, B and corresponding denominator files) to provide data on follow-up and outcomes.

• Patients and hospitals were grouped by quartiles of hospital rates of early follow-up visits.

• Using the cumulative incidence function, which accounts for the competing risk of death, we calculated unadjusted 30-day all-cause readmission rates.

Methods


Methods• Cox proportional hazards models to examine

unadjusted and adjusted relationships between hospital-level early follow-up and 30-day all-cause readmission.

• Outcome Sciences, Inc. served as the data collection and coordination center.

• Duke Clinical Research Institute served as the data analysis and coordination center.


• Early Follow-up: Any visit within 7 days after discharge from index hospitalization defined as an outpatient evaluation and management visit with a physician (HCPCS codes 992.xx–994.xx)

• Primary Outcome: Association between hospital-level rate of early follow-up and 30-day all-cause readmission rate

Early Follow-up and Outcome


Results: 30-day readmission• 21.3% of patients readmitted within 30 days

• Inverse relationship between early physician follow-up and the hazard of 30-day readmission

• Neither early follow-up with a cardiologist nor continuity of care were significant predictors


Hospital Variation in Early Follow-up

Median Follow-upVisit within7 days = 37.5%

225 Hospitals


Follow-up by Physician Type

37.6

63.975.9 81.3

7.315.9

25 30.8

0102030405060708090

100

7 14 21 28

Hos

pita

l Med

ian

Follo

w-up

%

Days

Any Physician Cardiologist


Follow-up by Same Physician

18.7

35.645.6 50.8

3.4 8.9 14 17.3

0102030405060708090

100

7 14 21 28

Hos

pita

l Med

ian

Follo

w-up

%

Days

Same Physician Same Cardiologist


Observed 30-Day Outcomes

30-Day Mortality p= 0.4430-Day Readmission p <0.01


30-Day Readmission RelationshipEarly Follow-up Unadjusted

HR95% CI P

ValueAdjusted

HR95% CI P

Value

Quartile 1 1.0 (REF) 1.0 (REF)

Quartile 2 0.86 0.78-0.94 <.01 0.85 0.78-0.93 <01

Quartile 3 0.85 0.76-0.94 <.01 0.87 0.78-0.96 <01

Quartile 4 0.87 0.79-0.95 <.01 0.91 0.83-1.0 .05

Covariates: age, sex, race, anemia, atrial arrhythmia, COPD, CKD, CAD, depression, diabetes, hyperlipidemia, hypertension, PVD, prior CVA/TIA , smoker, creatinine, systolic blood pressure, serum sodium, hemoglobin, LVSD, discharge process, LOS>7 days, year of admission


Results: 30-day mortality• 4.7% of patients died in the 30 days after

discharge

• 30-day mortality was significantly lower among patients admitted to hospitals which had a high rate of early follow-up with a cardiologist


• GWTG-HF is a voluntary registry of hospitals participating in quality of improvement and may not represent all hospitals.

• Clinical data were collected by medical chart review.

• Residual measured and unmeasured confounding variables may have influenced the findings.

• Analysis confined to patients age 65 years or older with fee-for-service Medicare.

• Limited data on home health visits, disease management programs, remote monitoring or follow-up by physician extenders (NPs/PAs).

Limitations


Conclusions• Among patients hospitalized for Heart Failure:

– Low Physician follow-up within 1 week– Most follow-up care was handled by a generalist/internist rather

than a cardiologist – Most follow-up is not by the same physician who evaluated the

patient during hospitalization.

• Hospitals with higher rates of early follow-up:– Lower risk of 30-day readmission

• Future studies should evaluate the effects of early follow-up on readmission


Conclusions

• Findings highlight a need for improvement and greater uniformity in coordination of care from in-patient to out-patient settings

• A central element of transitional care, out-patient follow-up

• varies significantly across hospitals and• for most patients, does not occur in a timely manner

• Early evaluation after discharge is critical

hernandez et al. jama, may 5, 2010 – vol. 303, no. 17 relationship between early physician...

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