HLM: Why the focus on heart failure patients?
Fonarow: The concern was greatest for heart failure patients. This study adds very striking, statistically significant, clinically relevant evidence that risk-adjusted mortality rates for Medicare beneficiaries hospitalized with heart failure have gone up. They’ve gone up in the first 30 days and that continues on out to one year. It looks as if the hospital readmission reduction program has been associated with a serious and devastating unintended consequence of increased mortality for heart failure patients.
HLM: How does this unfold at the hospital level?
Fonarow: Part of it is the financial resources being taken away by virtue of the penalty. Those of lower socioeconomic status treated at safety net hospitals are more likely to be re-hospitalized in a way that wasn’t adequately captured in the 30-day readmission metric. Those hospitals got oversized penalties. The most vulnerable patients are treated at the most vulnerable hospital, and desperately needed resources were taken from those hospitals, for which they no longer had available for staff or programs on patient safety and key therapies that can improve outcomes.
But there are also other ways. This financial penalty and public reporting led to hospitals putting pressure on clinicians to reduce 30-day readmissions and keep patients out of the hospital. So, the clinician trying to respond to the pressure and incentive has a patient who is at home and not doing well but they’d been hospitalized 21 days before and you’re in this dilemma. The clinical situation may necessitate hospitalization. You want to do the right thing for the patient, but maybe if I can buy a little more time and leave them at home, take that little extra risk it will work out OK and if they get hospitalized beyond 30 days that is OK.
There are patients being shunted from the ER to an outpatient observation unit rather than being hospitalized because of Medicare policies. Now, that patient can no longer for qualify for home health or skilled nursing facility or other resources because they were not hospitalized.
So, there are a number of ways by which these incentives inadvertently could have led to this harm that’s been observed.
HLM: Do you believe readmissions should be a quality metric?
Fonarow: Readmission reductions in isolation is not patient-centered. It needs to be in conjunction with meaningful patient-centered metrics including their health status and patient survival and coupled with strong measures to ensure there is not gaming and not unintended consequences. In light of this data, for heart failure patients, readmissions needs to completely and immediately cease and we must find ways to mitigate the damage that has already been done before ever reconsidering that as a valid metric for heart failure patients.
John Commins is a senior editor at HealthLeaders.