FEATURE: Krumholz discusses discrepancy in HF, MI death, readmission rates
Dr. Harlan M. Krumholz
Image source: Yale University
In a recent three-year period, 30-day risk-standardized mortality rates for acute MI and heart failure (HF) varied among hospitals and across the country, according to research published online July 9 in Circulation: Cardiovascular Quality and Outcomes.

"It continues to surprise me that there is such marked variation in performance," lead author Harlan M. Krumholz, MD, from Yale University School of Medicine in New Haven, Conn., told Cardiovascular Business News. "This study is a clear look at outcomes for hospitals around the country treating patients for heart attack and heart failure. There still seems to be a remarkable opportunity for improvement."

Krumholz added that the healthcare community should be "unsettled about the status quo, as these results do not represent where we should be."

The Centers for Medicare & Medicaid Services (CMS) publicly reports hospital-level risk-standardized 30-day mortality and readmission rates after acute MI and HF. The researchers sought to provide patterns of hospital performance, based on these measures. They summarized mortality and readmission results by hospital characteristics using data from the 2007 American Hospital Association (AHA) annual survey database.

The investigators calculated the 30-day mortality and readmission rates for all Medicare fee-for-service beneficiaries ages 65 years or older with a primary diagnosis of acute MI or HF, discharged between July 2005 and June 2008. They then compared weighted risk-standardized mortality and readmission rates across Hospital Referral Regions (HRRs) and hospital structural characteristics.

Across the U.S., the authors found that the median 30-day mortality rate was 16.6 percent for AMI and 11.1 percent for HF. The median 30-day readmission rate was 19.9 percent for AMI and 24.4 percent for HF.

"If we could move the top 25 percent down to where the bottom 25 percent are, we could save thousands of lives," Krumholz commented. "The challenge now is to assess how to best approach that process, and figure out what the hospitals with superior outcomes are doing, in order to learn from them."

He also said that while it is necessary for hospitals to become aware of their clinical performance, it is not alone sufficient. "Without the measurement, we have no insight into performance. The measurement is critical to understanding where you stand, and being accountable, but it's not enough -- this is just a first step," Krumholz added. He suggested that the next step is for the providers to seek methods of improvement.

The researchers observed geographic differences in performance across the country. Higher acute MI mortality is concentrated in a region from Oklahoma and Arkansas, extending into New Mexico, Texas, Kansas, Louisiana, Mississippi, Alabama, southern Missouri and western Tennessee. Meanwhile, lower acute MI mortality was found in small, densely populated HRRs, primarily in the Northeast, specifically New Jersey, Vermont and New Hampshire.

In contrast with mortality, hospitals with low 30-day acute MI readmission rates are found in the sparsely populated Northwest. Much of Oregon and Washington is also in the bottom quintile for acute MI readmissions. Almost all of the HRRs in the quintile of highest AMI readmissions could be found from the eastern border of Minnesota to the eastern border of Texas and most of the bottom quintile west of such a line.

The investigators also found that higher HF mortality rates are concentrated in the five westernmost states of the continental U.S. In addition, a region from Arkansas to southern Missouri and western Tennessee contains high mortality rates for HF, as well as high acute MI mortality rates. Hospitals in the quintile of lowest HF mortality are found in small northeastern HRRs. Northeastern New York, Vermont, and New Hampshire constitute an area of high HF mortality in the Northeast region. 

Like acute MI readmission rates, HF readmission rates are higher in the eastern U.S. and in the lower western U.S. HF readmission rates in the bottom quintile are found in the region stretching from western New Mexico to eastern Washington, which is also characterized by low acute MI readmission rates. HRRs with higher HF readmission rates are concentrated in the eastern U.S. Besides small urban HRRs along the Northeast coast, they can be found in a diagonal band from Arkansas, Louisiana, eastern Missouri and southern Illinois into western Pennsylvania.

While the findings may be eye opening, Krumholz said that research was not meant to vilify poor performers, but it is instead to illuminate the differences that exist.

"The biggest surprise for me was that high and low performance occurred in all types of hospitals -- both in large, teaching hospitals or small, rural facilities," Krumholz said. "As a result, it seems that performance is not just driven by the basic hospital characteristics. I believe it relates to the organization and culture of the provider. Therefore, any kind of hospital can embrace the systems and culture to develop the operations that enable it to produce better outcomes for its patients."

The authors wrote that the "high rates and the modest variation may indicate uniformly poor performance nationwide with respect to the transition from inpatient to outpatient status." They added that at the time of the study, there were no financial incentives for hospitals or the community to focus on this aspect of care, noting that hospitals were penalized by reducing readmission rates, as this would adversely affect hospital revenues.

"You don't want a system where people lack incentives to do the right thing," according to Krumholz. However, he noted that changing financial incentives is a "tricky" thing. "We will need to be careful not to give hospitals incentives to restrict access to sick patients. It's a delicate balance." However, Krumholz said that he and his colleagues believe the rates in this study contain a fair amount of preventable readmission and mortality.

He also noted that the system of care should observe the longitudinal episode of care, and not just at a piecemeal approach to the patient's treatment, which he defined as a more patient-centered, holistic approach.

The researchers also advocated for an "investment in research that provides insight about how these rates can best be improved."

"We really need a renewed interest in improving the how, and not just the what," Krumholz said. "Our group currently has a grant from the Agency for Healthcare Research and Quality, which is also funded by UnitedHealthcare, to observe top-performing hospitals to extract themes and lessons, by combining quantitative and qualitative methodologies. It's almost an anthropological approach to observing the culture and processes within these high-performing facilities."

He hopes other groups undertake similar studies in order to produce more uniform, superior statistics for this growing patient population.