JAMA Feature: Standardized early follow up for HF lowers readmissions

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Hospitals that consistently follow up with heart failure (HF) patients within one week of discharge have a lower rate of readmission at 30 days, according to a study in the May 5 issue of the Journal of the American Medical Association. However, one study author said there is no standard protocol for early evaluation.

"Clinicians, payors and policy makers seeking to promote efficiency and quality in healthcare are targeting hospital readmission rates. One-fifth of Medicare beneficiaries are rehospitalized within 30 days and more than one-third within 90 days," according to the study, conducted  by Adrian F. Hernandez, MD, of the Duke University School of Medicine in Durham, N.C., and colleagues.

In the study, patients were readmitted less often if they were followed up within seven days by any type of physician—primary care, general internist or cardiologist. However, patients followed up by cardiologists had a lower 30-day mortality rate," Hernandez told Cardiovascular Business News.

Hernandez and colleagues examined hospital-level variation in post-discharge physician follow-up and the relationship between rates of early follow-up (within seven days after discharge) and patient outcomes.

The study included 30,136 Medicare patients who were discharged to home from 225 hospitals participating in a quality improvement program from January 2003 through December 2006. Researchers found that 21 percent of patients were readmitted within the first 30 days after discharge. At the hospital level, the median rate of early follow-up was 38 percent.

Discharge from hospitals in which a greater proportion of patients received early follow-up was independently associated with lower rates of all-cause 30-day readmission.

"The ideal follow-up is within one week from discharge," Hernandez said. "We also looked at follow-up at 14 days and saw an association with fewer readmissions, which became weaker the further out from discharge."

Hernandez called the first week of discharge "crucial" for evaluating patient status. "Patients are no longer under 24-hour hospital supervision. They may or may not have picked up their medications or they may not have followed-up on a test. Early evaluation should include a review of therapeutic changes and a thorough assessment of the patient's clinical status outside of the highly structured hospital setting," he said.

The Centers for Medicare & Medicaid Services is currently in policy discussions regarding some type of change in HF treatment reimbursement to potentially penalize hospitals that readmit patients within 30 days of discharge. One idea is to have a lump sum payment for patient care for 30 days. "The rationale is to incentivize physicians to establish early follow-up for patients with heart failure," Hernandez said.

There is no systematic protocol for early follow-up of HF patients, said Hernandez, adding that public reporting or reimbursement incentives would be useful. "It's sometimes as simple as making a phone call when a patient misses an appointment. It's a safety net for these very vulnerable patients."

While the authors didn't study remote monitoring, Hernandez said this type of technology is often needed for these patients who may be too frail or have other patient issues. He and colleagues are currently designing a study to evaluate the benefit of remote monitoring on readmission rates.