By Leah Lawrence

Cardiologists are no strangers to analyzing 30-day readmission rates. Two of the "big three" conditions currently monitored by the Centers for Medicare & Medicaid Services' (CMS) Hospital Compare website are cardiac in nature—chronic HF and acute myocardial infarction (AMI).

Information about PCI 30-day readmission rates will soon also become publically available thanks to a partnership between the ACC's National Cardiovascular Data Registry (NCDR®) CathPCI Registry®, CMS, and the Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation.

For 5 years, these three organizations have been working to develop a voluntary public reporting measure for hospital 30-day risk-standardized PCI readmission. All hospitals that are members of the CathPCI Registry began receiving reports this month on 30-day hospital readmission rates for PCI. Those who choose to can begin to publicly report these data through CMS' Hospital Compare website in summer 2013.

"Patients have an important stake in the quality of care that they receive," said Frederick Masoudi, MD, MSPH, associate professor of medicine, division of cardiology at the University of Colorado Anschutz Medical Campus. "Knowing that data are available to the public provides an important incentive and motivation for health care providers to work and focus on quality of care delivered."

Public Accountability Spurs Improvements

Public reporting of certain health care measures is nothing new. In late 2002, the Hospital Quality Alliance: Improving Care Through Information was created. This organization is a public-private collaboration established to promote reporting on hospital quality of care to help consumers make informed health care decisions and US hospitals improve their quality of care.

"Patients who receive high-quality care during their hospital stays and during the transition to non-acute settings will likely have better outcomes, such as survival, functional ability and quality of life," a representative from CMS told CardioSource WorldNews in a statement. "The measurement of outcomes allows hospitals, policymakers, and other stakeholders to evaluate the quality of care delivered to patients and to seek improvements that will impact patient well-being."

One of the best recent examples of public reporting's impact on the quality of care in the cardiology arena is that of hospital door-to-balloon times. In 2002, CMS began public reporting of hospitals' door-to-balloon times for STEMI patients. Research revealed that, at that time, only about one-third of patients received primary PCI within 90 minutes.

"Once that information became publicly available, it stimulated enormous efforts to reduce times nationally," said Jeptha P. Curtis, MD, associate professor of medicine at the Yale School of Medicine. "Because of those efforts, we have seen dramatic improvements in the last 6 years."

Readmission Under the Radar

In 2010, the Affordable Care Act established the Hospital Readmission Reduction Program, which required CMS to reduce payments to hospitals with excess readmissions for heart failure, AMI, and pneumonia effective October 1, 2012.

In addition to this new penalization, readmission rates have gotten a lot of attention for a number of reasons, according to Dr. Masoudi, who has also served as the chair of the ACC/American Heart Association Task Force on Performance Measures.

"There are certain conditions for which readmissions are extremely common, and, needless to say, they are responsible for substantial health care expenditures," Dr. Masoudi said. "In addition, in contrast to process measures, such as whether a patient receives aspirin after MI, these outcome measures reflect more broadly on the health care system and measure more comprehensively the care patients receive."

In the past, the reduction of readmission rates was not necessarily aligned with financial models. In other words, when patients were readmitted, hospitals were still getting paid for those readmissions. "There was really no incentive for hospitals to focus on reducing readmission rates," Dr. Curtis said.

Measuring and publicly reporting readmission measures provides hospitals with an incentive—other than demonstrating a commitment to transparency—and a system to evaluate the entire spectrum of care they deliver to patients.

According to CMS, hospital staff can work collaboratively to better prepare patients for the transition to outpatient status, minimizing risk for adverse outcomes. Actions taken at discharge to reduce 30-day readmission rates include ensuring patients are clinically ready for discharge, reducing the risk of infection, reconciling medications, and educating patients about symptoms to monitor, among others.

Why Report PCI?

More recently, attention has turned to 30-day readmission rates for PCI, which is one of the most commonly performed cardiac procedures in the United States. Unfortunately, a closer examination of 30-day readmission rates for the procedure revealed rates higher than experts expected.

In 2009, Dr. Curtis and colleagues published results from a study that looked at Medicare fee-for-service admissions and readmissions for PCI in 2005. Data from more than 300,000 PCI procedures and more than 1,000 hospitals were included. Results indicated that the all-cause 30-day readmission rate was 14.6%.

"We found that about one in seven patients were readmitted within 30-day post-angioplasty," Dr. Curtis said. "By and large, patients undergoing PCI represent a somewhat healthier group than the overall Medicare population, so those data were surprising, and not what anyone expected to see."

Similar to the efforts with door-to-balloon times, the discovery of this high frequency of readmission post-PCI led to efforts to improve the quality of care in these patients.

According to CMS, most readmissions are unplanned and patients are readmitted with a wide range of CV and non-CV diagnoses. Varying readmission rates across hospitals suggest opportunities for improvement.

Thus, the partnership between Yale, the ACC, and CMS was born.

Setting PCI Apart

The new PCI readmission measure will compare hospitals' PCI readmission rates against CathPCI Registry unadjusted readmission rates taken from data for discharges between January 2010 and November 30, 2011.

"It is expected by the parthers that measuring 30-day readmission rates following PCI procedures will inform health care providers about opportunities to improve care, strengthen investment in quality improvement initiatives, and promote improvements in the quality of care Medicare patients receive and their outcomes.

Although PCI 30-day readmission rates will be reported on the Hospital Compare website similar to HF, AMI, and pneumonia, the PCI data are distinct in two ways. First, this is the first 30-day measure that centers on a procedural outcome rather than a patient condition.

"This is important because hospitals are often organized around procedures," Dr. Curtis said. "For example, where I work, all PCI patients end up in one of two units. Having them centralized in this manner makes it easier to design and implement strategies to reduce readmission rates."

Second, the PCI measure uses clinical data from the CathPCI Registry for the purposes of risk adjustment.

The existing Medicare readmission measures for heart failure, AMI, and pneumonia all use claims-based risk adjustment to calculate standardized risk for readmission. In other words, billing codes and underlying billing factors are used, to explain the difference in why patients are readmitted.

Partnering Up

According to Dr. Curtis, the partnership between the CMS and the ACC demonstrates a high level of commitment from both organizations. "It is a big step forward for the National Cardiovascular Data Registry to be working with CMS," Dr. Masoudi said in an interview. "It is a testimony to the credibility that the registries have in the eyes of CMS."

With this partnership, Dr. Curtis said, "We wanted to show that we can use clinical information to create risk-adjusted outcomes that are measurable and useful to hospitals, and to do it in a way that is publicly reported on a voluntary basis," Dr. Curtis said.

For the hospitals that participate in voluntary public reporting of PCI readmission rates, the benefits are two-fold, Dr. Masoudi added. Not only will it help improve transparency for consumers, it will also signal to other stakeholders that a hospital is committed to improving patient care for patients undergoing PCI procedures. "More and more hospitals are becoming used to the idea that the quality of care they deliver is available for public scrutiny," he said. "Participation in this program will demonstrate a willingness to show others around them that they care of about quality of care they provide."

References

• Centers for Medicare and Medicaid Services. Readmissions Reduction Program. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed April 24, 2013.
• Curtis JP, Schreiner G, Wang Y, et al. J Am Coll Cardiol. 2009;54(10):903-907.
• McNamara RL, Herrin J, Bradley EH, et al. J Am Coll Cardiol. 2006;47(1):45-51.
• National Cardiovascular Data Registry. PCI Readmission Measure. www.ncdr.com/WebNCDR/analytics/pcireadmissionmeasure. Accessed April 24, 2013.
• QualityNet. HQA Program Overview. http://qualitynet.org. Accessed April 23, 2013.

  Keywords: Motivation, Outcome Assessment, Health Care, Myocardial Infarction, Process Assessment, Health Care, Fee-for-Service Plans, Medicaid, Patient Discharge, Patient Protection and Affordable Care Act, Risk Adjustment, Quality Improvement, Registries, Quality of Life, Patient Readmission, Heart Failure, Investments, Health Expenditures, Medicare

  
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