Implementation of ACC’s Patient Navigator Program may lead to substantial improvements in the number of hospitals that prospectively identified and assessed readmission risk for patients with acute myocardial infraction (AMI) and heart failure (HF), according to a poster presented April 7 at the 2018 Quality of Care and Outcomes Research Scientific Sessions in Arlington, VA.

Tyler J. Gluckman, MD, FACC, et al., analyzed rates of pre-discharge identification and readmission risk assessment for AMI and HF patients who were hospitalized at 35 hospitals that participated in the Patient Navigator Program between 2015 and 2017. All participating hospitals were members of ACC’s ACTION Registry. As Patient Navigator Program participants, the 35 hospitals implemented strategies aimed at improving processes and outcomes of transition care. Institutions received quarterly reports on 36 performance measures, including pre-discharge identification of AMI and HF patients and assessment of their readmission risk. Participating hospitals were encouraged to share best practices through webinars, a listserv and an online dashboard. Baseline evaluations included up to 14,361 patients, and up to 3,860 patients were evaluated after two years.

By the end of the study period, 32 hospitals identified AMI patients at risk of readmission before discharge, compared with 24 hospitals at baseline. The number of hospitals identifying HF patients at risk of readmission increased to 34, up from 27 at baseline. At the beginning of the study, nine hospitals assessed readmission risk for AMI patients and 11 hospitals did so for HF patients. After two years, the number of hospitals that completed readmission risk assessments increased to 28 for AMI patients and 30 for HF patients.

The researchers conclude that while the Patient Navigator Program led to improvements in identifying and assessing readmission risk for AMI and HF patients, future research is needed to determine whether the improvements led to reductions in 30-day readmissions or other outcome measures.

Keywords: Patient Readmission, Transition to Adult Care, Patient Discharge, Heart Failure, Risk Assessment, Registries, Outcome Assessment, Health Care, National Cardiovascular Data Registries, ACTION Registry

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