Failing to prevent heart failure readmissions

Most hospitalists would like to think they help heart failure patients avoid readmission to the hospital. Numerous quality initiatives, from the American Heart Association's Get With the Guidelines (GWTG) program to individual hospitalist projects, have targeted this goal.

Thus, when a recent analysis of GWTG data found that increasing use of hospitalists had no significant impact on 30-day readmissions, it was reason for concern. In addition, the analysis of more than 30,000 patients treated at 166 hospitals from 2005 to 2008, which was published in the October 2013 JACC Heart Failure, found that greater use of hospitalists was associated with a slight increase in mortality.

The good news? Hospitalist use was associated with greater adherence to heart failure performance measures, especially when combined with high use of cardiologists. In a recent conversation with ACP Hospitalist, lead study author Robb D. Kociol, MD, associate director of advanced heart failure at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School in Boston, offered his perspective on how hospitalists should interpret the study's findings.

Q: What did you expect to find with this study?

A: I wasn't sure. There are reasons why potentially hospitalists' outcomes might be better—because the focus of hospitalists often is on efficiency of care, improving communication with outpatient providers, best utilizing the hospital services, and knowing the hospital systems. There's a possibility that would improve care transitions and outcomes. On the other hand, certainly cardiologists have more training in heart failure and are very aware of and up-to-date on the current guidelines and treatment methodologies, so there's some equipoise there.

Q: What conclusions can you draw about the hospitalist model based on the study results?

A: It's less about hospitalists per se as caretakers. Of the outcomes we looked at, increasing use of hospitalists in the hospital doesn't seem to correspond to any improvement. There was a very small association, in fact, with increased 30-day mortality, but the clinical meaningfulness of that finding is questionable, given the very small effect size. There's a very small reduction in length of stay with hospitalists, which is one of the things I did expect to see. Increasing use of cardiologists didn't affect outcomes either.

You can conclude going to a full hospitalist model or increasing use of hospitalists caring for these patients isn't going to be the silver bullet that solves the readmission problem or improves short-term outcomes. Maybe that's not the right thing to be focusing on if that's your goal—who's caring for the patients.

The more nuanced finding is that when we looked at defect-free adherence to the group of performance measures, we found that increasing utilization of hospitalists led to increasing adherence to these measures in hospitals that had a high level of cardiologist use as well. The converse was true, as well—increasing use of cardiologists was associated with increased defect-free adherence to performance measures in hospitals that use a lot of hospitalists. So there seems to be some kind of synergy in hospitals that use high levels of both hospitalists and cardiologists to care for the heart failure patients.

One question for another study is: Would a combined model of care—hospitalists in collaboration with cardiologists—lead to improved, at the very least, quality of care, and perhaps [also] outcomes?

Q: How could you potentially maximize that synergy between hospitalists and cardiologists?

A: It's complex. It really varies depending on the type of institution—for example, an academic institution with employed cardiologists is very different from a community hospital where it's all hospitalists and private-practice cardiologists. The financial incentives to consult someone are different. From a broad perspective, it would make sense for hospitalists and cardiologists to come out of their respective silos and work together and talk about how they can cooperate to improve care for heart failure patients. One of the things that we've done here at Beth Israel is we have a strong hospitalist group, and we have a heart failure group. We've been meeting and talking about outcomes including length of stay and readmission rates and how we can best combine our services, how we can standardize inpatient treatment protocols and order sets. We've noticed a significant reduction in our 30-day readmission rate.

Q: In general, have you observed a shift of heart failure inpatients from cardiologists' responsibility to hospitalists'?

A: Anecdotally, what I've noticed is that it varies by institution. I've been at large academic centers where every patient with heart failure goes to a cardiology team [and] large institutions where half seem to go to the medicine hospitalist service and half go to cardiology. I've been to institutions where they're all under hospitalists, with or without cardiology consults. That variation seems to reflect the fact we don't know what the best model is to take care of these patients. That's also seen in our data, when you looked at the variation across hospitals. [The assignment of heart failure patients to hospitalists varied from 0% to 83% across hospitals in the analysis.]

Q: Should the finding of lower length of stay and higher mortality with more hospitalist use raise concerns about efforts to reduce length of stay?

A: In prior analyses [including a study in the Jan. 4, 2012 Journal of the American Medical Association], we've seen there seems to be an inverse correlation between length of stay and, at least, readmission rates. Certainly, the question of whether or not we're pushing patients out of the hospital too quickly is a valid one. But these data weren't analyzed to look at that association here, and also in [prior] studies, even though decreased length of stay was associated with increased readmission rates, when we looked at mortality there was no effect. The decreased length of stay [in the current study] was .09 days per 10% increase in hospitalist use. The risk increase in mortality was 3%, so a very small effect size. You have to wonder how clinically meaningful those findings are.

Q: Since increasing use of hospitalists isn't the “silver bullet” to prevent readmissions, where do you think efforts should be focused?

A: One, I'm not sure 30-day all cause readmission rate is a good metric [for evidence, see study in June 2013 American Heart Journal]. I think most people in this field sort of agree with that. But in general, in improving outcomes and quality of care, where we really fall down is coordinating care, educating the patient, improving that transitional piece from hospital to home, communicating with outpatient physicians—all things where hospitalists can contribute a lot, because they're expert on those issues. Working together on these aspects of care coordination, both in the hospital and out, is really where the improvement in quality is going to come from.

Q: Is there any other advice you would offer hospitalists on this topic?

A: Recognizing when and where subspecialists can be useful for caring for the patient, and being willing to reach out and collaborate with us as we need to do with the hospitalists. More and more medicine is going away from these siloed departments and divisions and is really becoming a multidisciplinary game. And the more we can reach out across disciplines to focus on quality, I think that will improve outcomes.