Where: Massachusetts General Hospital, a 950-bed tertiary care facility in Boston.
The issue: Decreasing readmissions after percutaneous coronary intervention (PCI).
Even if patients have lifesaving access to cardiac interventions, inadequate follow-up can bring them right back to the hospital. As a junior resident, Jason Wasfy, MD, MPhil, would make follow-up appointments but found that patients often could not see a cardiologist for a few months—even after an acute myocardial infarction (MI). “I just didn't think that was right. . . . It's critically important that patients have access to cardiologists, especially right after they have an acute heart event, like an MI,” said Dr. Wasfy, now a cardiologist and assistant medical director of the Massachusetts General Physicians Organization.
With the goal of reducing preventable readmissions after PCI, he and colleagues developed an initiative spanning all phases of post-PCI care: the index hospitalization, postdischarge and outpatient settings, and any subsequent presentation to the ED. “If I were a patient with a recent stent, and I had chest discomfort and ended up in the ED, I'd want to see a cardiologist immediately, not just be readmitted to the hospital to see a cardiologist on the floor,” Dr. Wasfy said.
How it works
In 2015, clinicians started to assess inpatients' readmission risk after PCI using a validated score and to employ a discharge checklist, which ensured access to medications and close follow-up for those at high risk. To improve patient education and access, cardiology fellows had developed patient education videos and, in 2012, they had established a new post-MI discharge clinic. Additionally, in 2015, the team set up an automatic notification system to alert cardiologists when patients presented to the ED within 30 days of PCI, and cardiologists used a post-PCI risk algorithm to triage those patients.
Especially with new cardiac conditions, patients are scared, need support, and need to be educated on which types of chest symptoms should raise concern, said Dr. Wasfy, also an instructor in medicine at Harvard Medical School. “And the way we can help sort that out is through educating them, empowering them, and making sure they have access to us,” he said.
The costs of the initiative were minimal—a couple of thousand dollars per year or less—because much of the work was done on a volunteer basis, and the team was able to build out existing mechanisms to track patients in the ED after PCI, Dr. Wasfy said. “Because a lot of our fellows are really into quality and motivated to improve quality of care for our patients, a lot of people volunteered their time,” he said, noting that the fellows were often also the ones who saw patients in the ED.
To measure the impact, the team tracked the number of patients readmitted to the hospital after PCI. From 2011 to 2015, the 30-day readmission rate declined from 9.6% to 5.3%, according to results published in the September 2016 Circulation: Cardiovascular Quality and Outcomes. The protocol is still in effect on the hospital's cardiac floors.
Because readmission research is complicated, Dr. Wasfy noted two caveats to the findings: that they show a reduction in readmissions to Mass General only, and that readmissions after PCI are declining nationwide. To address these issues, the research team is working to validate Mass General's administrative data against larger, state-level datasets, he said. “I think it's important to show that at our hospital, the readmission rate went down more than at other hospitals,” Dr. Wasfy said. “Based on the magnitude of these events, it'd be hard to imagine that this is just part of a national trend, but we obviously want to confirm that with the most rigorous statistical methods possible.”
Despite adding the additional fellows clinic and asking cardiologists to double-book appointments, outpatient access remains the most difficult challenge, Dr. Wasfy said. “Our doctors are busy and the clinics are full, so trying to make sure that patients can be seen in the office in a timely way has been hard,” he said. The team is currently considering ways to use advanced practice providers to increase the capacity to see patients right after discharge, Dr. Wasfy said.
As the team works to confirm its results with statewide data, it is also revisiting and reforming the triage algorithm and trying to streamline the auto-notification system, he said. “[We're] trying to understand how we can get cardiologists to see patients in the ED as quickly as possible because we think that it not only is good care, but it also averts unnecessary readmissions,” Dr. Wasfy said.
Words of wisdom
Owing to its simplicity, much of the initiative could be recreated at other institutions, including in community hospitals, he said. “I think a lot of reducing readmissions is good old-fashioned doctoring: making sure we see our patients when they need to be seen, making sure we visit them in the ED, and making sure they're empowered to understand their disease,” Dr. Wasfy said. “These are the things we learned in medical school, they're really helpful for [reducing] readmissions, and they don't cost that much money.”