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Failing hearts drive ‘revolving door’

By David Gulliver
6/16/2009 © Health News Florida

Quality-of-care advocates pay a lot of attention to the control of congestive heart failure, because it’s one of the most common reasons for hospital admission.

So it’s discouraging to see that in 2008, data show, more patients with this condition returned through the “revolving door” of Florida hospitals within two weeks of discharge than the year before.

That rise translates to at least 500 more patients and an estimated $12 million in extra charges – about $4 million in payments.

“It is by far the biggest target for reducing readmissions,” said Dr. Anne Elixhauser of the Agency for Healthcare Research and Quality, a federal agency that identifies effective medical practices.

Readmissions are considered an important measure of quality of care, showing that the patient stayed long enough, didn’t get an infection and had good discharge planning.

Congestive heart failure, in which the heart cannot pump enough blood, can arise from high blood pressure, heart valve defects or a number of other causes. Patients have to be watched closely to avoid anything that would make the heart work harder, such as a rise in blood pressure, weight or body fluids.

A study reported by Elixhauser in 2008 showed one in five heart failure patients were readmitted to the hospital within 30 days of discharge and more than a third within a year. That made the rate 25 percent higher than any other diagnosis.

A more recent study, published in April in the New England Journal of Medicine, backed up those findings. Heart failure had the highest readmission rate of any medical condition or surgical procedure, nearly 27 percent -- or more than one out of every four patients.

It’s not possible to compare Florida data with the national studies directly, since the state Agency for Health Care Administration lets hospitals report the readmission rate at 15 days, instead of 30.

But Florida hospitals’ readmission rate for congestive heart failure can be checked for trend. In mid-2008, it was 13.3 percent, up from 12.5 percent in mid-2007, according to figures available at the FloridaHealthFinder.gov website.

Even though that’s less than 1 full percentage point, it accounts for many patients. Some 65,000 people were admitted to a Florida hospital with heart failure from mid-2007 to mid-2008. About 8,700 returned to that hospital or another within 15 days, running up millions of dollars in extra payments.

The data analysts who adjust rates to allow for differences between patient populations found that 39 Florida hospitals did better than expected in preventing readmissions. Five did worse than expected.

Officials at one of the high-readmission hospitals, Lake Wales Medical Center in Polk County, said its rates suffer because of its high proportion of low-income and uninsured patients. Many have trouble affording medications and finding transportation to follow-up appointments, and 10 percent don’t provide accurate phone numbers, said Michael Yungmann, chief executive officer.

But he pointed to the hospital’s mortality rates, which are in line with state expectations. “We feel very good about the quality of care that is being delivered. We haven’t seen any trends we view as alarming,” Yungmann said.

Dallas-based Tenet Healthcare operates two of the high-readmission hospitals, Hialeah Hospital and Miami’s North Shore Medical Center. In a statement, the company said it looks at readmissions as part of its quality improvement program.

Two others, Lehigh Regional Medical Center and Hialeah’s Palm Springs General Hospital, declined to comment.

While some readmissions are planned, and others unavoidable, hospitals that follow the best practices for different conditions generally have fewer of their patients return soon for more care. The Institute for Healthcare Improvement has been publicizing best practices for heart failure cases as part of its 5 Million Lives Campaign.

So why don’t more hospitals excel? It comes down to mindset and money, said Dr. Harlan M. Krumholz, a Yale University cardiologist who helped develop hospital quality-of-care measures used by the Centers for Medicare and Medicaid Services.

“There are all sorts of things in our hospitals’ systems that conspire in favor of readmissions,” he said. The doctors and nurses who care for a patient in the hospital often don’t have much communication with the patient’s family doctor or home-health aide. And there’s pressure to get patients out the door as quickly as possible.

People often leave hospitals with only a vague notion of what they’re supposed to do afterward and no follow-up appointment. They may be given a prescription but that doesn’t mean they’ll fill it or take it.

“I remember a woman very clearly,” Krumholz said. “No one sat down with her and asked realistically if she could afford the medications.”

There’s another financial problem.

“Hospitals make money when people come in,” Krumholz said. A heart failure readmission can mean the hospital bills the patient, insurer or Medicare twice for one bout of illness, he said.

Some hospitals, such as Baylor University Medical Center, have adopted new practices that succeed in slashing readmissions, he said. But others have tried such measures and scrapped them.

“The hospitals didn’t have money to pay for them,” he said. “Hospitals are losing money on this. It wasn’t good business.”

But he predicts that will change. CMS will add 30-day readmission rates to its Hospital Compare website this summer, he said, offering a national version of FloridaHealthFinder’s data.

The Obama administration has made clear it will address the revolving-door syndrome to improve quality and cut costs. In his radio address Saturday, the President said, “If doctors have incentives to provide the best care instead of more care, we can help Americans avoid the unnecessary hospital stays, treatments and tests that drive up costs.”