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2015 HSR&D/QUERI National Conference Abstract

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1022 — Clinical Practices Related to Lower Heart Failure Readmissions

Liu CF, VA Puget Sound Health Care System; Rinne ST, VA Connecticut Healthcare System; Cook MA, VA Puget Sound Health Care System; Wong ES, VA Puget Sound Health Care System; Heidenreich PA, VA Palo Alto Health Care System; Hebert PL, VA Puget Sound Health Care System;

Objectives:
Reducing heart failure (HF) readmission is a focus for US healthcare systems to improve quality and reduce costs. Few studies have addressed how clinical practices reduce hospital readmissions. This study examined the relationship between clinical practices for managing HF patients and the 30-day HF-specific readmissions.

Methods:
This was a retrospective cohort study using VA and Medicare databases and a facility survey of HF practices conducted by HF QUERI in 2008. The study included 35,533 patients with an admission for HF during 2007-2009 in 113 VA hospitals, which had at least 25 HF discharges. The facility survey collected information regarding HF patient management, including clinic structures, standardized programs/protocols, and post-discharge follow-up. The outcome was the 30-day HF-specific readmission at a VA, fee-basis, or fee-for-service Medicare hospital. We estimated the association between these facility-level clinical practices and 30-day HF-specific readmission using a mixed-effects logit regression that controlled for patient demographics and comorbidity and clustering by VA hospital.

Results:
Among the study sample, the 30-day HF-specific readmission rate was 11%. The adjusted results show that patients admitted to facilities that reported using standardized orders for outpatients (odds ratio (OR) = 0.82, p = 0.0035), a written contract signed by the patient at the time of discharge (OR = 0.77, p = 0.038), and having a HF follow-up clinic (OR = 0.87, p = 0.047) were associated with a lower risk of risk of readmission. Patients who were admitted to facilities with a standardized heart failure exercise program (OR = 1.15, p = 0.0014) and routine scheduling of the first post-discharge follow-up visit beyond 4 weeks after discharge (OR = 1.25, p = 0.014), compared to facilities scheduling the follow-up visit within 2 weeks, were associated with a high risk of readmission.

Implications:
Hospitals with standardized outpatient orders for managing HF patients, a written contract signed by the patient at the time of discharge, a HF follow-up clinic, and timely scheduling of a post-discharge follow-up visit were associated with lower risk of HF-specific readmission. However, having a heart failure exercise program was associated with a higher risk of HF-specific readmission.

Impacts:
This study identified clinical practices that could potentially reduce HF-specific readmissions. Further research on the unexpected positive relationship between HF exercise programs and HF-specific readmissions is needed.