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Performance Measure for Heart Failure Care

The VA is a leader in efforts to improve the quality of heart failure care. In a demonstration of its commitment to quality, the VA has provided data to the Centers for Medicare and Medicaid Services (CMS) so that CMS can report publically available comparisons of outcome and process measures for heart failure care to similar data from Medicare hospitals. CMS currently reports the following measures: 30-day all cause mortality; 30-day all cause readmission; measurement of left ventricular ejection fraction; use of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker if the left ventricular ejection fraction is < 40 percent; smoking cessation counseling; and patient education.1

During the last several years, heart failure performance measurement has focused on reducing 30-day readmissions, which occur in approximately 25 percent of patients according to the Hospital Compare website. Readmissions are a marker of many aspects of medical care, including severity of illness, quality of care by providers, quality of the health system in optimizing the transition of care, aggressiveness of care, patient adherence, and preference for location of care. The Department of Health and Human Services (DHHS) has made the assumption that $12 billion of the $15 billion dollars spent on readmissions could be saved due to eliminating preventable Medicare readmissions.

If the majority of readmissions were indeed preventable, it would be appropriate to hold hospitals accountable for these costs as is planned by CMS. However, preventability is extremely difficult to determine; in fact, researchers lack consensus on how to define a preventable readmission. Systematic reviews have shown wide variation in definitions of preventable admissions, with few studies of preventable readmissions deemed to be of high quality. For this reason, CMS has chosen 30-day all-cause readmission as the measure of quality. Recent studies suggest that the percent of Medicare readmissions that are preventable is much lower than the DHHS estimate of 75 percent. Researchers from Canada have estimated that the fraction of readmissions that is preventable is likely less than 20 percent.2

If better quality of care can improve the readmission rate, then randomized trials should be able to demonstrate this hypothesis. Indeed, more than a decade ago several studies found that the readmission rate for heart failure can be reduced through comprehensive discharge planning with a variety of interventions. Many of these interventions have since become standard care at VA hospitals. Whether more aggressive follow-up can continue to improve readmission rates is unknown. Paradoxically, researchers have found that readmission rates increase with closer follow-up as shown in a large VA randomized trial.

Indirect evidence also suggests that 30-day readmission rates are now a poor measure of hospital or system quality of care. An analysis of Hospital Compare data showed that those hospitals with the highest readmission rates had improved mortality rates. The VA Chronic Heart Failure Quality Enhancement Research Initiative (QUERI) has shown that for Veterans over the last decade, as process of heart failure care measures improved, 30-day mortality rates also improved while readmission rates worsened slightly.3

If readmissions are a poor measure of quality, what would be better? First, the VA and DHHS could improve on the National Quality Forum endorsed measure for beta-blockers at discharge if the left ventricular ejection fraction is below 40 percent. Current VA use among candidates is about 70 percent. An emerging area for quality measurement is the safe use of aldosterone antagonists. These medications have reduced mortality and admissions for heart failure in randomized controlled trials, though improper monitoring can lead to dangerous hyperkalemia.

Perhaps more patient-centered outcome measures can be tested. From the patient's perspective, spending less time in the hospital is preferable, and if given the choice, many patients may prefer early discharge despite an increased risk of readmission. Thus, an alternative outcome measure to a 30-day readmission rate is total hospital days during the 30 days following the first day of admission. If resources were available for patient surveys, then a standardized measure of health status at 30 days following readmission would be even better. We should remember that our main goals with measurement of performance should be to improve patient length of life, quality of life, and efficient use of resources. Researchers should continually evaluate and revise performance measures as the health care system evolves.

  1. Hospital Compare, Department of Health and Human Services,
  2. Van Walraven, C. et al., "Incidence of Potentially Avoidable Urgent Readmissions and their Relation to All-cause Urgent Readmissions," Canadian Medical Association Journal 2011; 183(14).
  3. Heidenreich, P.A., et al. "Divergent Trends in Survival and Readmission Following a Hospitalization for Heart Failure in the Veterans Affairs Health Care System 2002 to 2006," Journal of the American College of Cardiology 2010; 56(5):362-8.

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