High Heart Failure Readmission Rates: Is It the Health System’s Fault?

Introduction

Hospital readmissions remain a continued challenge in the care of the heart failure patient. Although small gains have been made over the past 5 years, still more than 20% of patients are readmitted within 30 days and up to 50% by 6 months. Predicting who will be rehospitalized is difficult, and much is unexplained. Does the hospital in today's health system play a major role? This was recently debated at the 2017 ACC Scientific Sessions, and my view is that they do. Health systems now comprise a network of hospitals, both primary and tertiary, skilled nursing facilities, ambulatory centers, primary care networks, subspecialty groups, and transitional care teams. Several key factors play a role in the admission of the heart failure patient. First, the actual admission of heart failure patients is largely controlled by health system's criteria for admission. Emergency room teams and the availability of same-day access clinics are important programs that can influence whether a patient is admitted. It turns out that the health systems that have low admission rates for heart failure patients also have low readmission rates, a finding suggesting that the organizational structure of the health system is important. The course and care of the patients through the hospital stay are also determinants. Evidence-based therapy that is initiated and implemented in the hospital, patient education, and socioeconomic barriers are all part of the health system's responsibility. The length of stay and the degree of decongestion are important components of readmission risk. If you want to reduce your 30-day readmission rate, keep your patient in the hospital longer. The transition from hospital to clinics and having access within 7 days, seeing familiar physicians in follow-up as a part of the network, and implementing several transition strategies are important in reducing the heart failure rehospitalizations.

More than one-half of health systems pay penalties for readmissions; those hospitals that are more likely to have high harm rates for their patients. Finally, the implementation of bundled care initiatives and coordination of care with skilled nursing facilities can play an enormous role in reducing heart failure admissions. Up to 50% of some patient populations end up in a skilled nursing facility. The organization of the care in these facilities is complex and sometimes not coordinated with the health system; thus it is the health system that can best optimize care.

So, in the argument of who is to blame for excessive heart failure rehospitalizations, the health system is partly at fault, and physician leaders need to fix it!