Elsevier

American Heart Journal

Volume 165, Issue 6, June 2013, Pages 987-994.e1
American Heart Journal

Clinical Investigation
Heart Failure
Are we targeting the right metric for heart failure? Comparison of hospital 30-day readmission rates and total episode of care inpatient days

https://doi.org/10.1016/j.ahj.2013.02.006Get rights and content

Background

Hospitals are challenged to reduce length of stay (LOS), yet simultaneously reduce readmissions for patients with heart failure (HF). This study investigates whether 30-day rehospitalization or an alternative measure of total inpatient days over an episode of care (EOC) is the best indicator of resource use, HF quality, and outcomes.

Methods

Using data from the American Heart Association's Get With The Guidelines-Heart Failure Registry linked to Medicare claims, we ranked and compared hospitals by LOS, 30-day readmission rate, and overall EOC metric, defined as all hospital days for an HF admission and any subsequent admissions within 30 days. We divided hospitals into quartiles by 30-day EOC and 30-day readmission rates. We compared performance by EOC and readmission rate quartiles with respect to quality of care indicators and 30-day postdischarge mortality.

Results

The population had a mean age of 80 ± 7.95 years, 45% were male, and 82% were white. Hospital-level unadjusted median index LOS and overall EOC were 4.9 (4.2-5.6) and 6.2 (5.3-7.4) days, respectively. Median 30-day readmission rate was 23.2%. Hospital HF readmission rate was not associated with initial hospital LOS, only slightly associated with total EOC rank (r = 0.26, P = .001), and inversely related to HF performance measures. After adjustment, there was no association between 30-day readmission and decreased 30-day mortality. In contrast, better performance on the EOC metric was associated with decreased odds of 30-day mortality.

Conclusions

Although hospital 30-day readmission rate was poorly correlated with LOS, quality measures, and 30-day mortality, better performance on the EOC metric was associated with better 30-day survival. Total inpatient days during a 30-day EOC may more accurately reflect overall resource use and better serve as a target for quality improvement efforts.

Section snippets

Data source

We obtained clinical data from GWTG-HF for patients 65 years or older. Hospitals participating in GWTG-HF submit clinical information regarding the medical history, hospital care, and outcomes of consecutive patients hospitalized for coronary artery disease, stroke, or HF using an online, interactive case-report form and Patient Management Tool (Outcome Sciences, Inc, Cambridge, MA). Through their Patient Management Tool, Outcome Sciences, Inc, serves as the data collection and coordination

Results

The study included 17,387 patients 65 years or older enrolled in GWTG-HF. We included 149 hospitals. The median hospital-level 30-day readmission rate was 23.2 (interquartile range [IQR] 19.1-26.3). The median observed hospital-level index admission LOS and overall EOC were 4.9 (IQR 4.2-5.6) and 6.2 (IQR 5.3-7.4) days, respectively. Among those readmitted, the median observed LOS for the second hospitalization was 5.0 days (IQR 3.0-8.0 days) and was not significantly different than the index

Discussion

The current emphasis on quality improvement and cost containment for highly prevalent chronic health conditions makes HF an ideal focus point.2, 13 Understanding how to measure efficiency, resource use, and quality of care among hospitals treating patients with HF will be central to this effort.14 Related to this, our analysis yields several important findings. First, although variation exists in both hospital-level LOS and EOC, we demonstrate an increased variation in the latter. Second,

Disclosures

The Get With The Guidelines-Heart Failure (GWTG-HF) program is provided by the American Heart Association. The GWTG-HF program is currently supported, in part, by Medtronic, Ortho-McNeil, and the American Heart Association Pharmaceutical Roundtable. GWTG-HF has been funded in the past through support from GlaxoSmithKline.

This project received infrastructure support from the Agency for Healthcare Research and Quality (Grant No. U18HS016964). The content is solely the responsibility of the

Acknowledgements

The authors would like to thank Erin LoFrese for her editorial contributions to this manuscript. Ms LoFrese did not receive compensation for her assistance, apart from her employment at the institution where the study was conducted.

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