>Operator:
It is now my pleasure to turn today's program over to Steve Dentel with the American Heart Association. Steve, the floor is yours.
Steve Dentel:
Thank you so much, Ginneen. Good afternoon and welcome. On behalf of the American Heart Association, Get With The Guidelines Heart program, and our webinar series sponsor, Amgen Cardiovascular, we welcome you to the first event in our webinar series, "Heart Science Amplified." Today's presentation is the first in our series of three offerings intended to amplify the conversation around key topics in heart failure. We invite you to join us throughout the series by registering for our next two offerings on Improving Guideline Directed Heart Failure Care with Dr. Clyde Yancy, and Transitions of Care with Dr. Nancy Albert.
On today's session, we will have the pleasure to hear from Dr. Gregg Fonarow who will discuss with us key factors that affect 30-day heart failure rehospitalizations, the impact that this has on patients and hospitals and what you and your hospital can do to positively affect readmissions.
I'd like to introduce our presenter for today. Dr. Gregg Fonarow is the Eliot CordayProfessor of Cardiovascular Medicine and Science at UCLA. He serves as director of the Ahmanson-UCLA Cardiomyopathy Center, co-director of UCLA's Preventative Cardiology program and clinical co-chief of cardiology UCLA Division of Cardiology. He attained the rank of Professor of Medicine, Geffen School of Medicine at UCLA in 2003. His research interests center on acute and chronic heart failure, preventative cardiology, quality of care, outcomes, and implementing treatment systems to improve clinical outcomes. Dr. Fonarow has published over 600 research studies in clinical trials in heart failure, disease management preventative cardiology and outcomes research. New therapies and management strategies for advanced heart failure in research into the pathophysiology of this disease are conducted at UCLA under his direction. He also has developed and successfully implemented a comprehensive atherosclerosis treatment program at the UCLA Medical Center which served as a model for the American Heart Association's Get With The GuidelinesProgram. It is now my pleasure to turn things over to Dr. Fonarow.
Dr. Gregg Fonarow:
Thanks, Steve. It's really a great pleasure to be here today and to present on this topic. I really want to thank you all for joining us. Here are my disclosures related to this presentation. And I think as you're all aware, the really vexing problem we face with hospitalizations as well as rehospitalizations for heart failure. And for our patients with heart failure that are hospitalized, data has shown that nearly 1 in 4 of these patients, 25%, are rehospitalized within 30 days, and that despite therapeutic advances over the last two decades, if anything there's been an increase in 30-day rehospitalizations, not a decrease. We see tremendous variations by hospitals even when we adjust for case mix, and while certainly some hospitalizations are not going to be preventable and some rehospitalizations are not going to be preventable, there are some that are, and that's what we want to really work on, on trying to prevent those rehospitalizations that with better care and better care transitions would indeed be preventable and much of the tremendous economic burden associated with heart failure is related to these hospitalization and rehospitalizations and that by preventing preventable rehospitalizations, we can get the same or better outcomes at lower cost.
So this next slide shows this kind of traditional approach to heart failure admission, with tune the patient up with diuretics, a little bit of education, list of their discharge prescriptions, pretty much consisting with whatever meds they came in on and have that patient go out of door, wave goodbye, don’t come back within 30 days, but of course we know many of these patients would be back very soon. So can we improve on this process and reduce rehospitalizations? Here's the data showing the temporal trends in readmissions, they're on the rise. This data from fee-for-service Medicare patients, highlighting the costs, looking at in 1993, 17.3% of patients hospitalized with heart failure were re-admitted for any cause within 30 days, and by 2006, it had increased to 20.1, and more recent data in the sort of 24-25% range. And recent trends have maybe stabilized or slightly gone down a bit, but a large proportion of patients still being rehospitalized with heart failure. The challenges are not just with rehospitalization, if we look at 30-day and one-year mortality rates going back from 1992 to more recent data on Medicare beneficiaries, and you think about all the therapeutic advances for heart failure with reduced ejection fraction in this time, but in real world patients, we see that the mortality rates really have not improved substantially. Maybe a slight decrease after we risk adjust, but we have a large problem where many of our patients with heart failure are not receiving the right therapies at the right dose at the right time, and that we're having preventable rehospitalizations as well as preventable death that could be amenable to reduction if we were more effective in our delivery in a more reliable way to patients.
This next slide illustrates that readmission is not just about the cost because here is data looking at with each successive readmission, the mortality rates, particularly in that first three months, go up successively. So the risk of death is greatest in the early period after a hospital discharge, and is directly related to the frequency of heart failure hospitalizations. So preventing some of these readmissions may translate to better outcomes for our patients, including mortality reductions.
Now, this slide illustrates that tremendous economic burden. Here at this time point was estimated at $40 billion in direct and indirect costs. Though recognized that the major driver of heart failure cost is hospitalization, and recognize this is also probably a substantial underestimate to avoid double counting if a patient has hypertension and is admitted with heart failure, those costs are attributed to hypertension. Same thing with coronary disease. So if we look at the cost related to heart failure directly and indirectly, the costs are perhaps three times higher than shown on this slide and the AHA estimates that if nothing were to change, by 2030, upwards of $160 billion in direct costs and indirect costs attributed to heart failure. So incredibly expensive. So trying to reduce those rehospitalizations that are preventable economically and for a sustainable health system makes sense.
Now here's data looking at by deciles of hospitals on 30-day readmission rates. And what you can see in each of these panels, there's a lot of variation between the lowest decile and the upper decile, more than double as far as the 30-day readmission rates. And this is true when you look at race ethnicity, by gender, by rural or urban, so there's a lot of variation of readmission rates by hospital and suggests that, in fact, that some of these rehospitalizations may, with better approaches to care, better care transitions, be preventable.
What do the Guidelines say about rehospitalization? This is from the HFSA 2010 Guidelines, practitioners who care for patients with heart failure are challenged daily with preventing common, recurrent rehospitalizations for exacerbations. Most of the costs associated with heart failure is due to these hospitalizations and estimates as many as one-half or two-thirds of hospital readmissions may, in fact, be preventable with better attention to modifiable factors and enhanced transitions of care.
Now, do we have therapies that improve outcomes for patients with heart failure? Certainly with heart failure, reduce EF is shown on this slide. We have a number of therapies proven in randomized clinical trials to reduce all-cause mortality with a very respectable number needed to treat. But you will see with many of these, with the exception of ICD, that there are significant reductions in heart failure hospitalizations. Focus on the data with regards to angiotensin receptor, neprilysin inhibitors were up and above that achieved with ACE inhibitors. There's an incremental 21% reduction in heart failure hospitalizations. And with the heart rate lowering drug, ivabradine, that there is, in fact, a 26% reduction in heart failure hospitalizations that can be achieved with these medications and these reductions are additive. So we actually have medical therapy that when appropriately applied to appropriately selected patients and in the right dose, we can improve outcome, not just lower mortality but substantially lower the risk of hospitalization.
Now, if we look at how these therapies are applied in practice as well as counseling as well as use of diagnostic tests, this is early data from the ADHERE Registry, looking at the original Joint Commission core measures for heart failure. You can see this tremendous variation between lagging and leading centers in their application of these therapies and diagnostic tests. But look at the difference in length of stay mortality between these lagging and leading centers, tremendous difference there. So suggesting better quality of care could translate to better and more efficient care of these patients where there's going to indeed be better outcomes.
When we look at our application of evidence-based medications and heart failure reduce EF, this, is from the Canadian effect registry done in the 2003-2004 time frame, and you can see that here the use of ACE inhibitor ARB at discharge was about three quarters of eligible patients without contraindications, the beta-blockers at discharge are single most important life prolonging medication for patients with heart failure with reduced EF but also reduce hospitalizations used in only one-third. You could think don't worry, the physician will discharge the patient and I'm sure over the next three months, 90 days of follow-up, someone for a perfect candidate without contraindications would initiate that therapy, but as you can see, very little post-discharge uptake in these medications. This slide also illustrates those at highest risk of mortality were even less likely to be treated. So we have treatment gaps beginning in the hospital continuing in outpatient basis, and the patients at greatest risk that would derive the best benefit from therapy are even less likely to be treated.
We also see with regards to continuity of care in follow-up tremendous variation. This is looking at the percentage of patients having a follow-up with any provider within seven days after discharge from a heart failure hospitalization, recognizing one in four patients are going to be rehospitalized in 30 days, and guidelines recommend early follow-up and overall only one-third of patients had follow-up within seven days and tremendous variation by centers. So there's opportunities here to improve quality of care as well as quality of follow-up in transitions of care.
Now what are the timings of readmissions after hospitalization? And what you can see is there are readmissions that occur within a few days of discharge and continue throughout that 30-day period, and it's true not just for heart failure but community acquired pneumonia and AMI. So this tells us really the transitions of care are very important in that entire 30 day period, and particularly in that first week, patients are very vulnerable for readmissions.
Now are some of these readmissions preventable? This is a study that looked back at patients who were readmitted, went through the medical records and tried to see were there things done involving the patient, the transitions of care, the providers, where things had been done differently in the investigators viewpoint potentially that readmission could have been prevented. And you see a host of reasons here. But overall, this added up to about two-thirds of the hospitalizations may have been preventable. Doesn't mean that you could argue about some of these components, but there's a fair number of things going on with medication and dietary non-adherence, failure to seek care with escalating symptoms, other reasons that are contributing to these rehospitalizations. So does rehospitalization prevention fall in this domain of quality of care? This is the IOM's definition, the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. And I would argue that this is aligned as we look at the domains of quality of care being timely, effective, safe, equitable, patient-centered, efficient, and cost-effective that preventing rehospitalizations really align very nicely along this for the preventable rehospitalizations. The reasons to focus on outcome and not just process measures I think are outlined here, certainly with the Joint Commission core measures in the early 2000s to the mid-2000s period with public reporting, there had been significant improvement in these measures. And one could then say, okay, we're improving care for our patients with heart failure, but some of these measures were more check the box. And when we actually look at outcomes for 30-day rehospitalization in this time period, there was not, in fact, a reduction occurring and the same thing for one-year mortality. So really tells us measuring and trying to improve clinical outcomes are as important and looking beyond just process of care measures.
So here's an example of what would have been judged by the Joint Commission CMS core measures as perfect heart failure care, 65-year-old hospitalized after a prior MI, heart failure for the third time this year, the LVEF was measured, the patient was discharged on an ACE inhibitor, but at a very low dose, was counseled to quit smoking, was provided all six components of the discharge instructions, so by the CMS core measure, 4 out of 4 defect-free care. This patient was also discharged on high dose loop diuretics without potassium supplementation, despite a reduced EF, was not on a beta-blocker, had no scale at home, first follow-up was scheduled four weeks after discharge, and post-discharge day 8 was re-admitted with fatigue, worsened heart failure and a potassium of 2.6. I think anybody would judge this to be high quality care, not look at this as potentially a preventable rehospitalization, and so really showing us that coupling process measures also with outcome measures is very important for capturing quality.
Here at the hospital level, an example of a Center Of Excellence in heart failure care. This center had an outstanding reputation, very high volume, performed many heart transplants, was ranked highly by "U.S. News & World Report," well-known faculty, lots of publications, extensive advertising, invested in health IT,and on the CMS process measures, 100%, four stars, touted providing the highest quality of care. But in looking at outcomes, their risk-standardized 30-day readmission rates were 28%, substantially worse than the U.S. national average. Gives a different perspective on the care actually being provided and outlining opportunities for improving.
So we really, with this data, about reporting on 30-day rehospitalization, and changes in how healthcare payments and incentives occur, it really creates an opportunity to incentivize caregivers and hospitals that think about the patient more globally and not that all of the responsibility ends at the time of discharge. There's certainly been barriers in the past to improving heart failure care that were not incentives focused on care transitions to better coordinate heart failure care, to fund multidisciplinary teams, to think about heart failure disease management programs, to fund palliative care program, to focus on really meaningful quality improvement rather than just check the box on process measures to really underlie and identify and improve systems of care, track and improve outcomes, and investigate better models of careuntil recently. And with the Affordable Care Act, where actually public reporting and penalties related to 30-day rehospitalizations after risk adjustment andhaving hospitals really face substantial financial penalties related to excess readmissions has really changed that all and really gravitates the focus on what can we really do to improve here.
So this slide just outlines some of the details of the Affordable Care Act regarding penalties. So Medicare is penalizing a substantial proportion of hospitals. The average payment reduction is 0.61%, but can be up to 3% of which 38 hospitals are facing that. This is looking at some select hospitals, including UCLA, what our penalties have been over each of the fiscal years, and some other select centers. Point here is just to really highlight there are some centers that are doing well and infrequently penalized, others that have shown significant improvement, and others where they’ve been worsening here. But these are substantial dollars and these are incentives for all of us to work together to try and reduce preventable rehospitalizations.
There's also been a movement towards value-based purchasing over episodes of care, and so additional incentives around trying to reduce preventable rehospitalizations. In addition, Medicare on Hospital Compare isnow reporting the value of care where the death rates and then the payments being made, and then making a determination of the value.