Factors Affecting Heart Failure Readmission Rates in VA Patients

Heart failure (HF) continues to grow as a significant health problem in the U.S., accounting for 1.1 million hospitalizations annually.¹ About 5.8 million Americans have HF, and 670,000 new cases are diagnosed each year.¹ The prevalence of HF increases with age. Persons aged > 65 years comprise the largest group of patients hospitalized for the condition. Heart failure-related hospitalizations place a major financial burden on patients, caregivers, and the national health care system. In 2010, the estimated cost of health care for HF was $35 billion with hospitalizations accounting for 1% to 2% of the total annual health care costs.^1-3 Furthermore, > 50% of patients with HF are rehospitalized before their first outpatient follow-up.⁴

To ensure patients are ready for discharge, HF guidelines recommend specific interventions for all hospitalized patients. These recommendations include successful transition from IV to oral diuretic therapy as well as the initiation of a ß-blocker and an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker (ARB) in stable patients with a left ventricular ejection fraction (LVEF) < 40% and without contraindications. Additionally, patients and their caregivers should receive comprehensive discharge instructions regarding medications, the importance of adherence and regular follow-up, sodium and fluid restriction, weight monitoring, physical activity, and a plan for worsening symptoms. When available, assistance with the hospital-to-home transition should also be provided.^5,6

Heart Failure Measures

Recognizing common factors essential to HF care, the Joint Commission has implemented HF core measures that all U.S. hospitals are required to meet to maintain accreditation status. These guideline-supported measures include receipt of diet, weight, and medication instructions; measured or scheduled assessment of LVEF; ACE-I or an ARB prescribed in patients with LVEF < 40%; and smoking cessation counseling before discharge for all patients with HF.

In addition to HF core measures, 30-day HF readmission rates have also become available to the general public as another hospital quality indicator. In 2009, the Centers for Medicare & Medicaid Services began publicly reporting 30-day HF readmission rates for Medicare patients. A CMS report indicated a 24.8% national 30-day HF readmission rate from July 1, 2007, through June 30, 2010.⁷ Unfortunately, even with the increased quality improvement effort, national HF rehospitalization rates have remained relatively steady in recent years.³

The VA health care system has a growing number of veterans with HF, and it is the leading discharge diagnosis in patients treated at VA hospitals. The number of HF-related hospitalizations at the VA health care system increased from just over 74,000 in fiscal year 2002 to 96,000 in 2009.⁸

To advance the care of veterans with HF and implement best practices, the VA launched the Chronic HF-Quality Enhancement Research Initiative (CHF-QUERI). The major goals of this initiative are to reduce hospitalization rates, increase use of life-prolonging care, empower patients and their caregivers in self-management, and improve appropriateness of HF therapies and tests. As part of its efforts, CHF-QUERI launched the HF Provider Network (HF Network), involving more than 712 VA health care providers (as of July 2014 there were more than 900 providers) committed to improving HF management throughout the entire VA health care system. The HF Network has already put into practice several quality improvement initiatives.

The National Hospital to Home initiative led by the American College of Cardiology and the Institute for Healthcare Improvement was launched throughout the VA system in January 2010.⁹ The main goal of this initiative is to reduce all-cause hospital readmission rates in patients with a discharge diagnosis of HF by improving medication management, early follow-up after discharge, and symptom management.

The Jesse Brown VAMC (JBVAMC) is an active participant of the Hospital to Home initiative, embracing the goals of reducing HF readmission rates and improving the transition of veterans from inpatient to outpatient care. The JBVAMC also has been successfully meeting or exceeding HF core measures except for providing discharge instructions. In May 2011, 91% of patients received discharge instructions, falling just slightly below the 93% target goal. Despite the implementation of HF care improvement initiatives and successful core measure performance, from July 1, 2007, to June 30, 2010, the average HF 30-day readmission rate at JBVAMC was reported to be 28.4%, compared with the national average of 24.8%. Additionally, the average readmission rate for fiscal year 2011 was 31% at JBVAMC, showing a further increase in readmission rates.

The cost of a hospital bed at JBVAMC ranges from about $2,000 to $5,000 per day. According to the American Heart Association’s Get With the Guidelines-HF registry, the mean hospital length of stay for HF in 2009 was 5.5 days.¹ Consequently, HF hospitalizations could potentially cost JBVAMC nearly $7 million annually. Therefore, HF readmissions not only affect patients and caregivers, but also represent a financial burden for JBVAMC.