Heart Failure Readmissions 2017 Where do we stand? · 4/3/2017 1 Heart Failure Readmissions 2017 Where do we stand? Peter Eckman, MD, FACC, FHFSA Section Head, Advanced Heart Failure

4/3/2017

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Heart Failure Readmissions 2017

Where do we stand?

Peter Eckman, MD, FACC, FHFSA

Section Head, Advanced Heart Failure

Disclosure InformationPeter Eckman, MD, FACC, FHFSA

Disclosure InformationPeter Eckman, MD, FACC, FHFSA

I have the following financial relationships to disclose:

Consultant for:

Abbott/St Jude Medical (Current and Future LVADs) SHAPE Medical Systems (prior)

Medtronic

Novartis (LCZ696, prior)

Grant/Research support:

Abbott/St Jude Medical (Prior)

Sensible Medical (Current Site PI)

Cardiac Profiles, Inc. (Prior)

Advisory Board:

Abbott/St Jude Medical (CardioMEMS)Medtronic (Polaris, Contractility Modulation System)

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What’s next?

If you think I know,

please see me afterwards

for a great deal on one of these:

How to prepare?

• Take great care of patients!

• Use clinical practice guidelines, AUC,

evidence-based tests and treatments

• Process improvement: Measure, change, re-

measure

• Focus on real descriptors of quality

• Embrace multidisciplinary, integrated teams of

care

Edward TA Fry, MD, FACC (http://www.acc.org/latest-in-cardiology/articles/2017/01/13/13/17/macra-how-to-prepare-for-the-unknown)

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• ACA = Affordable Care Act (“Obamacare”) (2010)

• MACRA = Medicare Access & CHIP Reauthorization Act (2015)

• SGR = Sustainable Growth Rate (1997)

• QPP = Quality Payment Program

• MIPS = Merit-based Incentive Payment System

• APM = Alternative Payment Models

• PQRS = Physician Quality Reporting Program

• VM = Value-Based Payment Modifier

• MACRA = Medicare Access & CHIP Reauthorization Act

– Passed in 2015 with SGR repealed

– Replaces SGR with QPP

– Bipartisan support

• SGR = Sustainable Growth Rate

– Prevent cost increase of physician payments from CMS

• QPP = Quality Payment Program

– Intended to create incentives for high-quality and cost-effective care:

– MIPS = Merit-based Incentive Payment System

– APM = Alternative Payment Models

• (A) MIPS = Merit-based Incentive Payment System– Combines PQRS, VBP, EHR incentives (meaningful use)

– Adds quality, resource use, advancing care information, and clinical practice improvement activities

– Quality (60%) – select 6 metrics with best fit to practice

– Advancing Care (25%) – replaces HER incentives

– Improvement Activities (15%) – Care coordination, engagement, patient safety, anticoagulation management improvement, etc.

– Cost (0%) – Postponed, comparison to peers

• 5% in 2017 will have small penalties (and rewards)

• Penalties/rewards will scale up over few years

• Low volume practices (~32% Medicare) exempt 2017 as only ~5% of spending

QPP = Quality Payment Program (A) or (B)

Reference: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/

MACRA-MIPS-and-APMs/Resource-Use-Performance-Category-slide-deck.pdf

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ACC/AHA Proposed MIPS Metrics

• HF: ACEi/ARB for LVSD

• HF: BB for LVSD

• Cardiac rehab patient referral from outpatient

setting (CMS page doesn’t include HF*)

• CAD: Inappropriate stress testing after PCI

• Stress imaging outside AUC for asymptomatic,

low-risk patients

• AF/AFL: Chronic anticoagulationhttps://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0ahUKEwi4-_34hPXSAhUM3IMKHfXRBI8QFgghMAE&url=https%3A%2F%2Fwww.acc.org

%2F~%2Fmedia%2FNon-Clinical%2FFiles-PDFs-Excel-MS-Word-etc%2FTools%2520and%2520Practice%2520Support%2FAdvocacy%2520at%2520the%2520ACC%2FACC

%2520AHA%2520Proposed%2520Measures.pdf%3Fla%3Den&usg=AFQjCNHEErUde3Z7nEGwfS9v8efuHSBoEg

*https://qpp.cms.gov/measures/quality

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Metrics Listed on CMS Site

• HF/Depression– % of patients with diagnosis of Major Depressive Disorder

and HF with communication to physician treating HF

• Functional status assessments– % of patients 65+ with HF who completed initial and F?U

patient-reported functional status assessments

• ACEi/ARB for LVSD– % of patients >18 with HF and current or prior LVEF<40%

with ACEi or ARB within a 12 month period OR at D/C

• BB for LVSD– % of patients >18 with HF and current or prior LVEF<40%

with BB within 12 month period OR at D/C

https://qpp.cms.gov/measures/quality

• (B) APM = Alternative Payment Models

– Prioritizes patient-reported outcomes and

measures of patient perception and measurable

clinical outcomes

– Those who meet thresholds of participation are

exempt from MIPS (ESRD, oncology examples)

– Participation in coordinated care delivery models

and assume financial risk for outcomes

– Bonuses can exceed payment increases from MIPS

• Could this be to Part B what DRG was to Part A?

QPP = Quality Payment Program (A) or (B)



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Are we being properly incentivized?

• Analysis of 171 centers with 43,143 participants in GWTG-HF registry

• July 2008 – June 2011

• 49% centers had excess readmission ratio (HF-ERR)

• No difference between low and high risk-adjusted 30-day readmission groups in median adherence to all performance measures (95.7% vs96.5%) or median percentage of deficit-free care (90.0% vs 91.1%).

• Composite 1-year death or all-cause readmission was not different (median 59.1% vs 54.7%)

• 1-year mortality rates were lower among high versus low HF-ERR (median 28.2% vs 31.7%, p=0.07)

• Quality of care and clinical outcomes were comparable

• It is therefore not clear that the hospital readmission reduction program (HRPP) is improving care

Pandey A et al, JACC: HF 2016;4:935-46

Pandey A et al, JACC: HF 2016;4:935-46

• “This metric has driven our entire provider workforce to construct machinery designed to reduce short-term post-hospitalization utilization, while doing little to improve quality for the 5.7 million…with heart failure.”

• “The knowledge of our misdirection in responding to the mandate of this metric and the inaction in modifying it should be a call to action toward patient enablement in selecting clinical care metrics-ensuring that future metrics indeed speak to patients’ interests for improving their own care. It is time to consider a systemic shift in our approach to driving quality.”

• Flaws in the 30-day penalty– 1) 30-days is an arbitrary time frame without validity or relevance

• 77% of readmissions occurred >30 days after discharge (EVEREST, e.g.)

– 2) Incentive to delay care until after 30-day time period

– 3) More diligent follow-up may actually INCREASE hospitalizations, which may be medically appropriate

– 4) Disease-specific, ambulatory management may not generate sufficient ROI in relation to the short-term penalties

– 5) Disproportionate impact on sickest/most vulnerable populations

– 6) Competing risk of death

Konstam M, JACC HF 2017;4(12):935-6.

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What if mortality was weighted

equally?

• Patients who die within 30 days of ADHF are excluded from readmission metrics

• Financial penalties are ~10x greater for readmission than mortality

• 1963 hospitals from FY2014

– Readmission penalties closely tracked excess readmissions (r=0.81), but were minimally and inversely correlated with excess combined readmission and mortality (r=-0.12)

• Note that age-adjusted mortality rates for US patients with HF have increased at the same time 30-day readmission rates decreased (ref 10,13)

Abdul-Aziz AA et al, JAMA Cardiology 2017;2(2):200-203.

Date of download: 2/16/2017Copyright © 2017 American Medical

Association. All rights reserved.

From: Association Between Medicare Hospital Readmission Penalties and 30-Day Combined Excess

Readmission and Mortality

JAMA Cardiol. 2017;2(2):200-203. doi:10.1001/jamacardio.2016.3704

Readmission Penalty vs Concordance of Readmission and Combined Mortality and ReadmissionFor the readmission low, high combined mortality and readmission population, the ERRAgg was less than 1 and the ECORAgg was more than 1. For the readmission high, low combined mortality and readmission population, the ERRAgg was greater than 1 and the ECORAgg was less than 1. DRG indicates diagnosis-related group; ECORAgg, excess combined outcome ratio; ERRAgg, excess readmission ratio.

Figure Legend:

• Questions have been raised about the use of

risk-adjusted 30-day readmission rates to

serve as a metric of hospital quality

• Poor to no correlation between rates and care

quality

• Rates are largely driven by severity of

underlying condition and SES of the patients

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Readmission identified by CMS as a

way to reduce costs

Image: Pixabay.com

LOS of Medicare Patients Hospitalized

for HF, 1993-2006

P<.001

Bueno. JAMA. 2010;303(21):2141-47.

Mortality Rates

P<.001

Bueno. JAMA. 2010;303(21):2141-47.

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Mortality

Heidenreich. J Am Coll Cardiol 2010;56:362-8.

Risk Adjusted Trends:

Readmissions vs. Mortality

Heidenreich. J Am Coll Cardiol 2010;56:362-8.

How to Reduce Readmissions?

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“Bridge Clinic”Patients Hospitalizations ALOS

(d)

CMI % Cardiology

Involvement

Bridge 142 145 5.4 2.33 89%

Non-bridge 508 639 5.0 2.17 75.6%

Abbott Northwestern

Feb ‘16 through Feb ‘17

Discharges to home or home health

Follow-up within 5 days

Patients %CV F/U %PCP F/U 30-day

Readmits

PPR A/E

Bridge 142 100% 19.3% 13.5% 0.48

Non-bridge 508 10.2% 20.2% 22.8% 1.07

Role of Cognitive Impairment?

• 720 consecutive patients with HF hospitalization

• Mini-Cog

– RN asks patient to repeat 3 unrelated words, complete

clock drawing test, asks for recall 3 words

• 23% of cohort had cognitive impairment

• Poor performance was a predictor of composite

(readmission or mortality) – adjusted hazard ratio

1.90 (1.47-2.44, p<0.0001)

Patel A et al, Circ HF 2015

Adjunct therapies – Anemia

• 2278 patients with systolic HF and Hgb 9-12

g/dL to darbopoetin alfa to target Hgb >13

or placebo

• Outcome: composite of

all-cause mortality or

hospitalization for

worsening HF

Swedberg, K et al, NEJM 2013.

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Adjunct therapies – Iron

• Intravenous iron (CONFIRM-HF) for

symptomatic HF and iron deficiency

Ponikowski P et al, Eur Heart J 2014.

SGLT2 inhibitors & HF readmissions?

• EMPA-REG OUTCOME with empagliflozindemonstrated reduction in HF hospitalization and all-cause death in patients with T2DM and established CV disease

• Dapa-HF (NCT03036124)*

– 4500 adult patients, LVEF≤40%, NTproBNP≥600 pg/mL and eGFR ≥30 ml/min/1.73 m2

– Primary outcome: time to first occurence of CV death or hospitalization for HF or urgent HF visit (3 years)

*https://clinicaltrials.gov/ct2/show/NCT03036124

Kosiborod M et al, presented at ACC 2017https://www.acc.org/education-and-meetings/image-and-slide-gallery/media-detail?id=7f5d0c3c0a2343a3a04b16fc60a883fb

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Kosiborod M et al, presented at ACC 2017

Kosiborod M et al, presented at ACC 2017

Are readmissions a sign

of poor quality care?

Gorodeski EZ et al, NEJM 2010.

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Relationship between LOS & readmissions

• Retrospective analysis of adults admitted in

CA during 2008 (n=47,563)

• Association between LOS during index

hospitalization for HF and readmission within

7- and 30-days

• Simulated 1-day increase in LOS decreased

readmissions between 1-8%

Carey K and Lin M-Y, Med Care Res Rev 2013.

LOSRE-

ADMISSIONS

This is hard

• How do you define HF admissions?

– ICD-9 codes? (May include HF as

comorbidity, but not the key reason

for hospitalization)

– DRG codes? (Excludes primary HF admission if a

procedure such as PCI or ICD implant)

– Manually?

• Who pays to do all this work?

• What is the appropriate comparison?

– Accurate attribution of acuity of illness is hard

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HF Readmissions

• AHRQ National Readmission Database

• 36 million discharges from 21 states with

reliable numbers; 49.1% of total US

hospitalizations

• 301,892 index admissions with 64,264

readmits within 30 days

• LOS 5.3 days for both

Arora S et al, Am J Cardiol 2017

All Readmits

Readmits for HF


Timing?

Etiologies of Readmissions

• Cardiac 49.8% (34.5% HF, 4.4% CAD, 4.3% Arr)

• Respiratory 13.1%

• Kidney/GU 8.9% (5.1% AKI on CKD)

• Infectious 8.1%


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Predictors of Readmissions

• Diabetes 1.06 (1.03-1.08)

• Chronic pulmonary disease 1.13 (1.11-1.16)

• Renal failure 1.12 (1.10-1.15)

• Discharge to facilities 1.07 (1.04-1.09)

• Transfusion 1.12 (1.08-1.16)

• CCI≥2, LOS≥3 days

• Obesity 0.84 (0.82-0.86)

• Higher SES ~0.93 (0.90-0.96)


Readmissions in HF Network Trials

• DOSE-AHF, CARRESS-HF, ROSE-AHF (n=744)

• 26% all-cause 30-day readmission/death

• Risk factors: elevated BUN, ACEi/ARB non-use,

lower baseline Na, non-white race, elevated

bicarbonate, lower SBP, depression, increased

LOS, and male sex

Vader JM et al, J Card Fail 2016

NP/RN Transitional Program

• Standardized stroke clinic

• Phase I – calling high risk <7 days and clinic <2-

4 weeks

• Phase II – all get 2-day RN call and NP <7-14

days

• 510 patients enrolled

• TSC visit 48% reduction in 30-day readmission

Condon C et al, Stroke 2016.

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Protocol-driven

allied health transition clinic

• 2 Visits: 1 week and 4-6 weeks

• 114 seen once, 80% came for 2nd visit

• HF NP and clinical pharmacist

• Physical exam, labs, medication education and reconciliation, medication adjustment and titration, and care coordination

• Average of 2.1 and 0.8 errors at visits 1 and 2

• Participants showed a 44% reduction in 30-day readmissions

Donaho EK et al, J Am Heart Assoc 2015.

Pharmacist counseling intervention?

• Randomized trial 851 (Vanderbilt and BWH)

• Medication reconciliation, inpatient

counseling, low-literacy adherence aids, and

phone follow-up

• No effect on time to first unplanned readmit

or ED visit but differed by site

• Adjusted HR 0.41 (0.17-1.00) in those with low

literacy

Bell SP et al, J Gen Intern Med 2016.

Multidisciplinary post-hospitalization

program

• Retrospective cohort, Greater LA VAMC (277)

• 6 clinic visits with PA, clinical pharmacist specialist, case manager, overseen by MD

• Focused on optimizing therapy, identifying etiology/exacerbating factors, medication titration, education, and medication adherence

• 9.0% vs 28.6% 90-day time to first HF readmit or all-cause mortality

• Adjusted HR 0.17 (0.07-0.41) with NNT of 7

Jackevivius CA et al, Ann Pharmacother, 2015

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Transitional Care Interventions –

Systematic Review & Meta-analysis• 47 trials

• High-intensity home-visit reduced all-cause readmission at 30-days (low SOE)

• Home-visits and MDS-HF reduced all-cause readmission over 3-6 months (high SOE)

• Home-visiting programs reduced HF-specific readmit and readmit or death (moderate SOE)

• Structured telephone support reduced HF-specific (high), but not all-cause readmits (moderate SOE)

• Neither telemonitoring or primarily educational interventions reduced readmission or mortality rates

Feltner C et al, Ann Intern Med 2014.

Multidisciplinary HF Clinics – Ontario

• 14,468 patients with 1,288 seen in HF clinics

Wijeysundera HC et al, Circ Heart Fail 2013

HF Clinic Non-HF Clinic p-value

Mortality (4 years) 52.1% 54.7% 0.02

Readmissions 87.4% 86.5% 0.009

HF-Readmits 58.7% 47.3% 0.001

CHAMPION - CardioMems• 64 centers, 550 patients, NYHA III

• Wireless implantable hemodynamic monitor versus usual care

• 83 vs 120 admits for HR 0.7 (0.6-0.84, p<0.0001) with device

Abraham WT et al for CHAMPION, Lancet 2011.

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CardioMEMS in practice

• First consecutive 2000 implants with ≥ 6m F/U

• Older (69.7 vs 61.6 years)

• More women (40% vs 28%)

• More HFpEF (34% vs 22%)*

Heywood et al, Circulation 2017. *EF only available in ~50% of 2000 patients

Blue = mPAP <25

Grey= 25< mPAP <35

Red= mPAP ≥35

Implantable PA Sensors and Cost

• US Medicare Claims Data of 1,114 patients with Cardiomems implant

• 1020 HFH in 6m prior

• 381 HFH, 139 deaths, and 17 VAD/Tx inin 6m after implant

• HR 0.55, 0.49-0.61

• 6-month comprehensive HF cost reduction of $7,433/patient

Desai AS et al, J Am Coll Cardiol 2017 [epub]

Age

Sex

Inpt/Outpt

Excluding death

Excluding death/VAD/Tx

SMILE: “ReDS Wearable System” (“SensiVest”)

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ReDS Guided Management Reduced the Number of

Heart Failure Hospitalization Over 90 Days

0

2

4

6

8

10

12

14

16

Number of Heart Failure Hospitalizations (N = 50)

87%Reduction

78% Increase

3 months with

standard care

3 months WITH

Sensible vest

3 months back to

standard care

Pre vs. ReDS: P = 0.01

Post vs. ReDS: P = 0.037

15

2

9

Abraham WT et al, HFSA 2015

Example of ReDS Guided Management

Furosemide IV (coordinated with GP) addition to 200 mg Furosemide PO ▲

C

r

2.9 3.14

Discha

rge

2.82.76 2.72 2.68

Abraham WT et al, HFSA 2015

Health Economics & Program Evaluation –

Heart Failure Care Coordination 10/13/2015

Melissa Hutchison, TC Tong

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58Health Economics & Program Evaluation

1. Evaluation of cost effectiveness of care coordination


Health Economics and Program Evaluation Framework

Logic Model

Describe program

Evaluation Design

Identify process and

impact measures

Economic Analysis

Determine cost-

benefit

Enables Decision-Making and Program Improvement

Heart Failure

Program

Committee, site-

based leaders

and/or physician

champions, and

staff to oversee

the program

Access to the EHR

and/or other

database

program(s)

Funding for Care

Coordinator,

office space,

training, patient

ed materials and

equipment

EHR build

capacity and

tracking/

reporting tools

Identify and

approach

appropriate patients

Provide in-person

patient education

Schedule follow-up

appointment(s)

Identify barriers

prior to discharge

and address

concerns

Improve optimal

care:

• Post-

discharge

follow-up

within 5 days

• Optimal

medication

therapy

• Timely

interventions

Increase

completed

follow-up visits

• Cardiac NP

/PA

• Primary care

• Cardiologist

Improve patient

self-

management

skills and

engagement

Improve

communication

between care

team across

settings

Improve patient

experience

Reduce length of

stay

Improve

consistency of

communication

between

patients and

care team

Reduce 30-day

readmissions

Reduce ED visits

and

hospitalizations

Increase survival

Reduce total

cost of care

Inputs/Resources

Care Coordinator Activities

Outcomes – Short Term

Outcomes – Intermediate and

Long Term

Outcomes – Intermediate and

Long Term

Care Coordinators provide consistent, coordinated and cost effective care to Allina Health patients with heart failure. Through ongoing relationship with

the patient/family, the Care Coordinator manages care between health care providers across the continuum to achieve patient goals and improve

outcomes.

Heart Failure Care Coordination Logic Model

v.20150916

Coordinate optimal

medication therapy

During hospitalization

Follow-up with

patients within 24-

48 hours of

discharge and at

least weekly until

stable, review

meds, diet, appts.,

and patient

concerns/goals

Attend follow-up

visit with patients

at cardiology clinic,

as able

Transition patients

from acute care

follow-up to self-

management

Availability for

cardiology

appointments

and 24/7 support

Identify patients

appropriate for

consults and

coordinate across

specialties

Assess self-

management skills

Coordinate

communication

among providers

Early assessment of

progressive or

urgent symptoms

and coordinate

appropriate

interventions

Enhance quality

of life

Increase

provider job

satisfaction

Multi-disciplinary

inpatient and

outpatient care

support and

resources

Improve

symptom

management in

alignment with

patient goals

Develop patient-

centered goals

Improve provider

efficiency

Post-discharge

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Analysis Plan

2008 2009 2010 2011 2012 2013 2014 2015

AbbottApr -

Jun

Jan -

Apr

Apr -

Jun

Jan -

Apr

Mercy Full Year Full Year

UnitedJune 11

- May 12

Sept 13

- Aug 14

Unity Full Year Full Year

• Study population: patients flagged eligible for heart failure care coordination

• Comparison cohorts

• Treatment: post-implementation

• Controls: pre-implementation

• Additional interventions such as LOS, RARE, CDIP, and others occurred during timeframe between

treatment and control study period

Treatment

Controls

Start Date


Data to be presented

Documents

Heart Failure Readmissions 2017 Where do we stand? · 4/3/2017 1 Heart Failure Readmissions 2017 Where do we stand? Peter Eckman, MD, FACC, FHFSA Section Head, Advanced Heart Failure