Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Relationship Between Early Physician Follow-up and 30-day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure Adrian F. Hernandez, MD, MHS, Mellissa A. Greiner, MS, Gregg C. Fonarow, MD, Bradley C. Hammill, MS, Paul A. Heidenreich, MD, Clyde W. Yancy, MD, Eric D. Peterson, MD, MPH, Lesley H. Curtis, PhD

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Disclosures The Get With The Guidelines– HF (GWTG-HF) program is provided by the American Heart Association/American Stroke Association. The data analyzed in this manuscript were collected while the GWTG program was supported in part through an unrestricted educational grant from GlaxoSmithKline. The individual author disclosures are listed in the manuscript.

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Background Hospital readmission rates are being targeted as an area to promote efficiency and quality in health care. 1/5 of Medicare patients are rehospitalized within 30 days and more than 1/3 are rehospitalized within 90 days. The most common readmission diagnosis is Heart Failure.

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Introduction Readmission after hospitalization for Heart Failure is common. Early outpatient follow-up after hospitalization has been proposed as a means of reducing readmission rates. There is little data describing patterns of follow-up after Heart Failure hospitalization and its association with readmission rates.

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 To examine associations between outpatient follow-up within 7 days post discharge from a Heart Failure hospitalizations and readmission within 30 days. Objective

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Study Population Inclusions: Hospitals fully participating from Heart failure patients 65 years and older who were Enrolled in fee-for service Medicare for at least 30 days after the index hospitalization Discharged to home If patient had multiple hospitalizations, we selected the first as the index hospitalization. Exclusions: Discharged to SNF or Hospice, and hospitals with fewer than 25 patients after prior exclusions.

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Study population: 41,496 GWTG-HF/OPTIMIZE CMS Excluded: Skilled nursing facility discharges: 9166 Hospice care: 804 Low volume hospitals (<25): 1390 Final study population of 225 hospitals and 30,136 patients. Study Population (cont.)

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Patient Characteristics Characteristic Quartile 1 (<32.4%) Quartile 2 ( ) Quartile 3 ( ) Quartile 4 (>44.5) P Value Median Age <.001 Female Sex African American <.001 Past Med Hx Atrial arrhythmia <.001 COPD <.001 CAD <.001 Chronic kidney dz <.001 Diabetes <.001 PVD <.001 Prior CVA/TIA Smoker <.001

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Data Source Included patients in GWTG-HF & its predecessor OPTIMIZE-HF: Episode of worsening Heart Failure Development of significant Heart Failure symptoms during a hospitalization for which Heart Failure was the primary discharge diagnosis. HF case-ascertainment methods similar to those used by the Joint Commission were used by Hospital Teams.

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 GWTG HF and OPTIMIZE-HF were linked to Medicare claims (Part A, B and corresponding denominator files) to provide data on follow-up and outcomes. Patients and hospitals were grouped by quartiles of hospital rates of early follow-up visits. Using the cumulative incidence function, which accounts for the competing risk of death, we calculated unadjusted 30-day all-cause readmission rates. Methods

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Methods Cox proportional hazards models to examine unadjusted and adjusted relationships between hospital-level early follow-up and 30-day all- cause readmission. Outcome Sciences, Inc. served as the data collection and coordination center. Duke Clinical Research Institute served as the data analysis and coordination center.

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Early Follow-up: Any visit within 7 days after discharge from index hospitalization defined as an outpatient evaluation and management visit with a physician (HCPCS codes 992.xx–994.xx) Primary Outcome: Association between hospital-level rate of early follow-up and 30-day all-cause readmission rate Early Follow-up and Outcome

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Results: 30-day readmission 21.3% of patients readmitted within 30 days Inverse relationship between early physician follow-up and the hazard of 30-day readmission Neither early follow-up with a cardiologist nor continuity of care were significant predictors

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Hospital Variation in Early Follow-up Median Follow-up Visit within 7 days = 37.5% 225 Hospitals

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Follow-up by Physician Type

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Follow-up by Same Physician

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Observed 30-Day Outcomes 30-Day Mortality p= Day Readmission p <0.01

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No Day Readmission Relationship Early Follow-up Unadjusted HR 95% CI P Value Adjusted HR 95% CI P Value Quartile 11.0 (REF) Quartile < <01 Quartile < <01 Quartile < Covariates: age, sex, race, anemia, atrial arrhythmia, COPD, CKD, CAD, depression, diabetes, hyperlipidemia, hypertension, PVD, prior CVA/TIA, smoker, creatinine, systolic blood pressure, serum sodium, hemoglobin, LVSD, discharge process, LOS>7 days, year of admission

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Results: 30-day mortality 4.7% of patients died in the 30 days after discharge 30-day mortality was significantly lower among patients admitted to hospitals which had a high rate of early follow-up with a cardiologist

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 GWTG-HF is a voluntary registry of hospitals participating in quality of improvement and may not represent all hospitals. Clinical data were collected by medical chart review. Residual measured and unmeasured confounding variables may have influenced the findings. Analysis confined to patients age 65 years or older with fee-for-service Medicare. Limited data on home health visits, disease management programs, remote monitoring or follow-up by physician extenders (NPs/PAs). Limitations

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Conclusions Among patients hospitalized for Heart Failure: –Low Physician follow-up within 1 week –Most follow-up care was handled by a generalist/internist rather than a cardiologist –Most follow-up is not by the same physician who evaluated the patient during hospitalization. Hospitals with higher rates of early follow-up: –Lower risk of 30-day readmission Future studies should evaluate the effects of early follow-up on readmission

Hernandez et al. JAMA, May 5, 2010 – Vol. 303, No. 17 Conclusions Findings highlight a need for improvement and greater uniformity in coordination of care from in-patient to out- patient settings A central element of transitional care, out-patient follow- up varies significantly across hospitals and for most patients, does not occur in a timely manner Early evaluation after discharge is critical