QualityTalk

Harlan M. Krumholz, M.D., S.M. is a practicing cardiologist and the Harold H. Hines, Jr. Professor of Medicine, Epidemiology and Public Health at the Yale University School of Medicine and director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. He also works closely with CMS and QIOs on current projects to improve care for heart failure patients and measure hospital performance. Author of more than 500 journal articles, Dr. Krumholz serves on numerous cardiovascular care committees for national organizations, including the American Heart Association and the American College of Cardiology. He received his medical degree from Harvard Medical School and a master’s degree in Health Policy and Management from the Harvard School of Public Health.

How did readmissions first come to light as an opportunity for improvement?

The view of hospitals as a ‘revolving door’ was invisible for a long time. It became a part of public discourse more than 10 years ago, when the article titled, “Readmission after Hospitalization for Congestive Heart Failure Among Medicare Beneficiaries” was published in the Archives of Internal Medicine. It elevated the issue of readmission rates as a national problem, because a study conducted by the Connecticut QIO found that in the six months following admission for acute myocardial infarction (AMI), 44 percent of patients were readmitted to the hospital at least once. Congestive heart failure was the most prevalent reason, accounting for 18 percent of all readmissions. The CMS Cooperative Cardiovascular Project (CCP), one of the QIO Program’s first nationwide quality improvement initiatives was built on this foundation. The CCP was designed as a large, one-time, cross-sectional evaluation of treatment for AMI in elderly patients.

Where should care transitions initiatives focus?

There are many obvious gaps in care: patients often leave the hospital without timely transfer of information to the next caregivers, without access to medications, without follow-up appointments set, and without an emergency plan if their condition suddenly worsens. Since the 1990s, studies have shown that improving the handoff between hospital and home can lead to a reduction in readmissions. To reduce readmission rates, we need to focus on the patient. We must ensure that patients are ready and knowledgeable enough to manage their care, and the system is poised to provide the support they need. Take medication management, for example. Some patients are taking 20 to 15 pills a day. Who are we kidding? That’s a full-time job! And it should be no surprise that it is difficult or impossible to comply with what is expected.

What are the challenges in developing a national method for measuring readmissions?

There are quite a lot of challenges in developing a measure that is suitable for public reporting. First and foremost, administrative claims data are the only national source of information available to us. Many people are concerned about the quality of claims data and its appropriateness for risk adjustment. We were able to develop a model for CMS based on claims data that produced estimates that were very close to the results of a model based on medical record data. This gave us confidence to move forward.

Do hospitals that do well on mortality have worse readmission rates?

Some hospitals were concerned that doing well on mortality would put them at a disadvantage with readmission rates, as they would be discharging a more ill group of patients. The data do not support that concern. Hospital mortality and readmission rates are not associated very strongly, if at all. Doing well on mortality does not dictate that a hospital will do poorly on readmission. The lack of any strong association suggests that they are measuring different aspects of quality.

Is there any such thing as an “unavoidable readmission?”

Certainly we are not going to be able to achieve zero readmissions — and many patients will need readmission despite outstanding care. Nevertheless, we know preventable readmissions are very common. The measure focuses on all-cause readmission because it is impossible in most cases to determine with certainty which of the readmissions are preventable. With better transitions we can reduce the risk of readmissions, but it is hard to know which ones are avoided.

Do hospitals with a high number of uninsured or underinsured patients have high readmission rates?

Some hospitals feel that they are at a disadvantage because many of their patients have a low socioeconomic status. The model used for the public measures does not adjust for the patient’s socioeconomic status. What we have found is that socioeconomic status is not a dominant factor in readmission risk and within the group of hospitals with low socioeconomic status there are institutions with a range of readmission rates. Having many patients with low socioeconomic status does not dictate that a hospital will have a high readmission rate.

What do you see as the next steps for QIOs and care transitions?

We have all the right ingredients — the will, the way and the commitment to finish. With the support of CMS and partner organizations, the will to effect change exists. We have the way through the initiatives led by QIOs on the state level and partnerships with other organizations seeking to reduce readmission rates through better transitions. Finally, with all of these pieces in place, there is commitment to finish. The victory in improving care outcomes over the last decade can be pinned, in large part, on the QIOs and CMS; now we have to continue to improve. With the knowledge we now possess, all we have to do is connect and implement.

From your perspective as a physician, what are the benefits of engaging in QIO initiatives?

The QIO Program is remarkable — full of creative professionals dedicated to making care better for patients. I have seen how the QIO Program can bring people together and help bring about change that would not have been possible otherwise. The program has helped make important gaps in quality visible and worked collaboratively to address problems. The QIOs are on the forefront of a change in the way quality is perceived and the effectiveness of our efforts to shift the level of performance by all providers. I feel so fortunate to have had the opportunity to work with the QIOs and I know that my contributions were amplified by these relationships. The QIO Program has an opportunity to make a big impact with projects like care transitions, which directly engages patients. The impact grows as more organizations partner with QIOs to add momentum and fuel the national movement for quality care.