Zubin J. Eapen

Hospital Readmissions Reduction Program

Hospital readmission measures have been touted not only as a quality measure but also as a means to bend the healthcare cost curve. The Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in 2012. Under this program, hospitals are financially penalized if they have higher-than-expected risk-standardized 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia. The HRRP has garnered significant attention from the medical community, both positive and negative. Here, we describe the reasons the HRRP was implemented, the penalties levied, the impact it has had on transitional care and readmissions, the pros and cons of the policy, and its future. Hospital readmissions are associated with unfavorable patient outcomes and high financial costs.1,2 Causes of readmissions are multifactorial, and rates vary substantially by institution.3,4 Historically, nearly 20% of all Medicare discharges had a readmission within 30 days.1 The Medicare Payment Advisory Commission has estimated that 12% of readmissions are potentially avoidable. Preventing even 10% of these readmissions could save Medicare

Outcomes in patients with heart failure with preserved, borderline, and reduced ejection fraction in the Medicare population

1 billion.5 Therefore, reducing hospital readmissions has been made a national priority. In 2008, the Medicare Payment Advisory Commission recommended to Congress that the Centers for Medicare & Medicaid Services (CMS) begin confidentially reporting readmission rates and resource use to hospitals and physicians.6 In 2009, CMS began publicly reporting hospital-level readmission rates, which were added to the Hospital Compare Web site.7 Before 2012, hospitals had little direct financial incentive to reduce readmissions. For Medicare beneficiaries with inpatient stays, hospitals receive payment with the inpatient prospective payment system (IPPS). This payment, based on a diagnosis-related group (DRG), covers the inpatient stay and any outpatient diagnostic and admission-related outpatient nondiagnostic services provided by the institution on the date of the patient’s admission or within 3 days immediately …

An evaluation of mobile health application tools.

BACKGROUND Studies on outcomes among patients with heart failure (HF) with preserved left ventricular ejection fraction (HFpEF), borderline left ventricular ejection fraction (HFbEF), and reduced left ventricular ejection fraction (HFrEF) remain limited. We sought to characterize mortality and readmission in patients with HF in the contemporary era. METHODS Get With The Guidelines-HF was linked to Medicare data for longitudinal follow-up. Patients were grouped into HFpEF (left ventricular ejection fraction [EF] ≥ 50%), HFbEF (40% ≤ EF < 50%), and HFrEF (EF < 40%). Multivariable models were constructed to examine the relationship between EF and outcomes at 30 days and 1 year and to study trends over time. RESULTS A total of 40,239 patients from 220 hospitals between 2005 and 2011 were included in the study: 18,897 (47%) had HFpEF, 5,626 (14%) had HFbEF, and 15,716 (39%) had HFrEF. In crude survival analysis, patients with HFrEF had slightly increased mortality compared with HFbEF and HFpEF. After risk adjustment, mortality at 1 year was not significantly different for HFrEF, HFbEF, and HFpEF (HFrEF vs HFpEF, hazard ratio [HR] 1.040 [95% CI 0.998-1.084], and HFbEF vs HFpEF, HR 0.967 [95% CI 0.917-1.020]). Patients with HFpEF had increased risk of all-cause readmission compared with HFrEF. Conversely, risk of cardiovascular and HF readmissions were higher in HFrEF and HFbEF compared with HFpEF. CONCLUSIONS Among patients hospitalized with HF, patients with HFpEF and HFbEF had slightly lower mortality and higher all-cause readmission risk than patients with HFrEF, although the mortality differences did not persist after risk adjustment. Irrespective of EF, these patients experience substantial mortality and readmission highlighting the need for new therapeutic strategies.

Do Countries or Hospitals With Longer Hospital Stays for Acute Heart Failure Have Lower Readmission Rates? Findings From ASCEND-HF

Background The rapid growth in the number of mobile health applications could have profound significance in the prevention of disease or in the treatment of patients with chronic disease such as diabetes. Objective The objective of this study was to describe the characteristics of the most common mobile health care applications available in the Apple iTunes marketplace. Methods We undertook a descriptive analysis of a sample of applications in the “health and wellness” category of the Apple iTunes Store. We characterized each application in terms of its health factor and primary method of user engagement. The main outcome measures of the analysis were price, health factors, and methods of user engagement. Results Among the 400 applications that met the inclusion criteria, the mean price of the most frequently downloaded paid applications was US

The Imperative of Overcoming Barriers to the Conduct of Large, Simple Trials

2.24 (SD

Do Countries or Hospitals With Longer Hospital Stays for Acute Heart Failure Have Lower Readmission Rates?Clinical Perspective

1.30), and the mean price of the most currently available paid applications was US

Trends in the Use and Outcomes of Ventricular Assist Devices Among Medicare Beneficiaries, 2006 Through 2011

2.27 (SD

Racial and Ethnic Differences in Outcomes in Older Patients With Acute Ischemic Stroke

1.60). Fitness/training applications were the most popular (43.5%, 174/400). The next two most common categories were health resource (15.0%, 60/400) and diet/caloric intake (14.3%, 57/400). Applications in the health resource category constituted 5.5% (22/400) of the applications reviewed. Self-monitoring was the most common primary user engagement method (74.8%, 299/400). A total of 20.8% (83/400) of the applications used two or more user engagement approaches, with self-monitoring and progress tracking being the most frequent. Conclusions Most of the popular mobile health applications focus on fitness and self-monitoring. The approaches to user engagement utilized by these applications are limited and present an opportunity to improve the effectiveness of the technology.

Heart Rate at Hospital Discharge in Patients With Heart Failure Is Associated With Mortality and Rehospitalization

Background—Hospital readmission is an important clinical outcome of patients with heart failure. Its relation to length of stay for the initial hospitalization is not clear. Methods and Results—We used hierarchical modeling of data from a clinical trial to examine variations in length of stay across countries and across hospitals in the United States and its association with readmission within 30 days of randomization. Main outcomes included associations between country-level length of stay and readmission rates, after adjustment for patient-level case mix; and associations between length of stay and readmission rates across sites in the United States. Across 27 countries with 389 sites and 6848 patients, mean length of stay ranged from 4.9 to 14.6 days (6.1 days in the United States). Rates of all-cause readmission ranged from 2.5% to 25.0% (17.8% in the United States). There was an inverse correlation between country-level mean length of stay and readmission (r=–0.52; P<0.01). After multivariable adjustment, each additional inpatient day across countries was associated with significantly lower risk of all-cause readmission (odds ratio, 0.86; 95% confidence interval, 0.75–0.98; P=0.02) and heart failure readmission (odds ratio, 0.79; 95% confidence interval, 0.69–0.99; P=0.03). Similar trends were observed across US study sites concerning readmission for any cause (odds ratio, 0.92; 95% confidence interval, 0.85–1.00; P=0.06) and readmission for heart failure (odds ratio, 0.90; 95% confidence interval, 0.80–1.01; P=0.07). Across countries and across US sites, longer median length of stay was independently associated with lower risk of readmission. Conclusions—Countries with longer length of stay for heart failure hospitalizations had significantly lower rates of readmission within 30 days of randomization. These findings may have implications for developing strategies to prevent readmission, defining quality measures, and designing clinical trials in acute heart failure. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00475852.

Short- and Long-term Rehospitalization and Mortality for Heart Failure in 4 Racial/Ethnic Populations

Randomized clinical trials remain the most reliable means of identifying the drugs, devices, and treatment strategies that will improve human health. There is increasing interest in the possibility that “personalized” medicine can be evaluated in much smaller trials because the average treatment effect is expected to be larger in highly selected cohorts. Smaller, biomarkerdriven trials can provide major insights into whom to treat and may be sufficient for selected disease states in which considerable treatment effects may be observed. However, a precise biological understanding of most chronic illnesses and biomarkers that might predict response has eluded investigators. Moreover, treatment effect sizes in chronic conditions are expected to be modest in most cases. As a result, determining the long-term balance of risk and benefit, particularly in comparative effectiveness trials, often requires large numbers of clinical events in representative populations. The conduct of large trials by government agencies, industry sponsors, academicians, and advocacy groups is limited by complexity and cost. As a result, many trials are too small to provide reliable estimates of the risk-benefit balance. Without adequate trials, clinicians will have insufficient guidance on how to meaningfully affect individual and population health. Achieving the “triple aim” (improving patient experience of care, improving health of populations, and reducing per