Author + information
- Published online April 10, 2017.
- aHeart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
- bWarren Alpert Medical School of Brown University, Providence, Rhode Island
- ↵∗Address for correspondence:
Dr. Mehdi H. Shishehbor, Director, Endovascular Services, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J3-05, Cleveland, Ohio 44195.
Hospital readmissions represent a significant health care cost and are considered a quality metric for both hospitals and health care providers alike. Much of today’s emphasis on this metric originates from the 2007 U.S. Centers for Medicare and Medicaid Services (CMS) report to congress, “Promoting Greater Efficiency in Medicare” (1). In that report, the CMS argued that readmissions cost the U.S. health care system approximately $15 billion per year and that tying reimbursement to readmissions might lead to significant cost reductions. Since then, certain initiatives have taken place including the 2010 Patient Protection and Affordable Care Act that established the Hospital Readmissions Reduction Program (2). Current readmissions for congestive heart failure, myocardial infarction, pneumonia, chronic obstructive pulmonary disease, elective hip and knee replacements—and coronary artery bypass graft surgery (starting in 2017)—have been tied to reimbursement and are publicly reported.
More than 8 million individuals in the United States have peripheral artery disease, and those with its most severe clinical manifestations, rest pain, skin ulceration and gangrene (collectively known as critical limb ischemia [CLI]), consume significant health care resources, often during hospital admissions and subsequent readmissions (3). Thus, it would not be surprising if CLI were ultimately considered for inclusion among the growing list of Hospital Readmissions Reduction Program conditions. A better understanding of CLI readmission prevalence, reasons, cost, and predictors is needed to inform such considerations.
In this issue of the Journal, Agarwal et al. (4) attempt to address some of these questions by analyzing readmission data from 212,241 patients with CLI from Florida, New York, and California in the Agency for Healthcare Research and Quality’s State Inpatient Database. They observed unplanned 30-day and 6-month readmission rates of 24% and 48%, respectively, rates much higher than those reported for congestive heart failure and pneumonia, as examples.
A number of predictors for readmission were identified, notably, female sex, private insurance versus Medicare/Medicaid/no insurance, and amputation. However, travel time was inversely related to readmissions, possibly highlighting the challenges with transportation in this population. Additionally, longer duration of stay was actually associated with a higher incidence of unplanned readmissions and few patients were discharged from the hospital to home (only 33.6%), reflecting the complexity of disease and comorbidities in patients with CLI. Any revascularization was associated with lower readmissions compared with no revascularization at all. Furthermore, those who required a major amputation actually had the highest rates of readmissions both at 30 days and 6 months among the entire cohort. The authors should be congratulated on their extensive analysis by once again highlighting the burden on health care and the challenges of treating patients with CLI.
Although the distinction between planned and unplanned readmissions is relevant given that patients with CLI may require repeat admissions for planned (so-called “staged”) procedures or minor amputations, the CMS defines readmissions more broadly as “admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital“ (2). Planned readmissions are, however, excluded from readmission reporting. Therefore, the observation that nearly 9% of readmissions at 6 months were planned requires further scrutiny. On the surface, this might suggest the complex nature of CLI treatment and the need for staged procedures beyond the index admission. However, CMS reimburses hospitals according to the highest diagnosis-related group for a given admission. If a patient undergoes revascularization followed by minor amputation, the hospital is only reimbursed for the higher of the 2 diagnosis-related groups. Hence, there may be a financial incentive to stage or bring patients back for additional procedures rather than to address them during the index admission. These competing incentives might be better aligned were reimbursements for CLI bundled under a single, longer episode of care that included wound care and/or minor amputations. More important, data regarding planned or unplanned readmissions are rarely captured correctly in administrative or even clinical databases, initiatives that can clearly capture planned versus unplanned readmissions are needed.
There are other reasons why 30-day readmission may not be a suitable quality metric for patients with CLI. Unlike coronary artery bypass graft surgery, myocardial infarction, or an acute decompensation of congestive heart failure, where the intent is to completely treat the condition during its index admission, complete healing of minor or major tissue loss after revascularization for CLI is an ongoing process whose resolution extends well beyond hospital discharge (frequently months). Furthermore, CLI disproportionally impacts those in certain geographic regions who have lower socioeconomic status (5–7). Quality of outpatient care and/or access to outpatient care may be inadequate for these individuals. Readmission penalties under such circumstances might punish those who need better care or greater access to care the most, ultimately resulting in higher rates of amputation and more prevalent nonhealing wounds.
So, what can we learn from the paper by Agarwal et al. (4) that will help to reduce readmission rates for CLI? A glance at Table 6 (Predictors of Unplanned Readmissions) reveals that most independent predictors are not modifiable. Indeed, of all of the identified predictors, revascularization may be the most easily modifiable. Unfortunately, a significant proportion of patients with CLI undergo major amputation in the United States without a vascular evaluation in the year before their amputation (8). And although there has been a reduction in amputation rates with concomitant increases in lower extremity revascularization over recent decades, there remain major sociodemographic disparities in the use of both revascularization and amputation in patients with CLI (9).
Beyond revascularization, what else can be done to reduce readmissions? To answer this question, we may need more robust data than those available in administrative databases such as that used by Agarwal et al. (4). Recently, using clinical data from our own institution, we showed that wound healing was a strong predictor of readmissions and nearly one-half of readmissions for CLI were wound related (10,11). Although there has been significant attention given to endpoints such as death and major adverse limb events in clinical trials of CLI patients, other important outcomes such as wound healing, time to wound healing, quality of life, and pain control are rarely reported or measured (12). Many of these endpoints directly impact readmissions, cost, and even major adverse limb events (10,11). A renewed focus on such endpoints may have a significant, positive impact on readmissions, cost, and the overall care of patients with CLI. Such an approach can only be achieved through multidisciplinary team efforts that offer personalized treatments focused on wound care, infection control, and cutting-edge revascularization, as needed (12,13).
Poor coordination and communication between the “CLI team” and the patient may also represent a significant impediment to reducing readmissions (Figure 1). Although some centers contain all components required for optimal CLI care, most do not. For example, wound care, infectious disease, vascular specialists, and other necessary providers may not work side by side at the same institution. This issue has moved to the forefront as new office-based laboratories emerge in the United States and offer revascularization for patients with CLI. Clearly, reducing readmissions will require increased awareness and education not only for patients but for others who may encounter these patients during the wound healing process. One area that will likely have a high yield is the emergency department, where many of these patients present with pain or worsening wound symptoms and are frequently admitted.
Despite these and other challenges, new advances in telemedicine and remote monitoring may have a significant impact on CLI care and ultimately on the likelihood of readmission. The potential to remotely monitor wounds using digital photography, assess perfusion continuously with implantable oxygen sensors (14), and offer clinical input via virtual consultation is exciting and may herald a new era in CLI care (Figure 1). Nevertheless, for the foreseeable future, CLI treatment will remain complex and we must better understand all involved issues before assigning and publicly reporting readmission as a quality metric or basing reimbursement decisions on associated readmission rates. In short, we must decide whether CLI readmission is a necessary or unnecessary evil in the care continuum of the CLI patient (15).
The authors thank Mrs. Laura Philippsen for her contribution to the figure.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
- ↵Medicare Payment Advisory Commission. Promoting greater efficiency in Medicare 2007. Available at: http://medpac.gov/docs/default-source/reports/Jun07_EntireReport.pdf. Accessed February 1, 2017.
- ↵U.S. Centers for Medicare & Medicaid Services. Hospital readmissions reduction program 2010. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed February 1, 2017.
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