The number of hospitalizations for Medicare patients 65 years or older who were discharged alive per category (N = 985) are demonstrated in color. The 30-day heart failure (HF) readmission measure (for which penalties apply) and Bundled Payments for Care Improvement (BPCI) initiative (representing the Centers for Medicare & Medicaid Services demonstration project) encompass 50% or less of this population with actively managed HF. HRRP indicates Hospital Readmissions Reduction Program.
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Ahmad FS, Wehbe RM, Kansal P, et al. Targeting the Correct Population When Designing Transitional Care Programs for Medicare Patients Hospitalized With Heart Failure. JAMA Cardiol. 2017;2(11):1274–1275. doi:10.1001/jamacardio.2017.3089
Heart failure (HF) is a costly syndrome associated with high hospitalization rates. The Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program (HRRP) and Bundled Payments for Care Improvement (BPCI) initiative represent 2 efforts to enhance health care value for patients with HF.1 But the International Classification of Diseases, Ninth Revision (ICD-9) primary discharge codes for HF used in HRRP and the diagnosis related groups (DRGs) used in the BPCI initiative may underestimate the true burden of hospitalizations for HF.2,3
As part of designing a transitional care program and participating in the BPCI initiative, we sought to compare the population of all hospitalized Medicare patients with actively managed HF with the population of patients qualifying for the HRRP’s 30-day readmission measure and for the HF BPCI initiative.
We categorized hospitalizations for Medicare patients 65 years or older who were discharged alive from an academic medical center into 3 groups for comparison: (1) actively managed HF, identified by a sensitive electronic data warehouse query and adjudicated by medical record review as definite clinical HF (ie, the primary or a secondary reason for admission and requiring medical intervention); (2) HF consistent with the 30-day HF readmission codes and criteria from the ICD-9; and (3) HF consistent with the BPCI initiative DRGs and criteria (Box).4,5 The Northwestern University institutional review board approved this study and granted a waiver of consent.
Potential cases identified via sensitive electronic query at time of admission, including prior or new HF diagnostic codes or problem list entry, inpatient medication orders (intravenous diuretic or carvedilol), BNP >100 ng/dL, inpatient HF telemetry order, prior cardiac MUGA, cardiac MRI, or cardiopulmonary exercise testing
Clinical notes and diagnostic testing reviewed by HF team (cardiologists, nurse practitioners)
Patients labeled as actively managed HF if definite clinical HF was the primary or a secondary reason for admission and requiring medical intervention including intravenous diuretic use
Principal discharge diagnosis of ICD-9 codes 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.X, 428.XXc
Discharged against medical advice
Transferred to acute care facility
Readmitted same day as discharge with same principal diagnosis code
Diagnosis related groups 291, 292, or 293 (heart failure and shock with MCC, with CC, or without CC/MCC)
Abbreviations: BNP, brain natriuretic peptide; CC, complicating or comorbid condition; HF, heart failure; ICD-9, International Classification of Diseases, Ninth Revision, Clinical Modification; MCC, major complicating or comorbid condition; MRI, magnetic resonance imaging; MUGA, multigated acquisition scan.
a Unable to account for all inclusion and exclusion criteria owing to lack of data availability.
b Criteria based on 2015 measure specifications.
cInternational Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes from the electronic data warehouse were re-coded as ICD-9 codes based on a crosswalk.
From August 1, 2015, to July 31, 2016, we retrospectively identified a total of 985 Medicare hospitalizations (mean [SD] patient age, 79.0 [8.5] years) during the same period. We identified 937 patients with actively managed HF, 468 patients by the HRRP criteria, and 355 patients by the BPCI criteria (Figure). We identified 507 patients (51.5%) with actively managed HF who were not captured by the HRRP or the BPCI criteria. Among these patients, the most commonly assigned DRGs were another cardiac DRG related to arrhythmia (DRG 308; 39 hospitalizations [7.7%]), a renal DRG (DRG 682; 31 [6.1%]), and a cardiac DRG related to cardiac catheterization (DRG 286; 30 [5.9%]). Of the 507 hospitalizations categorized as actively managed HF only, 76 (15.0%) were observation status and excluded from the HRRP and BPCI programs; 373 (73.6%) had a secondary ICD-9 code for HF.
Our study shows that in a single large academic medical center, the 30-day HF readmission measure and BPCI initiative encompass 50% or less of the population of Medicare patients 65 years or older with actively managed HF. By selecting narrower subpopulations of patients with HF for public reporting, financial penalties, and payments rather than including the broader population experiencing HF disease burden, the HRRP and BPCI programs may promote adverse, unintended health consequences in the population excluded. Administrators and care teams may choose to focus resources on those patients for whom their institution bears financial risk, leaving important patient cohorts vulnerable to recurrent events. Alternatively, because primary ICD-9 code and DRG information are frequently assigned only after discharge, care teams may choose to design prospective programs that apply to the wider group of patients with actively managed HF, thus globally enhancing HF disease management.
We did not apply all of the exclusion criteria delineated by the Centers for Medicare & Medicaid Services for HRRP or BPCI because longitudinal data on timing of Medicare enrollment and out-of-network hospitalizations were not available. However, this lack of data likely biased our results toward an overestimation of the number of patients with HF who are identified by the readmission measure or BPCI criteria. Our data are limited to a single large academic medical center, and our findings may not extend to other medical centers.
Shifts in payment models toward value and population health management require thoughtful definition of the at-risk population. A broader understanding of the epidemiology of patients hospitalized with HF has the potential to affect a larger at-risk population.
Corresponding Author: R. Kannan Mutharasan, MD, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Arkes Pavilion, Ste 6-071, Chicago, IL 60611 (email@example.com).
Accepted for Publication: July 20, 2017.
Published Online: September 20, 2017. doi:10.1001/jamacardio.2017.3089
Author Contributions: Drs Ahmad and Mutharasan had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Ahmad, Kansal, Jackson, Yancy, Mutharasan.
Acquisition, analysis, or interpretation of data: Ahmad, Wehbe, Jackson Anderson, Mutharasan.
Drafting of the manuscript: Ahmad, Mutharasan.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Ahmad, Wehbe, Mutharasan.
Obtained funding: Ahmad.
Administrative, technical, or material support: Ahmad, Kansal, Jackson, Anderson, Yancy, Mutharasan.
Study supervision: Anderson, Jackson, Mutharasan.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: Dr Ahmad is supported by award T32HL069771 from the National Heart, Lung, and Blood Institute of the National Institutes of Health and by a grant from the Eleanor Wood-Prince Grants Initiative: A Project of The Woman’s Board of Northwestern Memorial Hospital. Research reported in this publication was supported in part by grant UL1TR001422 from the National Institutes of Health National Center for Advancing Translational Sciences.
Role of the Funder/Sponsor: The funding agencies had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr Yancy is a deputy editor of JAMA Cardiology, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.
Additional Contributions: Anna Pawlowski, MBA (Northwestern University Feinberg School of Medicine), and Daniel Navarro, MS (Northwestern Medicine), assisted with data extraction from the Northwestern Medicine Enterprise Data Warehouse. Neither was compensated for this contribution.