Author + information
- Received May 31, 2016
- Revision received July 7, 2016
- Accepted July 10, 2016
- Published online December 1, 2016.
- Ambarish Pandey, MDa,
- Harsh Golwala, MDb,
- Haolin Xu, MSc,
- Adam D. DeVore, MDc,
- Roland Matsouaka, PhDc,
- Michael Pencina, PhDc,
- Dharam J. Kumbhani, MD, SMa,
- Adrian F. Hernandez, MD, MHSc,
- Deepak L. Bhatt, MD, MPHd,
- Paul A. Heidenreich, MD, MSe,
- Clyde W. Yancy, MDf,
- James A. de Lemos, MDa and
- Gregg C. Fonarow, MDg,∗ ()
- aDivision of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
- bDivision of Cardiology, University of Louisville School of Medicine, Louisville, Kentucky
- cDuke Clinical Research Institute, Durham, North Carolina
- dBrigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
- eDivision of Cardiology, Stanford University, Palo Alto, California
- fDivision of Cardiology, Northwestern University, Chicago, Illinois
- gRonald Reagan-UCLA Medical Center, Los Angeles, California
- ↵∗Reprint requests and correspondence:
Dr. Gregg C. Fonarow, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, 10833 LeConte Avenue, Room 47-123 CHS, Los Angeles, California 90095-1679.
Objectives This study sought to determine whether processes of care and long-term clinical outcomes for heart failure (HF) admissions across Get With The Guidelines-Heart Failure (GWTG-HF) program participating centers differ according to HF-specific risk-adjusted 30-day readmission rates (excess readmission ratio [ERR]) as determined by the Hospital Readmission Reduction Program (HRRP).
Background HRRP penalizes hospitals with higher than expected risk-adjusted 30-day readmission rates (ERR >1) for common conditions including HF. However, it is unclear whether the differences in this metric of hospital performance used by HRRP and related penalties are associated with measured quality of care and long-term outcomes.
Methods We analyzed data from the GWTG-HF registry linked to Medicare claims from July 2008 to June 2011. Using publically available data on HF-ERR in 2013, we stratified the participating centers into groups with low (HF-ERR ≤1) versus high (HF-ERR >1) risk-adjusted readmission rates. We compared the care quality, in-hospital, and 1-year clinical outcomes across the 2 groups in unadjusted and multivariable adjusted analysis.
Results The analysis included 171 centers with 43,143 participants; 49% of centers had high risk-adjusted 30-day readmission rates (HF-ERR >1). There were no differences between the low and high risk-adjusted 30-day readmission groups in median adherence rate to all performance measures (95.7% vs. 96.5%; p = 0.37) or median percentage of defect-free care (90.0% vs. 91.1%; p = 0.47). The composite 1-year outcome of death or all-cause readmission rates was also not different between the 2 groups (median 62.9% vs. 65.3%; p = 0.10). The high HF-ERR group had higher 1-year all-cause readmission rates (median 59.1% vs. 54.7%; p = 0.01). However, the 1-year mortality rates were lower among high versus low HF-ERR group with a trend toward statistical significance (median 28.2% vs. 31.7%; p = 0.07).
Conclusions Quality of care and clinical outcomes were comparable among hospitals with high versus low risk-adjusted 30-day HF readmission rates. These findings raise questions about the validity of the HRRP performance metric in identifying and penalizing low-performance centers.
The American Heart Association provides the Get With The Guidelines Heart-Failure program (GWTG-HF). GWTG-HF has been previously funded through support from Medtronic, GlaxoSmithKline, Ortho-McNeil, and the AHA Pharmaceutical Roundtable. Dr. DeVore has received research support from Amgen, the American Heart Association, and Novartis. Dr. Pencina has served as a statistical consultant to Bioventrix and Admittance; and has served on the data safety and monitoring board for the Lap HF trial run (Corvis Medical) and the Secret of CHF trial (Cardiovascular Sciences Foundation). Dr. Hernandez has received research support from Janssen, Novartis, Portola, Amgen, AstraZeneca, Bayer, Merck, Luitpold, and Bristol-Myers Squibb; and served as a consultant to AstraZeneca, Bayer, Bristol-Myers Squibb, Gilead, Boston Scientific, Janssen, and Novartis. Dr. Bhatt has served on the advisory board for Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; served on the board of directors of the Boston VA Research Institute, Society of Cardiovascular Patient Care; served as chair of the American Heart Association Quality Oversight Committee; served on the data monitoring committees of the Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Population Health Research Institute; received honoraria from American College of Cardiology (senior associate editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor-in-Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor-in-Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (secretary/treasurer), and WebMD (CME steering committees); served as the deputy editor of Clinical Cardiology, Vice-Chair of the NCDR-ACTION Registry Steering Committee, and Chair of the VA CART Research and Publications Committee; received research funding from Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi, The Medicines Company; received royalties from Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); served as site coinvestigator for Biotronik, Boston Scientific, and St. Jude Medical; and been a trustee of the American College of Cardiology; and conducted unfunded research for FlowCo, PLx Pharma, and Takeda. Dr. Fonarow has received research support from the Agency for Healthcare Research and Quality and National Institutes of Health; and has served as a consultant for Amgen, Baxter, Bayer, Janssen, Novartis, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 31, 2016.
- Revision received July 7, 2016.
- Accepted July 10, 2016.
- American College of Cardiology Foundation