Abstract
In the USA it is common for patients with acute decompensated heart failure to present for emergency care, observational care, or inpatient care hospitalization, for stabilization. Post-discharge, patients who are diagnosed with acute heart failure are more likely to have increased morbidity and mortality. In an effort to decrease adverse outcomes, regulatory requirements are becoming more pervasive and include reimbursement coverage determination and performance management. This chapter provides details of coverage requirements and monitoring that may apply in acute heart failure care when patients are treated by an observation (outpatient) or hospital service and hospital performance management expectations that may affect reimbursement.
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References
Bernheim SM, Grady JN, Lin Z, et al. National patterns of risk-standardized mortality and readmission for acute myocardial infarction and heart failure. Update on publicly reported outcomes measures based on the 2010 release. Circ Cardiovasc Qual Outcomes. 2010;3:459–67.
Heidenreich PA, Sahay A, Kapoor JR, Pham MX, Massie B. Divergent trends in survival and readmission following a hospitalization for heart failure in the Veterans Affairs health care system 2002 to 2006. J Am Coll Cardiol. 2010;56:362–8.
Bueno H, Ross JS, Wang Y, et al. Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993–2006. JAMA. 2010;303:2141–7.
Fingar K (Truven Health Analytics), Washington R (AHRQ). Trends in hospital readmissions for four high-volume conditions, 2009–2013. HCUP Statistical Brief #196. November 2015. Rockville: Agency for Healthcare Research and Quality.
Schwartz J, Strait KM, Keshawarz A, et al. Medicare hospital qualtiy chartbook. Performance report on outcome measures. September 2014. Prepared by Yale New Haven Health Services Corporation Center for Outcomes Research and Evaluation for the Centers for Outcomes Research and Evaluation for the Centers for Medicare and Medicaid Services 2014; https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/downloads/medicare-hospital-quality-chartbook-2014.pdf.
Mozaffarian D, Benjamin EJ, Go AS, American Heart Association Statistics Committee and Stroke Statistics Subcommittee, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133(4):e38–e360.
Merlo M, Pivetta A, Pinamonti B, et al. Long-term prognostic impact of therapeutic strategies in patients with idiopathic dilated cardiomyopathy: changing mortality over the last 30 years. Eur J Heart Fail. 2014;16(3):317–24.
Yancy CW, Jessup M, Bozkurt B, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):e240–327.
Israel EN, Farley TM, Farris KB, Carter BL. Underutilization of cardiovascular medications: effect of a continuity-of-care program. Am J Health Syst Pharm. 2013;70(18):1592–600.
Kiel RG, Deedwania P. The safety and tolerability of beta blockers in heart failure with reduced ejection fraction: is the current underutilization of this evidence-based therapy justified? Expert Opin Drug Saf. 2015;14(12):1855–63.
Albert NM, Yancy CW, Liang L, et al. Use of aldosterone antagonists in heart failure. JAMA. 2009;302(15):1658–65.
Linde C, Ståhlberg M, Benson L, et al. Gender, underutilization of cardiac resynchronization therapy, and prognostic impact of QRS prolongation and left bundle branch block in heart failure. Europace. 2015;17(3):424–31.
Meng K, Musekamp G, Schuler M, et al. The impact of a self-management patient education program for patients with chronic heart failure undergoing inpatient cardiac rehabilitation. Patient Educ Couns. 2016. pii: S0738-3991(16)30071-4. [Epub ahead of print].
Wyer P, Stojanovic Z, Shaffer JA, et al. Combining training in knowledge translation with quality improvement reduced 30-day heart failure readmissions in a community hospital: a case study. J Eval Clin Pract. 2016;22(2):171–9.
Kamrani AA, Foroughan M, Taraghi Z, Yazdani J, Kaldi AR, Ghanei N, et al. Self care behaviors among elderly with chronic heart failure and related factors. Pak J Biol Sci. 2014;17(11):1161–9.
Vasilevskis EE, Kripalani S, Ong MK, et al. Variability in implementation of interventions aimed at reducing readmissions among patients with heart failure: a survey of teaching hospitals. Acad Med. 2016;91(4):522–9.
Wu JR, Lennie TA, Moser DK. A prospective, observational study to explore health disparities in patients with heart failure-ethnicity and financial status. Eur J Cardiovasc Nurs. 2016. pii: 1474515116641296. [Epub ahead of print].
Dickson VV, Knafl GJ, Riegel B. Predictors of medication nonadherence differ among black and white patients with heart failure. Res Nurs Health. 2015;38(4):289–300.
Dickson VV, Knafl GJ, Wald J, Riegel B. Racial differences in clinical treatment and self-care behaviors of adults with chronic heart failure. J Am Heart Assoc. 2015;4(4). pii: e001561
Goo RA, Ma C, Juarez DT. Disparities in medication therapy in patients with heart failure across the State of Hawai’i. Hawaii J Med Public Health. 2015;74(1):5–8.
Walsh MN, Yancy CW, Albert NM, et al. Equitable improvement for women and men in the use of guideline-recommended therapies for heart failure: Findings from IMPROVE HF. J Cardiac Fail. 2010;16(12):940–9.
Donaho EK, Hall AC, Gass JA, Elayda MA, Lee VV, Paire S, Meyers DE. Protocol-driven allied health post-discharge transition clinic to reduce hospital readmissions in heart failure. J Am Heart Assoc. 2015;4(12). pii: e002296
O’Malley AS, Reschovsky JD, Saiontz-Martinez C. Interspecialty communication supported by health information technology associated with lower hospitalization rates for ambulatory care-sensitive conditions. J Am Board Fam Med. 2015;28(3):404–17.
RTI International for the Centers for Medicare and Medicaid Services. Accountable care organization 2015 program analysis quality performance standards narrative measure specifications. January 9, 2015. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf. Accessed 17 Apr 2016.
Centers for Medicare and Medicaid Services. ACO #10 – Prevention Quality Indicator (PQI): ambulatory care sensitive conditions: admissions for Heart Failure (HF). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-10.pdf. Accessed 17 Apr 2016.
Centers for Medicare and Medicaid Services. ACO #8 – risk standardized all condition readmissions. https://www.cms.gov/Medicare/Medicare-Fee-for-Service.-Payment/sharedsavingsprogram/Downloads/ACO-8.pdf. Accessed 17 Apr 2016.
Centers for Medicare and Medicaid Services. ACO #37 – risk standardized acute admission rates for patients with heart failure. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-37.pdf. Accessed 17 Apr 2016.
Medicare National Coverage Determinations Manual. https://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed 8 Oct 2010.
Centers for Medicare & Medicaid Services. Medicare Approved Facilities/Trials/Registries. http://www.cms.gov/MedicareApprovedFacilitie/. Accessed 13 Dec 2010.
Centers for Medicare & Medicaid Services. Decision Memo for Cardiac Rehabilitation (CR) Programs - Chronic Heart Failure (CAG-00437N). https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=270. Accessed 26 Feb 2014.
Davies P, Taylor F, Beswick A, et al. Promoting patient uptake and adherence in cardiac rehabilitation. Cochrane Database Syst Rev. 2010;7:CD007131.
Centers for Medicare & Medicaid Services. Pub 100–04 Medicare Claims Processing. http://www.cms.gov/transmittals/downloads/R1875cp.pdf. Accessed 8 Oct 2010.
Centers for Medicare & Medicaid Services. Fact sheet: two-midnight rule. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed 17 Apr 2016.
Centers for Medicare & Medicaid Services. Observation services fact sheet. August 18, 2015. https://www.cgsmedicare.com/partb/mr/pdf/observation_serv_factsheet.pdf. Accessed 17 Apr 2016.
Centers for Medicare & Medicaid Services. CMS Manual System. Pub 100–04 Medicare Claims Processing. Transmittal 2903. March 11, 2014. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r2903cp.pdf. Accessed 17 Apr 2016.
Centers for Medicare & Medicaid Services. Outcome measures. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/outcomemeasures.html. Accessed 17 Apr 2016.
The Joint Commission. Core Measure Set-Heart Failure. January 9, 2015. http://www.jointcommission.org/core_measure_sets.aspx. Accessed 23 Apr 2016.
The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures. http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx. Accessed 23 Apr 2016.
Hospital Consumer Assessment of Healthcare Providers and Systems Hospital Survey. http://www.hcahpsonline.org/home.aspx. Accessed 23 Apr 2016.
National Quality Forum. All-cause admissions and readmissions project 2015–2017. http://www.qualityforum.org/ProjectMeasures.aspx?projectID=80625. Accessed 23 Apr 2016.
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Albert, N.M. (2017). Regulatory Requirements in Acute Heart Failure. In: Peacock, W. (eds) Short Stay Management of Acute Heart Failure. Contemporary Cardiology. Humana Press, Cham. https://doi.org/10.1007/978-3-319-44006-4_3
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DOI: https://doi.org/10.1007/978-3-319-44006-4_3
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