Current Heart Failure Reports

, Volume 11, Issue 4, pp 347–353 | Cite as

Understanding the Relationship Between Readmission and Quality of Hospital Care in Heart Failure

  • Lauren Gray Gilstrap
  • Karen E. JoyntEmail author
Prevention of Heart Failure (M St. John Sutton, Section Editor)


Hospital readmission rates for heart failure (HF) are increasingly seen as a quality metric and are being used to define reimbursement rates and penalize underperforming hospitals. As disease patterns shift from single acute episodes of illness to more chronic and degenerative diseases, healthcare systems across the country are grappling with the challenge of providing quality care while simultaneously controlling both readmission rates and spending. Using HF as a prototypical example of chronic illness, this review begins by describing the historical underpinnings of readmission rates and how they have become a mainstream metric of healthcare quality. It then examines the controversial relationship between hospital quality and readmission rates. The paper examines several strategies to decrease readmission rates, including discharge planning and readmission reduction programs, as well as the relationship between readmission rates and mortality rates. The principal drivers of readmissions are discussed and the impact of new readmission-based financial policy is explored as well.


Heart failure Readmission Quality 


Compliance with Ethics Guidelines

Conflict of Interest

Lauren Gray Gilstrap declares that she has no conflict of interest.

Karen E. Joynt has received compensation from Cytokinetics for service as a consultant.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. 1.
    Lloyd-Jones DM, Larson MG, Leip EP, Beiser A, D'Agostino RB, Kannel WB, et al. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation. 2002;106:3068–72.PubMedCrossRefGoogle Scholar
  2. 2.
    Bleumink GS, Knetsch AM, Sturkenboom MC, Straus SM, Hofman A, Deckers JW, et al. Quantifying the heart failure epidemic: prevalence, incidence rate, lifetime risk and prognosis of heart failure: the Rotterdam Study. Eur Heart J. 2004;25:1614–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al. American Heart Association Statistics C, Stroke Statistics S. Heart disease and stroke statistics–2013 update: a report from the American Heart Association. Circulation. 2013;127:e6–245.PubMedCrossRefGoogle Scholar
  4. 4.
    Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. Forecasting the future of cardiovascular disease in the united states: A policy statement from the American Heart Association. Circulation. 2011;123:933–44.PubMedCrossRefGoogle Scholar
  5. 5.
    Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW, et al. Relationship between early physician follow-up and 30-day readmission among medicare beneficiaries hospitalized for heart failure. JAMA J Am Med Assoc. 2010;303:1716–22.CrossRefGoogle Scholar
  6. 6.
    Bueno H, Ross JS, Wang Y, Chen J, Vidan MT, Normand SL, et al. Trends in length of stay and short-term outcomes among medicare patients hospitalized for heart failure, 1993–2006. JAMA J Am Med Assoc. 2010;303:2141–7.CrossRefGoogle Scholar
  7. 7.
    H2h national quality improvment initiative 2012;2014.Google Scholar
  8. 8.
    Jenkins RL, Bemiss Jr EL, Lorr M. Duration of hospitalization, readmission rate and stability of diagnoses in veterans hospitalized with neuropsychiatric diagnoses. Psychiatr Q. 1953;27:59–72.PubMedCrossRefGoogle Scholar
  9. 9.
    MacDonell JA, McKenzie DA, Cheetham E. Social effects of intermittent readmission. The Gerontologist. 1968;8:38–42.PubMedCrossRefGoogle Scholar
  10. 10.
    Nielsen M, Blenkner M, Bloom M, Downs T, Beggs H. Older persons after hospitalization: a controlled study of home aide service. Am J Public Health. 1972;62:1094–101.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc. 1990;38:1290–5.PubMedGoogle Scholar
  12. 12.
    Gwadry-Sridhar FH, Flintoft V, Lee DS, Lee H, Guyatt GH. A systematic review and meta-analysis of studies comparing readmission rates and mortality rates in patients with heart failure. Arch Intern Med. 2004;164:2315–20.PubMedCrossRefGoogle Scholar
  13. 13.
    McAlister FA, Lawson FM, Teo KK, Armstrong PW. A systematic review of randomized trials of disease management programs in heart failure. Am J Med. 2001;110:378–84.PubMedCrossRefGoogle Scholar
  14. 14.
    Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med. 1998;158:1067–72.PubMedCrossRefGoogle Scholar
  15. 15.
    Rich MW, Vinson JM, Sperry JC, Shah AS, Spinner LR, Chung MK, et al. Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study. J Gen Intern Med. 1993;8:585–90.PubMedCrossRefGoogle Scholar
  16. 16.
    Jaarsma T, Halfens R, Huijer Abu-Saad H, Dracup K, Gorgels T, van Ree J, et al. Effects of education and support on self-care and resource utilization in patients with heart failure. Eur Heart J. 1999;20:673–82.PubMedCrossRefGoogle Scholar
  17. 17.
    Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med. 2009;360:1418–28.PubMedCrossRefGoogle Scholar
  18. 18.
    Krumholz HM, Merrill AR, Schone EM, Schreiner GC, Chen J, Bradley EH, et al. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circulation. 2009;2:407–13.PubMedGoogle Scholar
  19. 19.
    Patel A-MJAaS. New hospital compare measures help fill out the performance picture 2011;2014.Google Scholar
  20. 20.
    Toland B. Medicare launches 'hospital compare'. Pittsburgh Post-Gazette. 2001.Google Scholar
  21. 21.
    MedPAC Report to Congress: Improving Incentives in the Medicare Program. 2009;2014.Google Scholar
  22. 22.
    Jha AK, Orav EJ, Epstein AM. Public reporting of discharge planning and rates of readmissions. N Engl J Med. 2009;361:2637–45.PubMedCrossRefGoogle Scholar
  23. 23.••
    Bradley EH, Curry L, Horwitz LI, Sipsma H, Thompson JW, Elma M, et al. Contemporary evidence about hospital strategies for reducing 30-day readmissions: A national study. J Am Coll Cardiol. 2012;60:607–14. Analysis of over 500 hospitals regarding practices to reduce readmissions among AMI and HF patients. The study examined specific policies and practices at different hospitals and found that although most hospitals have a written objective to reduce readmissions but there is significant variation in the implementation of these practices. More research is needed to determine which policies are most effective at reducing preventable readmissions.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Kociol RD, Lopes RD, Clare R, Thomas L, Mehta RH, Kaul P, et al. International variation in and factors associated with hospital readmission after myocardial infarction. JAMA J Am Med Assoc. 2012;307:66–74.CrossRefGoogle Scholar
  25. 25.••
    Bradley EH, Curry L, Horwitz LI, Sipsma H, Wang Y, Walsh MN, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circulation. 2013;6:444–50. Using a web based survery, this group constucted a multivariable linear regression model, weighted by hospital volume, to determine strategies independently associated with risk-standardized 30-day readmission. The found that the following strategies were independently associated with lower readmission risk: partnering with community physicians, partnering with local hospitals, having nurses responsible for medication reconciliation, arranging follow-up appointments before discharge, having a process in place to send all discharge paper to the patient’s primary physician and assigning staff to follow up on test results that return after the patient is discharged.PubMedCentralPubMedGoogle Scholar
  26. 26.
    Hess CN, Shah BR, Peng SA, Thomas L, Roe MT, Peterson ED. Association of early physician follow-up and 30-day readmission after non-st-segment-elevation myocardial infarction among older patients. Circulation. 2013;128:1206–13.PubMedCentralPubMedGoogle Scholar
  27. 27.
    Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? N Engl J Med. 2010;363:297–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Press MJ, Scanlon DP, Ryan AM, Zhu J, Navathe AS, Mittler JN, et al. Limits of readmission rates in measuring hospital quality suggest the need for added metrics. Health Aff (Millwood). 2013;32:1083–91.CrossRefGoogle Scholar
  29. 29.
    Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for medicare beneficiaries by race and site of care. JAMA J Am Med Assoc. 2011;305:675–81.CrossRefGoogle Scholar
  30. 30.
    Jiang HJ. All-cause hospital readmissions among non-elderly medicaid patients, 2007. Healthcare Cost and Utilization Project (HCUP). 2010;2014.Google Scholar
  31. 31.
    Arbaje AI, Wolff JL, Yu Q, Powe NR, Anderson GF, Boult C. Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling medicare beneficiaries. The Gerontologist. 2008;48:495–504.PubMedCrossRefGoogle Scholar
  32. 32.
    Jiang W, Alexander J, Christopher E, Kuchibhatla M, Gaulden LH, Cuffe MS, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001;161:1849–56.PubMedCrossRefGoogle Scholar
  33. 33.••
    Joynt KE, Jha AK. Who has higher readmission rates for heart failure, and why? Implications for efforts to improve care using financial incentives. Circ Cardiovasc Qual Outcomes. 2011;4:53–9. Analysis of Medicare claims data from 2006 to 2007 looking at over 900,000 discharges. They found that patients discharged from public hospitals, patients from low-income communities, patients discharged from hospitals without cardiac services, patients discharged from hospitals in the lowest quartiles of nursing staffing and patients discharged from small hospitals all had higher readmission rates. This article raises concern that financially penalizing poor, underperforming hospitals based on readmission rates may further exacerbate the problem.PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Lindenauer PK, Lagu T, Rothberg MB, Avrunin J, Pekow PS, Wang Y, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: Retrospective cohort study. BMJ. 2013;346:f521.PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Bodenheimer T. The future of primary care: Transforming practice. N Engl J Med. 2008;359:2086–9.PubMedCrossRefGoogle Scholar
  36. 36.
    van Walraven C, Taljaard M, Etchells E, Bell CM, Stiell IG, Zarnke K, et al. The independent association of provider and information continuity on outcomes after hospital discharge: Implications for hospitalists. J Hosp Med Off Publ Soc Hosp Med. 2010;5:398–405.CrossRefGoogle Scholar
  37. 37.
    Cox J, Johnstone D, Nemis-White J, Montague T, Investigators I. Optimizing healthcare at the population level: Results of the improving cardiovascular outcomes in nova scotia partnership. Healthcare Q. 2008;11:28–41.CrossRefGoogle Scholar
  38. 38.
    Andrews M. Memphis hospital teams up with churches to deliver care. Kaiser Helath News. 2011.Google Scholar
  39. 39.
    Kowalczyk L. Healing meals: Hospitals hope that sending healthful food to patients’ homes will keep them from coming back. The Boston Globe. 2013.Google Scholar
  40. 40.
    Gerhardt G. Data shows reduction in medicare hospital readmission rates during 2012. Medicare and Medicaid Resarch Review.Google Scholar
  41. 41.
    Joynt KE, Jha AK. Characteristics of hospitals receiving penalties under the hospital readmissions reduction program. JAMA J Am Med Assoc. 2013;309:342–3.CrossRefGoogle Scholar
  42. 42.
    Joynt KE, Jha AK. A path forward on medicare readmissions. N Engl J Med. 2013;368:1175–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Huesch MD, Ong MK, Fonarow GC. Measuring heart failure care by 30-day readmission: Rethinking the quality of outcome measures. Am Heart J. 2013;166:605–610.e2.PubMedCrossRefGoogle Scholar
  44. 44.
    Joynt KE, Jha AK. Thirty-day readmissions – truth and consequences. N Engl J Med. 2012;366:1366–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Brigham and Women’s Hospital, Department of Medicine, Division of Cardiovascular MedicineBostonUSA
  2. 2.Harvard School of Public Health, Department of Health Policy and ManagementBostonUSA
  3. 3.VA Boston Healthcare System, Department of Medicine, Cardiology SectionBostonUSA

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