Reduction of Hospital Readmissions after Coronary Artery Bypass Graft
Reduction of Hospital Readmissions after Coronary Artery Bypass Graft: Literature Review
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Reduction of Hospital Readmissions after Coronary Artery Bypass Graft: Literature Review
Literature Review
Hospital readmissions within a short duration after the initial hospital admission contribute significantly to the overall cost of health care in the US. Specifically, hospital readmissions are linked to the increasing costs of healthcare and adverse patient outcomes. Besides, readmissions adversely impact hospital reimbursement and quality measures (Shah et al., 2019). Research indicates that coronary artery surgery is one of the most common reasons for the increase in hospital readmissions. For instance, statistics show that coronary artery bypass graft (CABG) is associates with approximately15% all-causes of readmission rates. According to Mary (2017), thirty-day readmission rates after coronary artery surgery in the US remain substantially high as 8.3% to 21.3%. Besides, research indicates that the leading cause of readmissions in CABG are complications like wound infections and pulmonary interferences such as pleural effusions. Moreover, the methodology used to perform CABG is also a vital factor in hospital readmissions. However, Deo et al. (2020) argue that CABG is amongst the common surgical procedures that lead to high rates of readmissions because the majority of individuals undergoing surgery are older adults who have significant chronic comorbidities. According to Fanari et al. (2017), the key to reducing hospital readmission is dependent on the delivery of high-quality care in the inpatient and enhancing transitional care upon patient discharge. However, due to limited health care resources, it is vital to identify the patients at risk for readmissions after CABG to direct potential interventions, which could assist in reducing the rates of readmissions and enhance the quality of care in hospitals.
According to Gai & Pachamanova (2019), Hospital Readmissions Reduction Program (HRRP), established in 2010 by Patient Protection and Affordable Care Act in the US, has yielded positive results in reducing hospital readmission by penalizing hospitals that have higher than anticipated readmission rates by decreasing Medicare payments. The HRRP is part of the Center for Medicare and Medicaid Service (CMS) value-based programs that are developed for better care for persons, improved care for populations, and reduced health care costs. Besides, studies indicate that other readmission reduction programs targeted at preventing readmissions for patients suffering from pneumonia and heart failure, which have higher readmission rates, have proved to be working. Hospitals that have experienced readmission rates higher than the risk-adjusted benchmarks have been financially penalized. Further, programs such as Home Health Care (HHC) have shown positive results of promoting well-being and decreased early hospital readmissions (McIlvennan, Eapen, & Allen, 2015). The beneficial effects have specifically helped the elderly patients who are at great risk of readmissions due to increased comorbidities. Besides, community-level programs for preventing readmissions have also reported positive effects of home nursing visits. Deo et al. (2020) noted that home nursing visits helped in the reduction of readmissions after CABG. Mainly, HRRP has produced a 67% reduction in the 30-day composite endpoint of readmission and death among patients after CABG. Deo et al. (2020) also noted that home visits by health care providers increase adherence to therapy, which assists in early identification and management of postoperative complications by frequent wound checks, measurement of weight, and early referral to treating clinicians.
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Additionally, early interventional strategies aimed at discharge education and post-discharge surveillance of patients can help decreased the 30-day readmissions. Besides, the HHC is associated with reduced hospital readmissions (Deo et al., 2020). However, there have been concerns whether the programs focused on reducing readmission rates such as the HRRP can result in unintended consequences for the patients of low socioeconomic status and the hospital serving such patients. However, Deo et al. (2020) argue that HRRP does not of resources to hospitals to fund the reduction initiatives and redesigning of care. Besides, the HRRP implemented before has targeted particular conditions such as acute myocardial infarction (AMI), pneumonia, heart failure, chronic obstructive pulmonary (COPD), total knee arthroplasty, and recently CABG was added.
Outcomes of readmission reductions suggest that HRRP implementation has been related to significant readmissions reduction. A study noted that, in 2012 and 2013, the implementation of HRRP led to a decrease in the readmission rates to 18.5% and 17.5%, respectively. The fewer readmissions translated to approximately 150,000 fewer hospital readmissions between 2012 and 2013. Following these findings, researchers suggested that HRRP may be meeting its intended purpose to decrease hospital readmissions and reduce spending by CMS. Additionally, HRRP has been noted to assist in forging collaborative relationships within hospitals, especially between medical institutions and the surrounding communities that emphasize the need for improved overall patient experience via hospitalization and cooperation. Besides, HRRP has created awareness and cooperation at the national level. Despite the evidence of reducing readmissions rate, HRRP has also been criticized for the possibility of unintended consequences of the program and the probability of disproportionately penalizing hospitals that care for the vulnerable population.
Some scholars also argue that HRRP may unintentionally take away resources from resources from hospitals like safety-net hospitals that care for the disadvantaged populations. Consequently, studies show that hospitals with the highest percentage of Medicaid or uninsured patients are 30% more likely to be readmitted, which is above the national average. Gai & Pachamanova (2019), however, noted that it is unclear whether the rates of readmission reduction after the implementation of HRRP are similar across hospitals. As a result, Gai & Pachamanova (2019) suggested that a lot needs to be learned whether hospitals can improve at the same rate when reducing hospital readmissions.
McIlvennan, Eapen, & Allen (2015) noted that the critical question in the outcome after the implementation of HRRP is not whether individual readmission is appropriate but whether hospital-level variance in readmission rate is fueled by preventable events. Besides, McIlvennan, Eapen, & Allen (2015) maintained that the goal of HRRP is to incentivize the care process that reduces preventable events, thus decreasing the overall readmission rates. However, financial penalties imposed by HRRP can inadvertently push some physicians and nurses to avoid readmitting patients who need hospital care (Hamm & Loria, 2019). According to Fanari et al. (2017), there is an elevated pressure to reduce the rates of readmissions nationally, particularly with the increased demand from the Affordable Care Act with financial incentives for the hospitals to reduce readmissions. However, the implementation of HRRP requires the comprehension of the clinical risk factors that could be predictive of CABG readmissions.
Most importantly, Medicaid status, extend the length of hospital stay, and disposition to a skilled nursing facility represent strong predictors for 30-day readmissions after CABG. Therefore, Shah et al. (2019) suggested that when implementing HRRP to reduce the rate of readmission, it is vital to consider improving the predictive factors. Overall, Gai & Pachamanova (2019) concluded that HRRP had been considered a success at both local and national levels. Overall, various studies have also found that HRRP has to lead to a reduction in the rate of hospital readmissions.
Summary
Hospital readmissions after CABG have become common and significantly contribute to increased overall health care costs and poor quality of care. The literature has revealed that CV is associated with the majority of readmission rates in the US. The literature has revealed that hospital readmission prevention programs such as HRRP have significantly contributed to the reduction in the rates of readmission. This program is more effective than other programs design to target the prevention of hospital readmissions for patients with conditions such as pneumonia and heart failure. Besides, the literature has also indicated that home health care has significantly contributed to the promotion of well-being and reduction in early hospital readmissions. Also, the literature has revealed that the HRRP can substantially benefit elderly patients who are at high risk of readmission.
Further, the literature has shown promising benefits of HRRP in reducing the 30-day readmissions after CABG. Despite the potential benefits of HRRP, the literature has also indicated that HRRP can have unintended adverse consequences on hospitals that do not meet the threshold for readmissions. The literature revealed that such hospitals might be disadvantaged because they mainly serve the low socioeconomic class of patients. From the literature, it would be unfair for such hospitals to be penalized for having a readmission rate higher than the set threshold. As a result, the literature suggests that successful implementation of HRRP requires an understanding of the predictive risk factors for CABG in various hospitals. Besides, the literature has revealed that hospitals are not facing similar healthcare challenges because some hospitals like safety-net hospitals may be penalized, yet they serve disadvantaged populations. Overall, the literature has shown promising benefits of HRRP in reducing readmissions after CABG.
References
Deo, S. V., Sharma, V., Altarabsheh, S. E., Raza, S., Wilson, B., Elgudin, Y., & Cmolik, B. (2020). Home health care visits may reduce the need for early readmission after Coronary Artery Bypass Grafting. The Journal of Thoracic and Cardiovascular Surgery.
Fanari, Z., Elliott, D., Russo, C. A., Kolm, P., & Weintraub, W. S. (2017). Predicting readmission risk following coronary artery bypass surgery at the time of admission. Cardiovascular Revascularization Medicine, 18(2), 95-99.
Gai, Y., & Pachamanova, D. (2019). Impact of the Medicare hospital readmissions reduction program on vulnerable populations. BMC health services research, 19(1), 837.
Hamm. N., & Loria, K (2019). Reducing Hospital Readmission Rates for Heart Attack, CABG, and COPD. Population Health Management: Population Health Management
Mary, A. (2017). Prevention of 30-Day Readmission After Coronary Artery Bypass Surgery. Home healthcare now, 35(6), 326-334.
McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation, 131(20), 1796-1803.
Shah, R. M., Zhang, Q., Chatterjee, S., Cheema, F., Loor, G., Lemaire, S. A., ... & Ghanta, R. K. (2019). Incidence, cost, and risk factors for readmission after coronary artery bypass grafting. The Annals of thoracic surgery, 107(6), 1782-1789.
