New research, conducted at St. Joseph Mercy Oakland Hospital and presented at the American College of Cardiology's 61st Annual Scientific Session, has shown that use of a 27-question, heart failure discharge checklist reduced the 30-day readmission rate of a cardiac event from 20 percent to only 2 percent.
The checklist is divided into three sections: medications and appropriate dose modification, counseling and monitoring intervention, and follow-up instructions. Every item on the list supports proven management practices for heart failure patients. Dr. Abhijeet Basoor, MD, who developed the checklist and served as lead investigator for the study, explained that the average heart failure patient will require 12 to 15 of the interventions listed to lower the chances of a subsequent cardiac event.
“The checklist provides simple reminders to instruct patients about things like diet, weight, blood pressure monitoring and appropriate drug dose up titration,” Basoor said in a news release. “The physician or nurse practitioner working with the patient uses the checklist, so hospitals don’t have to pay for additional nursing staff or home care follow-up.”
In addition to its relatively high 30-day readmission rate, heart failure treatment carries a $29 billion cost in the United States with readmissions costing hospitals an average of $2,084 per patient per day. According to the Kaiser Family Foundation, heart failure readmissions cost $12 billion in Medicare spending annually, and approximately 25 percent of Medicare patients with heart failure are readmitted to the hospital within 30 days of a cardiac event. Because prior studies have indicated that 50 percent of such readmissions are preventable, Medicare will begin to penalize hospitals with high readmission rates by refusing reimbursements once the Affordable Care Act goes into effect in 2014.
“In addition to lowering 30-day and six-month readmissions and the associated costs, we also showed that more patients in the checklist group were likely to be on correct medications and had appropriate drug doses than patients in the control group,” Basoor said.
If broadly adopted, this practice could translate into billions of Medicare dollars saved each year. While recent research has shown that proper patient education can reduce readmissions, this is the first study to test the use of a simple, discharge checklist that requires no extra cost to hospitals.
“Right now the checklist isn’t part of the standard medical record, so there could be resistance to using it,” Basoor said, “but if we show it’s really beneficial and easy to use, this could become a common practice. We’ve shown that quality of care can be improved at almost no additional cost. In the era of electronic medical records, we are working on transforming the checklist to an electronic form.”
The checklist was developed and used after approval of the hospital’s Cardiovascular Quality Integration Board. In a random controlled trial, 96 patients were followed for six months after discharge for an initial heart failure event. Doctors used the checklist before discharge in half of these cases while the other half they administered standard discharge treatment and instructions. After 30 days and again at six months post-discharge, data was collected. Both of the groups shared common cardiovascular risk factors including age, sex and attending physician groups. After excluding deaths during follow up, only one person in the checklist group was readmitted within 30 days of leaving the hospital as compared to nine who were readmitted from the control group. At six months, 11 patients in the checklist group had been readmitted as compared to 20 in the control group.