Becker's Clinical Quality & Infection Control

27 QUALITY IMPROVEMENT & MEASUREMENT Viewpoint: Pressure to Reduce Readmissions Can Hinder Care Quality, Patient Safety By Mackenzie Bean W hile CMS' Hospital Readmission Reduction Program success- fully reduces readmissions, the program may also produce unintended care consequences that threaten patient safety, ac- cording to an op-ed published in the Journal of the American College of Cardiology. Gregg Fonarow, MD, director of the Ahmanson-UC Los Angeles Cardiomyop- athy Center; Marvin Konstam, MD, chief physician executive of e CardioVascular Center at Boston-based Tus Medical Cen- ter; and Clyde Yancy, MD, chief of cardiol- ogy at Evanston, Ill.-based Northwestern University's Feinberg School of Medicine penned the article. e physicians argue pressure to reduce readmissions, particularly among heart failure patients, may encourage inappropri- ate care strategies and shi hospitals' focus away from meaningful quality improvement efforts and patient safety considerations. e physicians cited a study published July 18 in JAMA, which found a weak, but statistically significant, correlation between reductions in 30-day readmissions and reductions in 30-day mortality rates aer discharge. However, hospitals with stable or increasing readmission rates demonstrated increases in 30-day post-discharge mortality. e same study showed 30-day risk-adjust- ed post-discharge mortality in Medicare patients with heart failure increased from 7.9 percent in 2008 to 9.2 percent in 2014. e Hospital Readmission Reduction Program took effect in 2012. "It is interesting that the declines in 30-day readmission aer [Hospital Readmission Reduction Program] implementation are ac- cepted as evidence of the success of the pro- gram, but the reversal in more than a decade of declines in 30-day mortality for [heart failure] is dismissed," the authors wrote. "No level of reduction in readmissions or cost savings should be considered adequate justi- fication for this level of potential harm." e physicians acknowledged there is no proof of a causal relationship between increasing mortality rates and the Hospital Readmission Reduction Program. "Our concerns, if corroborated, should prompt immediate consideration for reas- sessment and revision of the HRRP. If harm has been the consequence of the [Hospital Readmission Reduction Program], we are obliged to exercise appropriate due dili- gence," they concluded. n Physicians With Low Quality Ratings Prescribe More Opioids, Barbiturates for Headaches By Brian Zimmerman P rimary care physicians and neurologists with poor quality ratings prescribe opioids and butalbital med- ications to headache patients at significantly higher rates than top-performing counterparts, according to an analysis conducted by the healthcare clinical navigation company Grand Rounds. For the analysis, researchers assessed physician prescrib- ing data and Grand Rounds quality rankings for more than 96 percent of the nation's practicing physicians to deter- mine prescribing patterns for headache patients. Primary care physicians with overall quality rates in the bottom 10 percent were 1.9 times more likely to pre- scribe oxycodone for headaches, 3.4 times more likely to prescribe hydrocodone and 5.0 times more likely to prescribe butalbital compared to top-performing pri- mary care physicians. Among neurologists, those rated in the bottom 10 percent were 1.5 times more likely to prescribe oxycodone, 2.8 times more likely to prescribe hydrocodone and 4.1 times more likely to prescribe butalbital. While hydrocodone, oxycodone and butalbital can provide short-term headache relief, they are meant to be treatments of last resort, as they can worsen headache severity over time — a condition known as medication overuse headache — and increase addiction risk. "The disparity in prescribing across physicians suggests a patient's chances of developing medication overuse headache can be dramatically reduced by simply ensur- ing that they are treated by a doctor who understands the risks associated with opioids and barbiturates and knows to use them only as a line of last resort," Nate Freese, senior director of data strategy with Grand Rounds, wrote in a blog post. "For the patient, this can mean the differ- ence between a quick, effective course of treatment and a life-altering addiction … Many healthcare challenges are exceptionally difficult to solve. When it comes to treating a headache, simply seeing the right doctor can make all the difference." n "When it comes to treating a headache, simply seeing the right doctor can make all the difference." -Nate Freese, senior director of data strategy at Grand Rounds

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