1
Northwestern University
Feinberg School of
Medicine
Northwestern Memorial Hospital
DISCLOSURES
• Consultant/speaker/honoraria: none
• Editorial Boards: American Heart Journal, American Journal of Cardiology (associate editor); Circulation; Circulation-Heart Failure; JACC- Associate Editor, HF, (2014)
• Guideline writing committees: Chair, ACC/AHA, chronic HF; member, hypertrophic cardiomyopathy, atrial fibrillation; former member, ACC/AHA Guideline Taskforce; chair, methodology subcommittee
• Federal appointments: FDA: Chair, Cardiovascular Device Panel; ad hoc consultant; NIH former CICS study section; Advisory Committee to the Director; AHRQ- adhoc study section chair; NHLBI- consultant; PCORI- methodology committee member
• Volunteer Appointments: American Heart Association-President, American Heart Association, 2009-2010; American College of Cardiology, Founder- CREDO
American College of Cardiology
Oregon Chapter Symposium
American College of Cardiology
Oregon Chapter Symposium
“How to Prevent Heart Failure
Readmission”
“How to Prevent Heart Failure
Readmission”
Clyde W. Yancy, MD, MSc, FACC, FAHA, MACP
Magerstadt Professor of Medicine
Professor of Medical Social Sciences
Chief of Cardiology
Northwestern University, Feinberg School of Medicine
&
Associate Medical Director
Bluhm Cardiovascular Institute
Chicago, IL
2
Let’s start with heart failure…
Stages, Phenotypes and Treatment of HF
Survival (years)
Ammar et al. Circulation 2007; 115:1563
Prevalence and prognostic significance of HF Stages
3
Stages, Phenotypes and Treatment of HF
Pharmacologic Treatment for Stage C HFrEF
Results: Mortality Reduction Based on Number of Guideline-Recommended Therapies at Baseline
24 Month Mortality
Adjusted Odds Ratios (95% CI Displayed)Number of Therapies(vs 0 or 1 therapy)
2 therapies
3 therapies
4 therapies
5, 6, or 7 therapies
Odds Ratio(95% confidence interval)
0.63 (0.47-0.85)(p=0.0026)
0.38 (0.29-0.51)(p<0.0001)
0.30 (0.23-0.41)(p<0.0001)
0.31 (0.23-0.42)(p<0.0001)
0 0.5 1 1.5 2
Fonarow GC, … Yancy, C. J Am Heart Assoc 2012;1:16-26.Fonarow GC… Yancy CW. J Am Heart Assoc 2012;1:16-26.
4
GAME-CHANGER?
Simplified schematic of the renin–angiotensin–aldosterone system.
von Lueder T G et al. Circ Heart Fail. 2013;6:594-605
Copyright © American Heart Association, Inc. All rights reserved.
Simplified schematic of the natriuretic peptide system (NPS).
von Lueder T G et al. Circ Heart Fail. 2013;6:594-605
Copyright © American Heart Association, Inc. All rights reserved.
5
Cardiac antiremodeling effects of angiotensin receptor neprilysin inhibitors (ARNi) in vitro and in vivo.
von Lueder T G et al. Circ Heart Fail. 2013;6:594-605
Copyright © American Heart Association, Inc. All rights reserved.
PARADIGM - HF
PARADIGM HF
6
Stages, Phenotypes and Treatment of HF
TOPCAT - Results
• 3,445 patients were randomized, 1,722 to spironolactone and to 1,723 to placebo.
• Baseline characteristics were similar between the two arms.
• The baseline EF was 56%
• 52% were female
• 2/3 of the patients had New York Heart Association (NYHA) class II symptoms.
• Hypertension was present in 92% of patients. Coronary artery disease was noted in 59% and atrial fibrillation in 35%.
• Baseline K was 4.3 mEq/L.
The primary endpoint of CV death, chronic HF (CHF) hospitalization, or resuscitated cardiac arrest over 6 years was similar between the spironolactone and placebo arms (18.6% vs. 20.4%, hazard ratio = 0.89, 95% confidence interval 0.77-1.04, p = 0.14).
• Individual components including CV mortality (9.3% vs. 10.2%. p = 0.35) and aborted cardiac arrest (3 vs. 5 events, p = 0.48) were similar between the two arms.
• CHF hospitalizations were lower (12.0% vs. 14.2%, p = 0.042); all-hospitalizations were similar (p = 0.25).
• Hyperkalemia (18.7% vs. 9.1%, p < 0.001) and renal failure, defined as doubling of creatinine >2 upper limit of normal were both significantly higher in the spironolactone arm.
7
Kaplan–Meier Plot of Time to the First Confirmed Primary-Outcome Event.
Pitt B et al. N Engl J Med 2014;370:1383-1392
Kaplan–Meier Plots of Two Components of the Primary Outcome.
Pitt B et al. N Engl J Med 2014;370:1383-
1392
TOPCAT – Adjusted results
8
Treatment of HFpEFRecommendations COR LOE
Systolic and diastolic blood pressure should be controlled
according to published clinical practice guidelines I B
Diuretics should be used for relief of symptoms due to
volume overloadI C
Coronary revascularization for patients with CAD in
whom angina or demonstrable myocardial ischemia is
present despite GDMT
IIaC
Management of AF according to published clinical
practice guidelines for HFpEF to improve symptomatic
HF
IIa C
Use of beta-blocking agents, ACE inhibitors, and ARBs
for hypertension in HFpEF IIa C
ARBs might be considered to decrease hospitalizations in
HFpEFIIb B
Nutritional supplementation is not recommended in
HFpEF
III: No
BenefitC
Now, health care reform…
The premise: what we spend on
health care--
9
National Health Expenditures per Capita,
1960-2010
Notes: According to CMS, population is the U.S. Bureau of the Census resident-based population, less armed forces overseas and population of
outlying areas, plus the net undercount.
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at
http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2010; file nhegdp10.zip).
5.2% 7.2% 9.2% 12.5% 13.8% 14.5% 15.4% 15.9% 16.0% 16.1% 16.2% 16.4% 16.8% 17.9% 17.9%
NHE as a Share of GDP
10
The U.S. as an outlier…
Bending the Curve 2
9Spending Growth Continues Downward Trajectory
Percent Increase in National
Health Care Spending
2003-2011
Source: Centers for Medicare and Medicaid, “National Health Expenditure Accounts”, 2013, available at: www.cms.gov/Research-Statistics-Data-and-Sy stems/Statistics-Trends-and Reports/NationalHealthExpendData/Downloads/tables.pdf; Department of Health and Human Services, “Growth in Medicare Spending Per Benef iciary Continues to Hit Historic Lows”, January, 2013, available at: http://aspe.hhs.gov/health/reports/2013/medicarespendinggrowth/longdesc.shtml; Marketing and Planning Leadership Council interviews and analysis.
Medicare Spending Growth
per Beneficiary
2010-2012
Tensions remain: Physicians
determine ~ 60% of all health care
costs; what do physicians think?
11
Date of download: 7/25/2013Copyright © 2012 American Medical
Association. All rights reserved.
From: Views of US Physicians About Controlling Health Care Costs
JAMA. 2013;310(4):380-388. doi:10.1001/jama.2013.8278
What about hospital costs and
executive compensation?
12
JAMA, Internal Medicine, 2014
Date of download: 1/20/2014Copyright © 2014 American Medical
Association. All rights reserved.
From: Compensation of Chief Executive Officers at Nonprofit US Hospitals
JAMA Intern Med. 2014;174(1):61-67. doi:10.1001/jamainternmed.2013.11537
Distribution of Chief Executive Officer PayHistogram of chief executive officer pay at US nonprofit hospitals in calendar year 2009.
Figure Legend:
Expanding Coverage3
6Will Coverage Expansion Offset Decline in Per Capita Utilization?
Source: CBO, “Letter to the Honorable John Boehner Providing an Estimate for H.R.6079, The Repeal of Obamacare Act,” July 24, 2012, av ailable at: www.cbo.gov; CBO, “Effects of the Affordable Care Act on Health Insurance Coverage—February 2013 Baseline,” February 5, 2013, available at: www.cbo.gov; Health Care Advisory Board interviews and analysis.
1) Disproportionate Share Hospital.2) Non-elderly population.
Projected Coverage Expansion
Net Reduction in Uninsured Individuals22013-2023
ACA Hospital Payment Cuts
1
13
Coverage options
• Employer based coverage
• Medicare
• Medicaid (CHIPs)
• Insurance
� Private (personal) Insurance
� Marketplace/Exchange
AFFORDABLE CARE ACT
Health Insurance Marketplace
38
AFFORDABLE CARE ACT
Health Insurance Marketplace
Those remaining uninsured
14
Proposed Medicaid Disproportionate Share Hospital (DSH) Allotments for Fiscal Year 2014 and Reductions
for States with Baseline DSH Allotments Greater Than $200 Million.
Neuhausen K et al. N Engl J Med 2013. DOI: 10.1056/NEJMp1310572
Every state has Medicaid but the definitions of poverty vary; in Mississippi: < $3,000/year.
Consumer (financial) Accountability = Transparency4
1HDHP1 Enrollees Have Greater Motivation to Price Shop
Source: KFF, “2012 Employer Health Benefits Survey,” available at: www.kff.org; New Choice Health, “N ew Choice Health Medical Cost Comparison,” available at: www.newchoicehealth.com; Healthcare Blue Book, “Healthcare Pricing,” available at: www.healthcarebluebook.com; Kliff S, “How much does an MRI cost? In D.C., anywhere from $400 to $1,861,” Washington Post, March 13, 2013, av ailable at: www.washingtonpost.com; Health Care Advisory Board interviews and analysis.
1) High-deductible health plan.2) $2,086; based on KFF report of average HDHP deductible.3) $733; based on KFF report of average PPO deductible.
Consumers Paying More Out-of-Pocket
Fall within HDHP deductible2
$730
$900
$1,269
$2,183
$411
• Price-sensitive shoppers will be acutely aware of price variation
• MRI prices range from $400 to $2,183
MRI Price Variation Across
Washington, DC
Fall within PPO
deductible3
What About Readmissions for HF?-
HRRP
15
The natural history of HF s/p HF
hospitalization
Jong P et al. Arch Intern Med. 2002;162:1689
0
25
50
75
100
Hospital Readmissions
0
25
50
75
100
Mortality
Median hospital LOS: 6 days
Annual mortality rate
NYHA class III HF: 12% [COPERNICUS
DATA]
NYHA class II HF: 7% [SCD-HeFT DATA]
20%
50%
30days
6months
12%
50%
30days
12months
33%
5years
Date of download:
3/10/2013
Copyright © The American College of Cardiology.
All rights reserved.
From: National Trends in Heart Failure Hospital Stay Rates, 2001 to 2009
J Am Coll Cardiol. 2013;61(10):1078-1088. doi:10.1016/j.jacc.2012.11.057
Heart Failure Hospital Stay Rate by Age Category/100,000 Persons
Heart failure hospital stay rate/100,000 over time from 2001 to 2009, stratified by age categories.
Figure Legend:
Date of download:
3/10/2013
Copyright © The American College of Cardiology.
All rights reserved.
From: National Trends in Heart Failure Hospital Stay Rates, 2001 to 2009
J Am Coll Cardiol. 2013;61(10):1078-1088. doi:10.1016/j.jacc.2012.11.057
In-Hospital Survival for Heart Failure Hospital Stay, by Hospital Day
Proportion of hospitalized heart failure patients who remain alive by hospital day, stratified by time periods 2001 to 2003, 2004 to 2006, and 2007
to 2009.
Figure Legend:
16
Frequency distribution of rehospitalizations for fee-for-service Medicare beneficiaries discharged after ~ 1,500,000 heart failure hospitalizations from >4,000US hospitals, 2004–2006.
Ross J S et al. Circ Heart Fail 2010;3:97-103
Copyright © American Heart A ssociation
Medicare Provisions in PPACA
Readmissions
Hospitals will have
1. Readmission rates
made publically
available
2. Hospitals with high
risk adjusted
readmissions with
no steps to reduce
readmission will be
required to report on
process.
• Source: US House of Representatives, “Amendment in the Nature of a Substitute to H.R. 4872, as Reported,” March 18, 2010; US Senate, The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act,” December 24, 2009; Health Care Advisory Board interviews and analysis.
Age, years over 65
Male
Cardiovascular
History of Percutaneous Transluminal Coronary Angioplasty (ICD9
V45.82)
History of Coronary Artery Bypass Graft Surgery (ICD9 V45.81)
History of heart failure (HCC 80)
History of Myocardial Infarction (HCC 81)
Unstable angina (HCC 82)
Chronic atherosclerosis (HCC 83-84)
Cardiopulmonary-respiratory failure and shock (HCC 79)
Valvular heart disease (HCC 86)
Comorbidity
Hypertension (HCC 89-91)
Stroke (HCC 95-96)
Renal failure (HCC 131)
Chronic Obstructive Pulmonary Disease (HCC 108)
Pneumonia (HCC 111-113)
Diabetes (HCC 15-20, 120)
Protein-calorie malnutrition (HCC 21)
Dementia (HCC 49-50)
Hemiplegia, paraplegia, paralysis, functional disability (HCC 100-
102, 68-69, 177-178)
Peripheral vascular disease (HCC 104-105)
Metastatic cancer (HCC 7-8)
Trauma in last year (HCC 154-156, 158-162)
Major psychiatric disorders (HCC 54-56)
Chronic liver disease (HCC 25-27)
Not Adjusted for in the Model
Systolic blood pressure on admissionHeart rate on admission
Respiratory rate on admissionBody mass indexBUN on admission
Creatinine on admissionSodium on admissionHemoglobin on admissionBrain natriuretic peptide on admission
Left ventricular ejection fractionLeft ventricular end diastolic diameterFunctional status (New York Heart Association Class)
Socio-economic statusMechanical ventilation (initial)Inotropic agent treatment
Krumholz HM, et al. Circulation 2006;113:1693-1701.
30-Day Mortality Risk Adjustment in HF: Hierarchical Regression Model for HF Based on Administrative Claims Data
17
Medicare Assessment and
Penalty- 2014• Hospitals’ Heart Failure 30 day readmission
benchmark data are measured from July 1, 2003-June 30, 2011
• In 2013, up to a 1% penalty on all DRGs was withheld from those hospitals with 30 day excessive readmissions
• In 2014, up to a 2% penalty is allowed
• By 2015 up to a 3% penalty on all DRGs can be withheld those hospitals with 30 day excessive readmissions
The imperfectness of the HRRP
• Unexplained excess mortality may be an off-target association
• Safety net and teaching hospitals are disproportionately impacted by penalties
• Readmissions are front-loaded in the 30 day window; a 30 day period is not physiological
• Fewer than half of the causes for readmission are related to the primary illness
• Patient population matters: CMS, Frailty, Race, Poverty; Physicians and hospitals may not
Comparison of Risk-Adjusted Hospital Readmission Rates and Mortality Rates 30 Days after an Index
Admission for Heart Failure.
Gorodeski EZ et al. N Engl J Med 2010;363:297-298.
18
Date of download: 2/11/2013Copyright © 2012 American Medical
Association. All rights reserved.
From: Characteristics of Hospitals Receiving Penalties Under the Hospital Readmissions Reduction Program
JAMA. 2013;309(4):342-343. doi:10.1001/jama.2012.94856
Date of download: 2/11/2013Copyright © 2012 American Medical
Association. All rights reserved.
From: Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial
Infarction, or Pneumonia
JAMA. 2013;309(4):355-363. doi:10.1001/jama.2012.216476
The denominators used to calculate the percentage of 30-day readmissions on each day after hospitalization were 329 308 30-day readmissions following heart failure hospitalization, 108 992 30-day readmissions following acute myocardial infarction hospitalization, and 214 239 30-day readmissions following pneumonia hospitalization.
Figure Legend:
Date of download: 2/11/2013Copyright © 2012 American Medical
Association. All rights reserved.
From: Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial
Infarction, or Pneumonia
JAMA. 2013;309(4):355-363. doi:10.1001/jama.2012.216476
The denominators used to calculate the percentage of 30-day readmissions due to common readmission diagnoses during each cumulative period after hospitalization for heart failure were 44 257 readmissions for days 0 through 3, 104 362 for days 0 through 7, 201 005 for days 0 through 15, and 329 308 for days 0 through 30. Analogously, following acute myocardial infarction hospitalization, the denominators used were 20 801 readmissions for days 0 through 3, 43 687 for days 0 through 7, 73 641 for days 0 through 15, and 108 992 for days 0 through 30. Following pneumonia hospitalization, the denominators used were 32 829 readmissions for days 0 through 3, 71 995 for days 0 through 7, 134 033 for days 0 through 15, and 214 239 for days 0 through 30.
Figure Legend:
19
Unadjusted 30-day all-cause and HF-related readmission
rates and 95% CI by payer.
Allen L A et al. Circ Heart Fail 2012;5:672-679
Copyright © American Heart A ssociation
N.B., very low
rate of HF
related
readmissions
Frailty• Distinct biological syndrome
• Characterized by profound weight loss, sarcopenia, physical exhaustion, weakness, decline in walking speed and reduced functional capacity; “Fried” or “Lach’s” criteria
• Prevalence: 3% @ 65-70; 23% @ >90
• Attributable to inflammation and associated with elevated C-reactive protein, factor VIII and reduced vit D
Murad K, Kitzman, D. Heart Failure Reviews. 31 May 2011
20
Frailty and multiple co-morbidities in the elderly patient with
heart failure: implications for management
Khalil Murad1, 2 and Dalane W. Kitzman3
Update on HRRP – FY ‘14
Proportion of Hospitals Facing No Readmissions Penalty (Panel A) and Median Amount of Penalty (Panel B),
According to the Proportion of Hospital's Patients Who Receive Supplemental Security Income.
Joynt KE, Jha AK. N Engl J Med 2013. DOI:
10.1056/NEJMp1300122
21
Physician Volume, Specialty, and Outcomes of Care for Patients With Heart Failure Clinical Perspective
by Karen E. Joynt, E. John Orav, and Ashish K. Jha
Circ Heart FailVolume 6(5):890-897September 17, 2013
Copyright © American Heart Association, Inc. All rights reserved.
A, Relationship between physician volume and 30-day risk-adjusted mortality, stratified by hospital volume: adjusted for patient characteristics, physician specialty, and hospital
characteristics including teaching status, hospital size, urban vs rural location, region of the country, and ownership (public, private nonprofit, private profit).
Joynt K et al. Circ Heart Fail 2013;6:890-897
Copyright © American Heart Association, Inc. All rights reserved.
Update on the HRRP- FY ‘14
22
Hospital Discharge
Recommendation or Indication COR LOE
Performance improvement systems in the hospital and early postdischarge outpatient setting
to identify HF for GDMTI B
Before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits,
the following should be addressed:
a) initiation of GDMT if not done or contraindicated;
b) causes of HF, barriers to care, and limitations in support;
c) assessment of volume status and blood pressure with adjustment of HF therapy;
d) optimization of chronic oral HF therapy;
e) renal function and electrolytes;
f) management of comorbid conditions;
g) HF education, self-care, emergency plans, and adherence; and
h) palliative or hospice care.
I B
Multidisciplinary HF disease-management programs for patients at high risk for hospital
readmission are recommended I B
A follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of hospital
discharge is reasonableIIa B
Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients is
reasonableIIa B
Healthcare Reform; A grand idea,
an imperfect plan, a failed
hypothesis?
Hmm…
23
6
7Multiple Pay-for-Performance Initiatives Underway
Source: Centers for Medicare and Medicaid Services, “CMS Hospital Inpatient Quality Reporting Program Hospital-Acquired Condition Measures,” March 21, 2011; Health Care Advisory Board interviews and analysis.
1) Includes eight possible conditions. Penalties involve reduced Medicare inpatient payments by 1% starting in FY 2015 to bottom 25% of all hospitals, relative to national average.
2) Example based on Pleasantville Hospital model of 16,000 annual discharges: 25th percentile: 0 events, 50th percentile: 0.442*16=7 events,75th percentile: 1.627*16=26 events, 95th percentile: 5.202*16=82 events.
Initiative Description
Readmissions
Penalties
• FY 2013 readmissions penalty
based upon readmissions performance between July 1, 2008
and June 30, 2011
• Penalties start at 1% of Medicare
inpatient revenue, rising to 3% by FY 2015
Value-Based
Purchasing Program
(VBP)
• Performance assessed on 20
quality, satisfaction metrics• Payment withhold commences
at 1% in FY 2013, rises to 2%
by FY 2017
Inclusion of Medicare Spending per
Beneficiary metric in FY 2015
• All part A and B payments included during episode of care
• Includes transfers, readmits,
additional admits
Pay-for-Performance Payment Changes
• Distribution of HAC events
per 1,000 discharges in hospitals1
Based on 16,000 annua l
discharges, occurrence of 26+
HACs results in bottom
quartile performance,
Medicare payment penalty2
• Hospital Acquired Conditions (HAC) in FY2015
Fostering Payment Innovation
From 30,000 Feet: ACA as a Grand Experiment
6
8Affordable Care Act Sets in Motion Decade of Change
Source: Centers for Medicare and Medicaid Services; Health Care Adv isory Board interviews and analysis.
1) Value-Based Purchasing.2) Accountable Care Organization.
• Medicaid CapitationPilot Operation
2010
• Shared Savings Program
• (Early Adopters)
• Hospital VBP1
(Phase 1: Quality)• Hospital VBP
(Phase 2: Efficiency)
• Readmission Penalties for Poor Performers
• Pediatric ACO2 (Shared Savings) Pilot
• Shared Savings Program
• (Competitive Pressure Expansion)
• Integrated Care Demonstration (Medicaid Episodic Bundling)
• National Episodic Bundling Pilot
• Payment Adjustments for Hospital Acquired Conditions
• Officially
Announced
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
The critical question--
• Will health care reform measures taken to reduce health care costs – HRRP, VBP, ACO, Bundled Payments --preserve quality, improve quality or hamper quality?
Reduce Costs Improve Quality
HRRP yes no
VBP yes ?
ACO ? ?
Hospital acquired conditions
yes ?
Bundled Payments
? ?
24
Conclusions
• Health care costs may be declining, i.e., the rate of growth in health care spending is slowing
• Improved access to care may not be fully realized
• The economics of US health care remain complex and convoluted
• We should subject major components of health care reform – HRRP, VBP, HAC, ACO and Bundled Payments- to the scrutiny used for new drugs and devices. “first do no harm…”
• The Affordable Care Act is an imperfect law. At what point do we challenge its imperfection?