Introduction
Today, one in six patients discharged from the U.S. hospital is readmitted in under 30 days (Cagliostro, 2022). Hospital readmissions impose a substantial financial burden on healthcare systems and increase patient morbidity and mortality. Congestive heart failure (CHF) is a significant public health concern affecting more than 5 million Americans annually. CHF is the most common cause of hospital readmissions among Medicare patients accounting for up to 25 percent of the total readmission rates and continues to be challenging (Madanat et al., 2021). In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Hospital Readmission Reduction Program (HRRP), intending to reduce the readmission rates by reducing payments to hospitals with higher-than-expected readmission rates following admission with heart failure (HF). Although, after the initiation of the HRRP, the readmission rates started to decline, the readmission rates in Illinois remain higher compared to national data statistics. According to the Illinois Department of Public Health (2022), in the state of Illinois, heart failure patients readmitted to the hospital within 30 days from a previous hospital stay accounted for 22.24 percent compared to the national average of 21.97 percent during the period from 2016-2019. Higher hospital readmission rates for HF in Illinois may indicate problems in the quality of care, transition of care, and management following discharge. The healthcare system aims to provide high-quality and effective care while decreasing healthcare costs. The research analysis is needed to understand how hospitals have reduced readmissions by utilizing national statistics and databases (Ferro et al., 2019).
Background and Significance
In 2012 heart failure accounted for more than $ 30 billion of US health care spending (Madanat et al., 2021). Each year, Medicare spends an estimated $17 billion or more on unplanned hospital readmissions. The direct cost burden is expected to increase by 240 percent ($68.9) billion by 2030. Hospitalization rates in patients with CHF are calculated to be 18 per 100,000, leading to 700,000 inpatient admissions per year. The cost of one day of hospitalization for acute HF is approximately $ 1800 (Bassor et al., 2013). With decreased 30-day readmissions, community hospitals potentially could have saved hundreds of thousands of Medicare dollars and hundreds of millions nationwide.
Nearly 1 in 4 CHF patients are readmitted to the hospital within 30 days, suggesting that about one-quarter of HF readmission may be preventable (Khan et al., 2021). Preventable hospital readmission within 30-days has drawn the attention of policymakers because they are associated with poor outcomes and high costs (Ferro et al., 2019). Thus, to reduce the rate of hospital readmissions, healthcare providers and other stakeholders must understand the cause and develop strategies promoting improvements in quality and care transitions among these populations.
Heart failure readmissions may be preventable in up to 50 percent of cases (Bassor et al., 2013). Factors contributing to preventable readmission include inadequate discharge planning, noncompliance with medications and diet, physician errors, inconsistent monitoring of patients in outpatient settings, and lack of education on the prevention of comorbidities and HF exacerbation. Non-clinical factors such as socioeconomic, health literacy, and health system failures also play a role in hospitalization and readmission in patients with HF (Madanat et al., 2021). Health literacy affects HF patients’ knowledge of the disease process, self-care management, proper diet, essential information, and services needed for appropriate decision-making. In addition, patients with low health literacy have trouble processing educational material and experience difficulties comprehending communication with their health care provider due to anxiety, cognitive impairment, or language barrier (Becker et al., 2021). Financial difficulties are another factor that plays a role in hospital readmissions by limiting adherence and compliance with medications, self-monitoring, and follow-up, which lead to worsening of the patient’s health condition (Al-Tamimi et al., 2021). Providing adequate discharge instructions, educating regarding HF monitoring, and providing patients with appropriate, affordable resources have shown to decrease readmission rates, yet these valuable strategies are underutilized.
Methods
Sponsored by the Agency for Healthcare Research and Quality (AHRQ) (2022), the Healthcare Cost and Utilization Project (HCUP) are a family of healthcare databases that enables researchers and other stakeholders to study and analyze healthcare delivery and patient outcome over time at the national, regional, state and community levels. Within HCUP, the Nationwide Readmission Database (NRD) is designed to support various analyses of national readmission rates using information from the HCUP. These data sets allow health care providers and other stakeholders to identify trends, patterns, and individual factors to answer critical clinical questions and expedite decision-making (Weiss & Jiang, 2021). In addition, the database includes data from all payers and the uninsured, which makes it a unique source of information to study the impact of the HRRP on nationwide readmissions across all insurance types. It contains data on primary discharge diagnosis codes, patient demographics, the length of stay, and hospital costs. For the paper’s analysis, the relationship between expected payers such as Medicaid, Medicare, private insurance, self-pay and readmission rates among patients with CHF will be examined to identify the target population with the highest readmission rates. The goal is to find if any association exists between hospital readmission rates and expected payers, distribution costs, and length of hospital stay, particularly in patients with CHF.
Results
Table 1: Top 4 diagnoses of 30-day all-cause adult hospital readmissions (2018)
| Diagnosis | # Of Readmissions |
| Septicemia | 314,600 |
| Heart Failure | 233,100 |
| Diabetes | 122,400 |
| COPD | 106,300 |
Table 1 presents the top 4 diagnoses at index admission with the highest number of 30-day all-cause hospital readmission in adults. When evaluating the most common hospital stays due to readmission, HF at index admission had one of the highest 30-day all-cause readmissions (233,100), followed by septicemia, the leading cause of hospital readmissions.
Table 2: Percentage of heart failure patients readmitted to hospital within 30 days (time frame 2016-2019)
| Entity | Readmission Rates |
| National Average | 21.97% |
| Illinois State | 22.24% |
Readmission rates show whether a hospital is doing its best to prevent complications, teach patients at discharge, and ensure patients make better home transitions. Table 2 shows the all-cause 30-day readmission rates for patients discharged from a previous hospital stay for HF on national and state (IL) levels. As demonstrated above, patients with HF in Illinois have slightly higher readmission rates than national statistics.
Table 3: Hospital inpatient statistics for heart failure patients
| Entity | Age (mean) | Average Length of Stay (LOS), days | Median Length of Stay (LOS), days | Median $ charge per patient |
| National | 72.09 | 6.2 | 5 | 15,879 |
| Illinois | 74.48 | 5 | 3 | 19,606 |
According to the data in Table 3, there is no difference in the mean age of patients with HF admitted to the hospitals between Illinois and national levels. However, a significant difference in LOS is found when one compares the LOS between U.S. hospitals and the State of Illinois. The average LOS on the national level is relatively long in comparison to Illinois. Looking at the state and federal median charges for inpatient stay related to CHF hospitalization, it becomes evident that the median payment per patient in Illinois is much higher than national statistics despite the shorter duration of hospital stay. These are significant findings regarding cost and possible health outcomes.
Table 4: 30-day all-cause adults hospital readmissions for heart failure by expected payer (2018)
| Type of Insurance | Number of index admissions | 30-day readmissions Rank | 30-day readmissions Number | 30-day readmissions Rate |
| Medicare | 775, 900 | 2 | 178,000 | 22.9 |
| Medicaid | 110,000 | 4 | 30,800 | 28.0 |
| Private Ins. | 89,400 | 2 | 15,800 | 17.6 |
| Self-pay | 27, 900 | 5 | 5,100 | 18.2 |
Exploring the type of insurance and number and rate of 30-day readmission for a patient with HF yields valuable information in potential indicators for the likelihood of 30-day all-cause hospital readmissions for HF patients. Heart failure was among the top conditions at index admission, with the most readmissions for each expected payer: Medicare (7.8%), Medicaid (4.3%), private insurance (2.8%), and self-pay (3.7%). Patients with Medicare are among the highest group among expected payers with the highest number of readmissions (178 000).
Table 5: Hospital cost for heart failure patients by expected payer (2017)
| Insurance Type | Aggregate Hospital costs, $, millions | Aggregate Hospital costs, % | Number of Hospital stays, thousands |
| Medicare | 9,397 | 4.6 | 806 |
| Medicaid | 1,613 | 1.9 | 112 |
| Private Insurance | 1,941 | 1.6 | 121 |
| Self-pay | 338 | 2.4 | 32 |
Examining the relationship between the payer type and the amount of spending per hospital stay for patients with HF provided interesting findings. Heart failure was one of the most expensive conditions during the hospital stays expected to be paid for by Medicare, Medicaid, private insurance, and self-pay. Among all four expected payer groups, Medicare had the highest hospital costs compared to other payers.
Strengths and Limitations
For hospitals looking for ways to reduce readmission rates, it is helpful to learn more about societal and demographic factors that may increase the risk of readmission for patients (Walker, 2018). Assessing these factors leading to hospital readmissions allows for meaningful use and application to clinical practice. For example, a look at different types of insurance shows that a patient’s health insurance type correlates with hospital readmissions. In this instance, Medicare and Medicaid patients are more likely to experience higher rates of readmission and aggregated hospital costs for heart failure compared to patients with private insurance. Part of this can be explained by the fact that Medicare patients generally cover older patients who are more likely to have a higher risk for chronic health conditions and disease exacerbation. In addition, differences in data on readmission rates for HF patients, the lengths of hospital stay, and median charges per patient between U.S. hospitals and hospitals in Illinois may cause one to conclude that some hospitals are doing much better than others. Thus, research is needed to identify factors that contribute to a decrease in hospital readmissions among HF patients and learn from other hospitals’ experiences in such matters.
One of the disadvantages of the data derived from HCUP of NRD is the variation in participating states each year, as evidenced by the above data derived from the time frame between 2016-2019 (AHRQ, 2022). The lack of current data limits the ability to make changes in everyday practice by neglecting to account for current and evolving factors affecting hospital readmission rates at the national and state levels.
Discussion
According to the report findings, readmission for HF following an inpatient hospitalization is common and costly. Based on HCUP data analysis, Medicare patients and patients over 72 years of age and older are found to be more likely to be readmitted to the hospital for all-cause HF. Privately and self-pay insured patients had the lowest aggregate readmission rates. In addition, Medicare had the highest hospital aggregated costs compared to other payers. According to the American Journal of Nursing (2021), the contributing factors to higher readmission rates among Medicare patients compared to other groups is due to life spans and comorbidities. For example, by 2017, hypertension was present in 91.4 percent of Medicare patients, diabetes in 48.9 percent, and lipid disorders in 53.1 percent.
Notably, despite the initiation of HRRP and the decline in national readmissions in Medicare since 2012, Illinois showed a higher rate of readmissions for CHF patients than national statistics. Higher rates of hospital readmissions in Illinois may suggest problems in the quality of care, transition of care, and management following discharge among targeted populations. The high readmission rate for CHF in Illinois can also result from the short length of original hospital stay compared to national data. However, the observational studies did not support a reasonable concern about early discharge leading to readmission (Alper et al., 2022). Thus, one must investigate what strategies were implemented in other hospitals to reduce the occurrence of hospital readmissions among targeted populations and help reduce health care costs.
Practical strategies for preventing HF readmissions should include interventions across a full continuum of care from hospital to outpatient healthcare settings and homes (Chamberlain, 2018). There are many strategies implemented in the past and employed with varying degrees of effectiveness. Adequate discharge instructions, appropriate medication dose teaching, education regarding HF monitoring, follow-up telephone calls, coordinated care between inpatient and outpatient providers, and strict follow-up have decreased readmission for HF patients. Still, these strategies are surprisingly not often utilized by healthcare organizations across the U.S. (Basoor et al., 2013). The study by Basoor et al. (2013) conducted a prospective randomized controlled trial involving 96 inpatients with CHF. Among those patients, 48 patients were provided with a checklist at discharge that included appropriate counseling, medication education, and follow-up instruction. In contrast, the other half of those patients were discharged without instructions. Patients who received the CHF discharged checklist had higher rates of outpatients and medication compliance and reduced 30-day readmission rates than those who did not receive the appropriate discharge checklist.
According to Becker et al. (2022), communication interventions at discharge are associated with fewer hospital readmissions, improved treatment adherence, and improved patient satisfaction. While several factors influence the risk of hospital readmissions, shortcomings in educating patients at hospital discharge may be one of the main modifiable factors. Thus, communication strategies addressing patient knowledge in the transfer of care may improve patient adherence, leading to better outcomes. In addition, communication interventions at discharge can enhance the quality of care and be considered cost-effective.
Healthcare providers are uniquely positioned to improve patient outcomes by examining and analyzing patient data and trends on local and national hospital readmission rates. This data is vital as it can give insights to see which factors will impact future health outcomes and develop appropriate policies and interventions.
Conclusion
Congestive heart failure is the most common cause of hospital readmissions in the United States. Although with the initiation of the HRRP in 2012, the readmission rates started to decline, the readmission rates in Illinois remain higher compared to national statistics. Medicare patients are more likely to be readmitted to the hospital within 30-days of the previous hospitalization compared to other groups of payers. Identifying populations at risk for readmission can help to define opportunities to improve the quality of care, potentially leading to a decrease in readmissions.
Reducing hospital readmission rates represents a unique opportunity for health care providers and other stakeholders to improve the cost and quality of patient care. Identifying evidence-best practices to reduce hospital readmissions would likely improve unnecessary health care utilization and costs, promote patient centered-care, and increase value in the healthcare systems. For example, adequate discharge planning, patient education, medication reconciliation, scheduling a follow-up appointment before discharge, follow-up telephone calls, and coordinated care between inpatient and outpatient providers reduced CHF readmissions. Examining and analyzing patient data and trends on local and national hospital readmission rates is essential to see which factors will impact future health outcomes and develop appropriate interventions.
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