Readmissions: an unavoidable nemesis

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Readmissions: an unavoidable nemesis This presentation was presented at the Thoratec Corporation Economic Summit held on September 30-October 2 in La Jolla, CA.

1 Readmissions: an unavoidable nemesis This presentation was presented at the Thoratec Corporation Economic Summit held on September 30-October 2 in La Jolla, CA. Please note that this presentation and content thereof represents the ideas and opinions of the presenters, who are solely responsible for such content, and not necessarily those of 1 1 Thoratec Corporation. Margaret Murray, RN, DNP University of Wisconsin Hospitals and Clinics ma.murray@hosp.wisc.edu

2 Disclaimer This reimbursement information is intended to provide the health care professional with information related to billing, coding and reimbursement requirements that may apply to Thoratec products. It is being provided for general informational and educational purposes only, and is not intended, and does not constitute, reimbursement or legal advice. Use of codes identified here does not guarantee coverage or payment at any specific level and is not intended to increase or maximize payment by any payer. Laws, regulations and coverage policies are complex and updated frequently. In addition, reimbursement policies vary widely from insurer to insurer and will reflect different patient conditions. You should check the current law and regulations and insurer s policies to confirm the most current coverage, coding or billing requirements. Any questions should be directed to your attorneys or reimbursement specialist. The health care professional is responsible for all aspects of reimbursement, including using codes that accurately reflect the patient s condition, procedures performed, and products used and ensuring the veracity of all claims submitted to third party payers. 2

3 Presentation Overview Readmissions- admit vs. observation Statistics on readmission Readmission etiology Strategies 3

4 What is a readmission? Readmission: a)admission order requirements b) the certification requirement c) the 2-midnight benchmark 4 ( Programs/Medicare-FFS-Compliance-Program)

5 What is Observation? Observation status: a) Any pt with diagnosis R/O b) Can last up to 48 hours for Medicare c) Private insurance may cap at 24 hrs d) Utilizes a bed, requires periodic monitoring by nursing and necessary to evaluate pt s condition Can Convert from Observation to Admission 5 DecisionsGUIDELINES_April2007.pdf

6 Heart Failure Statistics 5 million people affected 1 in 9 deaths (all causes) $32 billion/year 6

7 Heart Failure Readmissions CMS reviewed all high cost and largest number readmissions (Medicare patients) 3.3 million pts readmitted with cost $41 billion Heart failure accounted for highest population readmitted 134,500 pts at cost of $1.7 billion 2011, AHRQ Payer.pdf 7

8 History of Readmissions in MCD pts REMATCH Readmissions frequent during study period both groups Rate 4.5/pt/year 8 Rose, et.al, (2001). Long-term use of a LVAD for end-stage heart failure. N Engl J Med 345:

9 HeartMate BTT trials BTT Study Median LOS 25 d Median days out of hospital 60d (0-418) 54 of 133 pts rehospitalized (40.5%) Median rehosp. 4 days Etiology rehosp.- AEs 38% reduction readmits from HM XVE to HM II DT Study Infection source of prolong index LOS and readmissions 9 Miller, LW et. al. (2007). N J Engl of Med. 357(9): Slaughter, M.S. et. al. (2009). Park, SJ et.al. (2012). Circulation: Heart Failure 5:

10 INTERMACS DATA ( ): ALL Causes Time Frame Episodes Rate Percentage < 3 months post index hospitalization > 3 months post index hospitalization < 30 DAYS post index hospitalization N/A N/A Device type # pts readmitted/# total episodes Percentage LVAD 576/ % BIVAD 13/ % TAH 9/ % 10

11 Planned vs. Unplanned In group of CF devices- 52% unplanned 1 Decrease survival with each unplanned admission Higher in DT group In group of CF devices 2-87% urgent 10% elective 3% life- threatening Smedira et.al. (2013). Unplanned Readmissions after HeartMate II implant. JACC: Heart Failure. 1(1): Forest et. al. (2013). Readmissions after Ventricular Assist Device: Etiologies, Patterns, and Days out of the Hospital. Ann Thor Surg. 95:

12 What do we know from Literature? Lead author Date pub Journal Yrs reviewed Forest 2013 Annals of Thoracic Surgery Smedira 2013 JACC: Heart Failure Hasin 2013 JACC: Heart Failure Tsiouris 2014 Journal of Heart and Lung Transplant Haglund 2015 ASAIO Number of pt BTT or DT 92 BTT and DT 118 BTT and DT Hospital Montefiore Medical Center Cleveland Clinic 115 BTT Univ. of Minnesota 150 BTT and DT Henry Ford Hospital 81 BTT Vanderbilt University 12

13 Hospital Readmissions After Continuous-Flow Left Ventricular Assist Device Implantation: Incidence, Causes, and Cost Analysis Shahab A. Akhter, MD, Abbasali Badami, MBBS, Margaret Murray, RN, DNP, Takushi Kohmoto, MD, PhD, Lucian Lozonschi, MD, Satoru Osaki, MD, PhD, and Entela B. Lushaj, MD, PhD Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 13 Akhter, et.al, (2015). Annals of Thoracic Surgery. Readmissions after CF LVAD Implantation

14 Our Patient Population All causes readmission All continuous flow device pts N= 122 (103 BTT pts and 19 DT)

15 Patient Demographic 93% pts were out of hospital Median index LOS= 17 days Readmitted Patient Group N=68 Average 2.2 admissions per pt Longer median VAD time 15

16 30 Day Readmission from Index Hospitalization N=30 (44%) Risk Factors: Older pts Less time on VAD Lower PA pressures 16

17 Most Common Readmission Diagnosis Overall Top Readmission Cause Gi bleed GI events Cardiac Infections 17

18 BTT vs. DT Readmissions BTT DT Highest time frame for readmits days Nonischemic-less readmits Younger age pts less readmissions Higher unplanned readmits Greater frequency of LVAD associated hemorrhage Medical management (comoribity) Infection readmits 18

19 Top 6 Readmission Etiologies Cardiac (fluid overload, RV failure, arrhythmias) GI bleeding Infection- both VAD (later) and non-vad related Pump thrombosis/ device complication Strokes Elective Procedures 19

20 Different Studies Readmission Etiology 30 days to 6 months 1-5 Cardiac 30-47% GI bleed 14-30% Other types of bleed 14-20% Infection (non-vad related % Infection (VAD related)4.3-22% Strokes 3-5.6% 1-5 : Tsiouris et.al. (2014); Hasin et.al. (2013); Akther et.al. (2015); Allen et.al., (2010); Haglund et.al. (2015), Dunlay et.al. (2014). 20

21 Beyond the First Year Year 2: cardiac (30%) bleeding (30%) Year 3: cardiac(30%) bleeding (30%) infection (22%) pump thrombosis (14%) elective procedure (4%) Hasin et. al. (2013) 21

22 70% Percentage of Readmissions Based on Time Frames 60% 50% 40% 30% 20% 10% 0% less 30 days 3 months 6 months 1 year 22

23 Number of Readmits Per Patient Per Year months 6 months > 18 months Number of readmits per patient/year 23 Range overall excludes REMATCH

24 Average Time Out of Hospital 93% Akther et.al., (2015); Forest et.al., (2013) 21,464/23,034 days 30,191/31,220 days 87% Allen et.al., (2010) 70% Hasin et.al. (2013); Tsiouris et.al. (2014) 24

25 Risk Factors for Readmission No risk factors identified GI bleed < 30 days Decreased hemoglobin at readmission Living farther away Device duration Longer CPB time Older BTT vs. DT Number PRBC transfused Preop BUN/Cr Not receiving inotropes 25

26 Readmission Prevention Etiology Younger Nonischemic etiology BTT Higher BNP Higher Hemoglobin at admission Closed aortic valve 26

27 Complication associated with survival PRBC associated with decrease overall survival Time frame of transfusion does not matter Correlation 27 Smedira et.al., 2015

28 Survival Post Readmission % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 30 d 6 month 1 yr 2 yr 3 yr Readmit pts Non-readmit pts 28

29 Longest Readmission Etiology Etiology GI bleed Cardiac AKI Stroke Infection Other Median 7.5 days 13.2 days 6 days 5 days 5 days 11.7 days 29

30 Cost Based on Etiology of Readmission Cost Per readmission Etiology $7,546 (all causes) $111,925 Pump thrombosis $53,130 Cardiac $31,181 Stroke $11,886 Bleeding (all cause) $11,506 Infection (mostly driveline) 30

31 Medicare Payment for Readmission Types Cost Per readmission Unadjusted Medicare Base Payment Etiology $7,546 (all causes) (all causes) $111,925 Pump Replacement: $155,763 Pump thrombosis Cardiac Procedure: $75,570 $53,130 Heart Failure Admit: $16,120 Cardiac $31,181 Stroke: $ Stroke $11,886 GI Procedure: $ Bleeding Admission: $ Bleeding (all cause) $11,506 Infection: $ Infection procedure: $ Infection (mostly driveline) W upda am 31

32 Prevention strategies 32 Haglund et. al., 2015, p. 415

33 Readmissions Necessary to manage some patients Complex and multifactorial Burden to patient and healthcare system, but not without associated payment to the provider Prevention 33

Complications of Left Ventricular Assist Device Chronic Support. Dr. Tal Hasin RMC, Beilinson, Petach-Tiqva, Israel

Complications of Left Ventricular Assist Device Chronic Support. Dr. Tal Hasin RMC, Beilinson, Petach-Tiqva, Israel No disclosures Probability of survival Survival (%) Survival with LVAD Destination Bridge