EMR-based risk stratification plus increased support for highest-risk patients improves readmission rates in heart failure

Risk stratification using an electronic medical record (EMR) combined with the use of evidence-based interventions for patients at highest risk helped reduce readmissions for heart failure, a new study found.

Researchers at a teaching hospital in Texas performed a prospective controlled before-and-after study of adult inpatients with heart failure and those with two concurrent control conditions, acute myocardial infarction (MI) and pneumonia. They used a risk prediction model in an EMR-based software program, which extracts real-time clinical and nonclinical data from the patients' records in the first 24 hours after heart failure admission, to stratify 30-day readmission risk each day.

Patients deemed at highest risk for readmission were given intensive evidence-based interventions using existing hospital resources. The study's main outcome measure was readmission for any reason and to any hospital within 30 days of discharge. The study results were published online July 31 by BMJ Quality & Safety.

Eight hundred thirty-four patients were discharged with a diagnosis of heart failure during the preintervention period (Dec. 1, 2008, to Nov. 30, 2009), and 913 patients were discharged with a diagnosis of heart failure during the postintervention period (Dec. 1, 2009, to Nov. 30, 2010). In the concurrent control group, 637 patients were discharged with acute MI or pneumonia in the preintervention period and 597 were discharged in the postintervention period. The mean age in both the heart failure group and the control group was 58 years.

In the heart failure group, the unadjusted rate of 30-day readmission was 26.2% before the intervention and 21.2% afterward, representing a relative reduction of 19% (P=0.01). This decline was also seen in adjusted analyses (adjusted odds ratio, 0.73; P=0.01). Unadjusted readmission rates for acute MI and pneumonia, the concurrent control group, did not change after the intervention (15.5% before vs. 16.7% after; P=0.56); adjusted analyses also showed no difference (adjusted odds ratio, 1.09). The authors calculated that the number needed to treat ratio for heart failure patients in the postintervention period was 20.

The trial was not randomized or double-blind, took place in only one safety-net hospital, and did not examine cost-effectiveness. In addition, among other limitations, data on heart failure patients in other nonintervention hospitals were not available, the authors noted. However, they concluded that their study provided “preliminary evidence” that stratifying risk and allocating resources using EMR-based tools can help reduce readmission rates in patients with heart failure.

“By concentrating care management efforts on about one-quarter of patients with [heart failure] we were able to demonstrate a 26% relative reduction in the odds of readmission and an absolute reduction of 5.0 readmissions per 100 index admissions,” they wrote. Future studies, they said, should examine the cost-effectiveness of this and similar approaches to allocation of resources.