One quarter of older patients admitted for heart failure are readmitted within 30 days of discharge, resulting inincreased morbidity for seniors and high healthcare costs. In an effort to reduce the readmission rate, a risk-standardized hospital readmission rate for heart failure is now publicly reported, and health reform proposals include penalties for hospitals with high readmission rates. Yet despite this intense public interest, the phenomenon of readmission is poorly understood, and risk-standardized readmission rates vary widely among hospitals. Since quality of hospital, transitional and post-discharge care plays an important role in readmission risk;we approach this problem from a systems perspective. My long-term goal is to develop a research career dedicated to improving healthcare systems at the local, regional and national level so that they maximize care quality, patient safety, coordination and communication for older patients. The goals of this proposal are to build my skill set in this area, acquire data for hypothesis testing and future interventions, and to expand my mentoring relationships to encompass geriatric and transitional care experts. The specific career development aims are: (1) to build a foundation of geriatric and aging-related knowledge;(2) to develop expertise in quality assessment in multiple domains using a variety of techniques;(3) to gain experience in the use and analysis of Medicare claims data, and in the integration and merging of a diverse group of large datasets;and (4) to develop advanced expertise in organizational behavior, human ergonomics, systems analysis and other techniques necessary for building safe and patient-centered healthcare systems. I will accomplish this through a combination of coursework, mentorship and research activities. The research goal of this proposal is to develop a better understanding of the modifiable healthcare delivery factors that have an impact on readmissions for geriatric patients. The specific research aims are: (1) to compare clinical, transitional, and post-discharge care for older patients with heart failure admitted to hospitals in the top, middle and bottom ten percent of readmission rates nationally;(2) to describe the etiology and preventability of readmissions in patients admitted to these hospitals;(3) to determine the proportion of variation in risk-standardized readmission rates for heart failure attributable to hospital referral region characteristics;and (4) to identify regional characteristics that are associated with readmission rates for older patients admitted with heart failure. My mentorship team includes experts in heart failure readmissions and quality measurement (H. Krumholz, E. Bradley), and an expert in multi-factorial geriatric conditions (M. Tinetti). Relevance: Older patients have a disproportionately high risk of readmission after hospital discharge and are particularly vulnerable to inadequate healthcare systems. This study is intended to identify the areas in which clinicians, hospitals, and the healthcare environment have influence over readmission rates, in order to develop targeted, high-impact interventions to reduce morbidity in older patients after the hospital-to-home transition.

Public Health Relevance

One quarter of patients admitted for heart failure (HF) are readmitted within 30 days of discharge. Since older patients are at high risk for adverse events during hospitalizations, and since re-hospitalizations alone cost the healthcare system over $17 billion a year, it is highly desirable to avoid readmissions by keeping patients healthier. This study is intended to determine what influence clinicians, hospitals, and the broader healthcare environment have over readmission rates, in order to develop targeted, high-impact interventions to help keep older patients with HF safe at home instead of back in the hospital.

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Clinical Investigator Award (CIA) (K08)
Project #
5K08AG038336-04
Application #
8527660
Study Section
Special Emphasis Panel (ZAG1-ZIJ-4 (A1))
Program Officer
Salive, Marcel
Project Start
2010-09-30
Project End
2014-08-31
Budget Start
2013-09-01
Budget End
2014-08-31
Support Year
4
Fiscal Year
2013
Total Cost
$169,439
Indirect Cost
$12,551
Name
Yale University
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
043207562
City
New Haven
State
CT
Country
United States
Zip Code
06520
Horwitz, Leora I; Lin, Zhenqiu; Herrin, Jeph et al. (2015) Association of hospital volume with readmission rates: a retrospective cross-sectional study. BMJ 350:h447
Bradley, Elizabeth H; Sipsma, Heather; Horwitz, Leora I et al. (2015) Hospital strategy uptake and reductions in unplanned readmission rates for patients with heart failure: a prospective study. J Gen Intern Med 30:605-11
Butala, Neel M; Johnson, Benjamin K; Dziura, James D et al. (2015) Association of inpatient and outpatient glucose management with inpatient mortality among patients with and without diabetes at a major academic medical center. J Hosp Med 10:228-35
Al-Damluji, Mohammed Salim; Dzara, Kristina; Hodshon, Beth et al. (2015) Hospital variation in quality of discharge summaries for patients hospitalized with heart failure exacerbation. Circ Cardiovasc Qual Outcomes 8:77-86
Bikdeli, Behnood; Strait, Kelly M; Dharmarajan, Kumar et al. (2015) Intravenous fluids in acute decompensated heart failure. JACC Heart Fail 3:127-33
Dharmarajan, Kumar; Hsieh, Angela F; Kulkarni, Vivek T et al. (2015) Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort study. BMJ 350:h411
Horwitz, Leora I; Masica, Andrew L; Auerbach, Andrew D (2015) Introducing Choosing Wisely®: Next steps in improving healthcare value. J Hosp Med 10:187-9
Salim Al-Damluji, Mohammed; Dzara, Kristina; Hodshon, Beth et al. (2015) Association of discharge summary quality with readmission risk for patients hospitalized with heart failure exacerbation. Circ Cardiovasc Qual Outcomes 8:109-11
Horwitz, Leora I; Grady, Jacqueline N; Cohen, Dorothy B et al. (2015) Development and Validation of an Algorithm to Identify Planned Readmissions From Claims Data. J Hosp Med 10:670-7
Fogerty, Robert Lawrence; Rizzo, Tara Michelle; Horwitz, Leora Idit (2014) Assessment of internal medicine trainee sign-out quality and utilization habits. Intern Emerg Med 9:529-35

Showing the most recent 10 out of 45 publications