BOSTON—Disparities are rampant in heart failure care, Karen E. Joynt, MD, MPH, of the Harvard School of Public Health and Brigham and Women’s Hospital in Boston, said during a presentation Sept. 19 at the 15th annual Heart Failure Society of America (HFSA) scientific meeting. When it comes to monitoring and reporting readmission rates, patient and community factors are forgotten and measurements center instead on the hospital and its practices.

While HF care has improved over the last decade, black patients have higher HF readmissions than whites. Hispanics also have higher readmission rates compared with whites. Additionally, underserved populations such as those on Medicaid see higher HF readmissions compared to those who hold private insurance. “Patients on Medicaid have strikingly high readmission rates,” Joynt offered.

Joynt noted that there are attribution problems within the system. “We must ask why these disparities happen and how we can get around them,” she said. “How can we attribute these types of problems?” Hospitals see variability in terms of outcomes, “some perform well and some perform poorly,” Joynt offered. “While we think EMRs might help, or follow-up might help, we still don’t know how this will help the overall underserved patient populations.

“Do hospitals impact disparities?” she asked. Previous research reporting hospital variability showed that hospitals in Oxford, Miss., had a three-fold difference between HF readmissions compared to Odgen, Utah. Joynt offered that the availability of care, the fragmentation of care, health information exchanges and the way the environment and neighborhoods are built may lead to poorer outcomes.

Additionally, Joynt looked at whether there are problems within the current policies. “Do our policies match our clinical goals given the complex situations at hand?” she asked. Currently, she said that the new federal readmission policies may be penalizing hospitals more severely than anticipated. But who are those being penalized? Minority serving hospitals and hospitals with fewer financial and clinical resources, she said.

“Are hospitals responsible for readmission rates?” Joynt asked.

“While there are some things in a hospital's control—inpatient treatments, scheduling and outpatient follow-up—factors beyond a hospital’s control include patient resources and compliance, family support and a patient’s ability to afford medications.”

To get around these types of issues that are out of a hospital's control, hospitals could implement better discharge planning, create transitional care programs and strengthen the links to outpatient resources.

By incentivizing the behavior desired from hospitals, the policies may actually limit hospitals from doing the best they can for their patients, Joynt said.

“Be mindful of disparities,” she said. “What we are doing is essentially asking different hospitals to do vastly different work. 

“Do we really know what is effective?” Joynt asked. “Readmissions are not dropping. Do we really know what strategies are effective to gain improvements in readmissions across the board?

“We have a number of problems with readmissions, particularly how they relate to patients across vulnerable groups,” Joynt concluded. Comorbidities, health literacy and community issues such as poverty and access to care should be taken into consideration when reporting hospital HF readmission rates.