Facility Variation in Heart 

Failure Readmissions

Chuan-Fen Liu, PhD MPH

HERC Cyber Seminar

January 16, 2013

1 
Acknowledgement 

• Funded by VA Health Services Research and 

Development Service (IIR-09-354)

• Study Team

– Seattle: Chuan-Fen Liu, PhD; Paul Hebert, PhD; 

Chris Bryson, MD; David Au, MD; Stephan Fihn, MD; 

Edwin Wong, PhD; Mark Perkins, Pharm D; Pam 

Green, PhD; Jeff Todd-Stenberg; Margaret 

Nordstrom, MA; Jaclyn Lemon, BS

– Durham: Matt Maciejewski, PhD

– Los Angeles: Elizabeth Yano, PhD

– Iowa City: Peter Kaboli, MD

– Palo Alto: Paul Heidenreich, MD

2 
Outline

Background

Objectives

Methods

Preliminary Results

 Heart failure readmission rates and costs

 Facility variation in health failure readmissions

3 
Organizational Factors Related to 

Hospital Readmissions

Aim 1: Assess variation in hospital-level 

readmission rates and costs among VA 

inpatients, including both VA and Medicare 

readmissions, for the two most common 

medical conditions: heart failure (HF) and 

chronic obstructive pulmonary disease (COPD) 

Aim 2: Identify VA hospital-level organizational 

factors associated with readmissions

4 
Policy Issues

• Hospital readmissions are frequent, costly and 

reflect poor quality of care

• 30-day readmission rate in Medicare 

– Overall: 20%

– HF: 25%

• Public reporting of Medicare readmission rates 

for HF, acute myocardial infraction, and 

pneumonia began in 2009

– VA hospitals included Medicare Hospital Compare in 

2011

• Medicare reimbursement penalty for excessive 

readmissions under Affordable Care Act began in 

2012

5 
Readmission Rates in VA

• Kaboli et al (2012): 30-day readmission rates 

decrease over time 

– Overall: 16.5% in 1997-1998 to 13.8% in 2009-2010

– HF cohort: 20.5% in 1997-1998 to 19% in 2009-2010

• Heidenriech et al (2010): Improved HF hospital 

mortality, but slightly worsened HF readmission 

rates during 2002-2006

• VA Hospital Compare 

– HF 30-day readmission rate: 20.81% for over 65 years 

old in FY2007-2009

• Include readmissions in VA only

6 
Reduce Hospital Readmissions 

• Effective Interventions

– Discharge Planning

– Patient Education

– Post-Discharge Management

• CHF QUERI: Hospital to Home Initiative 

(H2H)

• Debate over preventability of readmissions

7 
Objective for Today’s Talk

• Estimate the HF readmission rates and 

costs, accounting for readmissions in VA and 

Medicare

• Examine facility variation in HF readmission 

rates

8 
Study Design

• Retrospective cohort study of HF inpatients

• Study Periods

– Three cross-sectional patient cohorts identified 

in FY2007, 2008, and 2009

– One year follow-up period for each cohort

9 
Data Sources

• VA Administrative Data

– Patient Treatment File, Outpatient Encounter 

Files, Fee-Basis File, Vital Status, DSS National 

Extracts (inpatient, outpatient, lab, pharmacy), 

CDW vital records

• Medicare Claims

– MedPAR, Carrier, Hospital Outpatients

• Facility Surveys of CHF Practices 

– Conducted by CHF QUERI in 2008

10
Study Samples

• Patient identification specification based on 

Medicare HF readmission performance measure

• Identify patients with an index admission in VA 

hospitals based on principle discharge diagnosis

– ICD-9 codes: 402.01, 402.11, 402.91, 404.01, 

404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 

and 428.xx

• Index admission: 1st admission in a VA facility for 

each patient in a given year

11
Outcomes – Readmission Rates

• Readmission

– 1st hospitalization after the index admission

• Readmission rates

– All-cause and HF specific

– Main outcome: 30-day all-cause readmission rate

– Secondary outcomes: 60-day, 90-day, 1-year

• Source of readmissions

– VA 

• VA hospitals 

• Non-VA care via fee-basis (in process)

– Medicare

12
Outcomes – Readmission Costs

• Includes costs of all readmissions in 1 year 

after the index admission

• Payers’ perspective:

– VA expenditures 

• DSS costs for VA care

• VA payments for non-VA care (in process)

– Medicare payments

• VA only and total (VA + Medicare)

• In 2009 dollars: inflation adjusted using 

Consumer Price Index

13
Patient Characteristics

• Sociodemographic: age, gender, race, marital 

status, income means test, disability rating

• Access to VA care: distance to the closest VA 

hospital/clinic

• Health Status: comorbidity (DCG), BMI

• Health Behavior: medication adherence, BMI 

• Clinical Factors (lab results and vital signs): 

blood pressure, respiratory rate, heart rate, 

sodium level, blood urea nitrogen, glucose, O2

saturation, PO2, PCO2

14
Analytical Approaches

• Descriptive analysis

• Adjusted readmission rates at the hospital 

level using the hierarchical models 

– GLIMMIX in SAS

– Medicare HF readmission model

• Adjust for age, gender, 35 HCC categories from DCG 

• Further analysis

– Alternative risk adjustment measures

– Cost model – two-part model

15
Preliminary Results

16
HF Cohort 2007

Aliv e at discharge, n=14,834

Met a broad definition of heart 

failure admission, n=20,451

Does not meet strict CHF 

criteria (n=1,332)

Death during index (n=458)

has FY07 index CHF 

admission, n=15,292

Institutionalized or nursing home 

patients (n=1,322)

Community liv ing, n=19,129

Cohort matching diagnosis 

criteria, n=17,797 Not "v alid" index admission 

(transferred, discharged AMA, 

admitted in a non-VA hospital) 

(n=2,505)
Readmission Status in 1 Year

2007 (n=14,834)

2008 (n=14,707)

2009 (n=15,412)

Able to be readmitted, 

n=39,158

 

 

Readmitted for any 

cause in VA or 

Medicare, 70.1%

No readmission at 

1-year , 29.9%

 

 

First readmission

in VA, 83.2%

 First readmission

in Medicare, 16.8% Death, 19.5%

 

 Alive, 80.5%

 
Patient Characteristics

Patient 

Characteristics

Readmission* 

(n=10,488) 

No readmission*

(n=4,346) 

Age (mean/SD) 71.1 (11.3) 70.1 (11.7)

≥65 years old (%) 67 61

Female (%) 2 2

Receive free VA care (%) 96 93

Medicare eligible in 2007 (%) 78 70

Mortality in 1 year (%) 32 21

DCG score (mean/SD) 2.6 (1.2) 2.3 (1.1)

Comorbid conditions

 Hypertension (%) 88 85

 Ischemic heart disease (%) 75 64

 Myocardial infarction (%) 21 15

 Diabetes (%) 58 53

 COPD (%) 52 46

19

*1-year readmission in VA or Medicare

2007 cohort
Unadjusted Readmission Rates

80.0%

70.0%

70.7%

60.0%

7.5%

50.0%

40.0%

44.9%

36.9% 5.6%

30.0%

4.8%

34.2%

63.2%

Medicare

VA only

20.0%

2

3.

5 % 25.5%

8.8%

6%

.0

20.3% 7.0%

10.0%

39.3%

32.1%

21.4%

1

4.

3

6%

.2% 5.7%

25.4%

0.0%

18.4% 14.6%

8.6%

30-day 60-day 90-day 1-year 30-day 60-day 90-day 1-year

All-Cause

Type of Readmissions

Heart Failure

Readmission Rate

20

2007 cohort
Number of Readmissions

in One Year

2.5 

2.3

2 0.6

1.5 

1 

1.1

1.7 0.5

Medicare

VA only

0.5 

0 

0.6

All-Cause Heart Failure

1-year

Type of Readmissions

Number of Readmissions

21 2007 cohort
Unadjusted Readmission Costs

$35,000 

$30,000 

$

$

3

6,

0,

191 

573

tsoC no $25,000 issimad $20,000 ean R $15,000 Medica

VA

e

e

$11,121

 onl

r

$10,000 

$24,363 

$2,054 

y

M

7,937

$5,000 $

$

4

772 

,362

$

$1,431 

$9,067 

 $- 

$6,505 

3

$

0

3,

-

590 

day 60

T

-d

y

a

p

y 

e of Readmissi

9

o

0

ns

-day 1-year

2007 cohort

22
Facility Level Readmission Rates

23
Facility Level Readmission Rates 

30-day Total All-cause 30-day Total HF Specific

Number

Unad

R

jus

ea

te

d

d

m

 

ission Ra

Ad

t

jus

e*

ted Unad

R

jus

ead

te

mi

of (n=120) (

d

n

Patients

ean

(n= 127) 

ssion Rate*

=120)

Adjusted

117 (83)

nge 

24.5% 24.1% 12.7% 12.5%

th

in – max) 1 - 543 12.5%

 percentile 

 percentile 

56 21

-

%

39.8% 13.5

2

%

1.

-

1

3

%

7.2% 3.0

1

%

0

-

.

2

6

3

%

.1% 4.3%

10

-

.9

2

%

1.7

th

th percentile 

104 24.8% 23.1% 13.0% 12.1%

160 27.5% 26.8% 15.0% 13.1%

*Exclude 7 facilities with fewer than 25 patients

M

Ra

(m %

25

50

75

24

2007 cohort
Higher readmission rates at the facility 

level after including Medicare data 

(unadjusted)

25 2007 cohort
Stabled readmission rates overtime a

facility level (unadjusted)

t 

26
All-cause Readmission Rates

Number

of 

Patients

(n= 127)

30-day Total All-cause 

Readmission Rate*

(n=120)

30-day HF Specific

Readmission Rate*

(n=120) 

Unadjusted Adjusted Unadjusted Adjusted

Mean 117 (83) 24.5% 24.1% 12.7% 12.5%

Range 

(min – max) 1 - 543 12.5% - 39.8% 13.5% - 37.2% 3.0%-23.1% 4.3% -21.7%

25th percentile 56 21% 21.1% 10.6% 10.9%

50th percentile 104 24.8% 23.1% 13.0% 12.1%

75th percentile 160 27.5% 26.8% 15.0% 13.1%

27

*Exclude 7 facilities with fewer than 25 patients

2007 cohort
Adjusted 30-Day All-cause Readmission 

Rates

28 2007 cohort
HF Specific Readmission Rates

30-day Total Readmission Rate* 30-day HF Specific

Number (n=120)

of 

Patients

(n= 127) Una justed d d A justed

n

Unad

R

jus

ead

te

m

(

d

n

ission Rate

=120)

Adjus

*

ted

117 (83)

ge 

24.5% 24.1% 12.7% 12.5%

– max) 1 -

5

5

6

43 12.5% -

21%

39.8% 13.5

2

%

1.

- 37.2% 3.0%-23.1% 4.3% -21.7

 percentile 

 percentile 

1% 10.6% 10.9%

 percentile 

104 24.8% 23.1% 13.0% 12.1%

160 27.5% 26.8% 15.0% 13.1%

xclude 7 facilities with fewer than 25 patients

Mea

Ran

(min %

25th

50th

75th

29

*E

2007 cohort
Adjusted 30-Day HF Specific 

Readmission Rates

30 2007 cohort
Summary

• Accounting for VA only readmissions 

underestimates readmission rates and costs, 

especially for HF specific readmissions

• 25% were readmitted in 30 days and 70% 

were readmitted in one year

• Wide variation in readmission rates across 

VA hospitals

31
Next Steps

• Complete readmission rates and costs for 

HF cohorts

• Combine facility surveys and patient level 

data to examine organizational factors 

associated with HF readmissions 

32