Centers for Medicare and Medicaid Services’ readmission reports inaccurately describe an institution's decompensated heart failure admissions

• Published in: Clinical cardiology (Mahwah, N.J.) N.J.), 2017-09, Vol.40 (9), p.620-625
• Main Authors: Cox, Zachary L., Lai, Pikki, Lewis, Connie M., Lenihan, Daniel J.
• Format: Article
• Language: English
• Subjects: Academic Medical Centers; Aged; Aged, 80 and over; Centers for Medicare and Medicaid Services, U.S. - standards; Female; Heart failure; Heart Failure - classification; Heart Failure - diagnosis; Heart Failure - therapy; Heart failure/cardiac transplantation/cardiomyopathy/myocarditis; Humans; International Classification of Diseases; Male; Medicaid; Medicare; Patient admissions; Patient Readmission - standards; Process Assessment, Health Care - standards; Quality and Outcomes; Quality Indicators, Health Care - standards; Reproducibility of Results; Retrospective Studies; Tennessee; Terminology as Topic; Time Factors; United States
• ISSN: 0160-9289; 1932-8737
• DOI: 10.1002/clc.22711

Hospitals typically use Center for Medicare and Medicaid Services’ (CMS) Hospital Readmission Reduction Program (HRRP) administrative reports as the standard of heart failure (HF) admission quantification. We aimed to evaluate the HF admission population identified by CMS HRRP definition of HF hospital admissions compared with a clinically based HF definition. We evaluated all hospital admissions at an academic medical center over 16 months in patients with Medicare fee‐for service benefits and age ≥65 years. We compared the CMS HRRP HF definition against an electronic HF identification algorithm. Admissions identified solely by the CMS HF definition were manually reviewed by HF providers. Admissions confirmed with having decompensated HF as the primary problem by manual review or by the HF ID algorithm were deemed “HF positive,” whereas those refuted were “HF negative.” Of the 1672 all‐cause admissions evaluated, 708 (42%) were HF positive. The CMS HF definition identified 440 admissions: sensitivity (54%), specificity (94%), positive predictive value (87%), negative predictive value (74%). The CMS HF definition missed 324 HF admissions because of inclusion/exclusion criteria (15%) and decompensated HF being a secondary diagnosis (85%). The CMS HF definition falsely identified 56 admissions as HF. The most common admission reasons in this cohort included elective pacemaker or defibrillator implantations (n = 13), noncardiac dyspnea (n = 9), left ventricular assist device complications (n = 8), and acute coronary syndrome (n = 6). The CMS HRRP HF report is a poor representation of an institution's HF admissions because of limitations in administrative coding and the HRRP HF report inclusion/exclusion criteria.