Post-Discharge Appointment for Heart Failure Patients

ACP does not support NQF measure #2439: “Post-Discharge Appointment for Heart Failure Patients.” This measure is appropriately specified to assess performance at the level of the facility and implementation will counteract the unintended consequences of the re-admission measures. Unlike the re-admission measures, this measure will likely decrease length of stay for patients who are appropriately readmitted for acute exacerbations of heart disease. Also, this measure will likely encourage facilities to participate with their referral base. In contrast to other care coordination measures that only require documentation of the referral to fulfill the measure requirements; this measure is appropriately specified to encourage facilities to close the referral loop. While this measure is a step in the right direction towards reducing preventable readmissions, it may be ineffective as a quality measure. Programs directed at shared savings from lower utilization of hospital services might be more successful in reducing admissions than programs initiated to date. Furthermore, we note several suggestions for developers to consider when they submit the measure to NQF for re-endorsement. First, we encourage facilities to distribute referrals equally so as to avoid placing undue burden on a select number of clinicians who manage patients during the recovery period. Second, there is insufficient evidence to identify the most appropriate follow-up location (e.g., PCP office vs. HF clinics). While developers cite clinical guideline recommendations to form the basis of the measure, the evidence on which the recommendations are based includes flawed studies that identify differences in impact depending on where the patient was seen. Without identification of an appropriate follow-up setting, implementation could promote overuse without clear benefit. Third, there is insufficient evidence to support the benefit of follow-up referrals without further intervention on improvements in clinical outcomes. Fourth, the numerator does not specify any scheduling requirements. It is unclear whether scheduling an appointment post-hospitalization satisfies the numerator requirements. If the patient schedules the followup appointment post-hospitalization, facilities may face challenges with obtaining detailed appointment information. Reliability results for data abstraction were fair, substantiating this concern. Fifth, successful follow-up relies on the availability of the ambulatory network. It is unfair to penalize facilities for failures in the ambulatory care network. A quality measure may be more effective if aimed at criteria for hospital admission or availability of outpatient clinics for treatment of heart failure prior to hospitalization.