Home health providers throughout the industry often tout their success in curbing hospital readmissions. Exactly how well providers hit on that mission, though, is being called into question.
Medicare patients hospitalized for heart failure and referred to a home health agency for care after discharge may be at “a significantly higher risk” of 30-day all-cause readmissions compared to those who do not receive home health services, a recent study has found. Similarly, heart failure patients in home health may also be at heightened risk for death.
The findings on readmission and mortality rates of home health patients with heart failure were highlighted in an Archives of Medical Science study published in August.
“We were a bit surprised,” Dr. Cherinne Arundel — associate professor of medicine at George Washington University, chief of the hospitalist section for the Veterans Affairs Medical Center in Washington, D.C., and the study’s lead author — told Home Health Care News. “Patients who do get home health care services receive home visits by skilled nurses, who provide care under the direction of patients’ primary care physicians. These nurses are skilled in educating patients in diet, medications and recognition of early symptoms, all of which are expected to lower the risk of readmissions.”
The study is based on more than 6,400 Medicare patients who were hospitalized for acute heart failure in 106 Alabama hospitals between 1999 and 2001. Of those patients, 1,369 received a discharge home health care referral. Patients who received referrals were typically older and had more complex medical conditions, such diabetes, lung disease and dementia. They also experienced more adverse in-hospital events, such as pneumonia or pressure sores.
To minimize differences, researchers used a method called propensity score matching, which made the observed group of home health patients look similar to a group of patients not getting home health services.
Matched patients had a mean age of 78 years old and were mostly women.
Specifically, 30-day all-cause readmission occurred in 28% and 19% of patients receiving and not receiving home health referrals, respectively, the study found. All-cause mortality over 30 days was 3% for non-home health patients and 7% for home health patients.
Despite the study’s findings, home health providers and current patients shouldn’t panic just yet.
The study did, indeed, note an increased risk for readmissions and mortality, but there are several possible explanations for its less-than-encouraging findings, according to the researchers.
Patients referred for home health care are generally sicker and often more medically complex, for example. Although the study sought to compare home health patients to a comparable group of non-home health patients, it’s possible it simply didn’t account for certain nuances, such as a diabetic home health patient having “more severe diabetes” than his or her control group counterpart.
That higher level of medical complexity could be why the patient was referred for home health services in the first place, Dr. Ali Ahmed, a senior author of the study, told HHCN. Ahmed is a professor of medicine at George Washington University and associate chief of staff of the health and aging division of the VA Medical Center.
“We couldn’t guarantee that patients had diabetes of similar severity and intensity,” he said. “Both groups had an equal number of patients with diabetes … but if the diabetics in the home health care group had longer duration of diabetes with lots of complications, they obviously will have poorer outcomes, and that was something we were unable to control for.”
Additionally, there might be other benefits that patients see from home health services that weren’t accounted for, such as functional or quality of life improvements, Arundel said.
“It’s possible the severity of comorbid diseases within our home health care group was more severe and we were unable to capture that with observational data,” she said. “The other thing, too, is perhaps the rates of rehospitalization would have been higher without a home health care referral.”
Heart failure is the leading cause of hospital readmission within 30 days of discharge.
Millions of Americans receive home health care referrals each year, with patients with heart failure making up the largest chunk of those referrals. Older adults who are hospitalized, in particular, are at an increased risk for future hospitalization and poor health outcomes.
Even if the study’s findings could be partially explained, they still aren’t desirable, especially because the home health Medicare program accounts for a portion of the United State’s $3.3 trillion in health care spending, Ahmed said.
“We are not implying that there is a causal association between home health care [and readmissions and mortality rates],” he said. “But are there opportunities to improve it and have a better impact on outcomes?”
Ahmed and Arundel have conducted similar research analyzing readmission and mortality rates of hospice patients. In general, that research has found that hospice patients have higher mortality rates, but lower readmission rates.
Written by Robert Holly