Multidisciplinary Clinic to Identify Near Misses and Decrease Readmission Rates After Hospitalization for Myocardial Infarction.

Abstract

Approximately 20% of Medicare beneficiaries are readmitted to the hospital after an index myocardial infarction (MI). Since July 2009, the Centers for Medicare and Medicaid Services began publically reporting hospital data on 30-day readmission rates for MI. This metric is now considered a quality measure, and hospitals with rates above the national average are subject to penalties.1 Starting on October 1, 2012, the University of Virginia was subject to such penalties. One third of our post-MI readmissions occurred within 1 week of discharge, and half did not have follow-up within 2 weeks of discharge. Although early outpatient follow-up has been associated with reduced 30-day readmissions after hospitalization for heart failure,2 it is unclear whether early follow-up improves outcomes in post-MI patients.3,4 To address this problem, we created a multidisciplinary clinic to bridge the gap between hospital discharge and subsequent outpatient follow-up with primary care and cardiology. Our hypothesis was that early follow-up in a multidisciplinary post-MI clinic would result in improved clinical outcomes, including reduction in readmissions. This would occur in part by identifying and resolving a near miss (defined as a reversible problem likely to result in death or serious morbidity within 30 days). There were several challenges in establishing the clinic. First, we had to assure the cardiology faculty that the clinic would not serve as a continuity clinic, rather patients would be referred back to their cardiologist or appropriate follow-up would be arranged. Second, referral to the clinic relied on medicine residents placing the order. To ensure this would happen on a routine basis, we converted the clinic referral order in the electronic medical record discharge order set into a hard stop such that it would automatically occur unless justification was provided. Third, the number of patients seen in the clinic fluctuates …