title: A systematic review and meta-analysis on the association between quality of hospital care and readmission rates in patients with heart failure.
abstract: In recent years, readmission rates have been increasingly used as a measure of quality of hospital care for patients with heart failure. The aim of this systematic review is to assess the scientific evidence regarding the relation between hospital readmission rates and quality of hospital care for patients with heart failure.
  
  
  METHODS
  We defined quality of hospital care for patients with heart failure by adhering to the performance measures developed by the American College of Cardiology (ACC)/American Heart Association (AHA). Relevant articles published in English and indexed in the bibliographic databases Embase, Medline OvidSP, Web of Science, Cochrane Central, and PubMed were reviewed.
  
  
  RESULTS
  Of the 2,638 studies identified, 18 were included. They varied widely in their methodology, data sources used, and study populations. We found mixed but rather limited evidence that there is a relationship between the ACC/AHA process measures and the rate of readmission. Four of 10 studies showed a significant correlation of readmission rate with "angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use." Three of 9 studies showed a significant correlation between readmission rates and "evaluation of left ventricular systolic function." One of 7 studies showed a significant correlation with "smoking cessation counseling," and 2 of 8 showed a significant correlation with "providing discharge instructions." No evidence was found for a relationship between readmission rates and the performance measure "warfarin for atrial fibrillation."
  
  
  CONCLUSIONS
  Readmission rates after heart failure are mostly not related to the evidence-based ACC/AHA in-hospital process indicators for heart failure. It is unclear whether in-hospital quality of care is the key determinate of the readmission rate or whether readmissions are likely influenced more by postdischarge care. Further research is needed to clarify whether the readmission rate is a reflection of hospital care or quality of care on a larger level, especially when it is used for a pay-for-performance scheme to measure quality of hospital care.
authors.affiliation: Department of Public Health, Centre for Medical Decision Making, Erasmus MC, Rotterdam, the Netherlands. Electronic address: c.fischer@erasmusmc.nl.
authors.forename: Claudia
authors.initials: C
authors.lastname: Fischer
authors.affiliation: Department of Public Health, Centre for Medical Decision Making, Erasmus MC, Rotterdam, the Netherlands. Electronic address: e.steyerberg@erasmusmc.nl.
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.affiliation: Ahmanson-UCLA Cardiomyopathy Center, UCLA Division of Cardiology, Los Angeles, CA. Electronic address: gfonarow@mednet.ucla.edu.
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.affiliation: Department of Family and Preventive Medicine, University of California San Diego, La Jolla, CA. Electronic address: tganiats@ucsd.edu.
authors.forename: Theodore G
authors.initials: TG
authors.lastname: Ganiats
authors.affiliation: Department of Public Health, Centre for Medical Decision Making, Erasmus MC, Rotterdam, the Netherlands. Electronic address: h.lingsma@erasmusmc.nl.
authors.forename: Hester F
authors.initials: HF
authors.lastname: Lingsma
mesh_terms: D019468:Disease Management; D019983:Guideline Adherence; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D010359:Patient Readmission / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care