Hospital Readmissions for Heart Failure Drop, Mortality Does Not Among Veterans

There was a decline in the risk-adjusted 30-day readmission rate for heart failure among patients receiving care in the Veterans Affairs Health Care System (VAHCS), according to study results published in JAMA Cardiology. However, mortality failed to see a similar decline in the same time frame.

The decade spanning 2007 through 2017 saw an intensified focus on reducing hospital readmissions among patients with heart failure, there being no threat of financial penalties for hospitals in the VAHCS failing to meet this goal. During this time, in 2012, CMS also initiated its Hospital Readmissions Reduction Program, which promised financial penalties for high readmission rates.

Their goal was common: improve care and reduce readmissions.

Data for the cohort study of 164,566 patients with 304,374 hospital admissions pertained to all Veterans Affairs—paid admissions for heart failure between January 2007 and September 2017. These data were analyzed from October 2018 to March 2020.

The results show that most (98%; n = 298,260) of the admissions occurred among male patients, a majority of whom were white (64.4%; n = 195,205), and they had a mean (SD) age of 70.8 (11.5) years.

For 30-day readmission rate comparison, the authors looked at 5 time periods: 2007 to 2008, 2009 to 2010, 2011 to 2012, 2013 to 2014, and 2015 to 2017. The adjusted odds ratio (aOR) for the 30-day readmission rate declined over the course of the study, to 0.85 (95% CI, 0.83-0.88) for 2015 to 2017. There was also an improvement in the aOR when readmission for days 31 through 60 were investigated: 0.86 (95% CI, 0.84-0.89).

This trend continued when looking at the aOR for 30-day readmission rate by region from the first period (2007-2008) to the last (2015-2017), where the rate fell in all regions, except for the West:

• Northeast: 0.88 (95% CI, 0.82-0.94)
• South: 0.83 (95% CI, 0.79-0.87)
• Midwest: 0.81 (95% CI, 0.76-0.86)

However, the aOR for mortality risk remained stable, at 1.01 (95% CI, 0.96-1.06).

“Stratification by left ventricular ejection fraction [LVEF] showed similar readmission reduction trends and no significant change in mortality, regardless of strata,” the authors noted. This result applied both to those with an LVEF greater than 40% or less than 40%.

Additional results for 2007-2008 through 2015-2017 showed improvements in both mean (SD) body mass index (BMI), systolic blood pressure (SBP), and B-type natriuretic peptide (BNP) level (P <.001 for all), which the authors believe signal “an overall decline in heart failure illness severity”:

• BMI: 95.3 (26.0) kg/m² to 98.5 (27.2) kg/m²
• SBP: 135.4 (23.3) mm Hg to 136.5 (22.1) mm Hg
• BNP: Quintile 1 (0-310 pg/mL): 15.5% (5678/52,748 patients) to 18.3% (12,090/78,058 patients) Quintile 5 (>2212 pg/mL): 27.1% (9914/52,748 patients) to 21.6% (14,228/78,058 patients)

“One-fifth of patients in this cohort were readmitted and 1 in 20 died within 30 days of heart failure admission, highlighting the ongoing need for effective and well-evaluated efforts to improve quality and value of care for patients with heart failure,” the authors concluded. “Future investigations should focus on evaluating the effectiveness of specific approaches to readmission reduction to inform efficient and effective application in individual health systems, hospitals, and practices.”

Interventions that target readmissions should be a goal, they suggested, as should outpatient monitoring, especially in cases where a patient with heart failure is readmitted for a noncardiovascular cause or they have heart failure with preserved ejection fraction, which has a slower disease course and can be handled with diuretic titration.

Reference

Parizo JT, Kohsaka S, Sandhu AT, Patel J, Heidenreick PA. Trends in readmission and mortality rates following heart failure hospitalization in the Veterans Affairs Health Care System from 2007 to 2017. JAMA Cardiol. Published online June 17, 2020. doi:10.1001/jamacardio.2020.2028