JAMA Feature: HF hospitalization rate declines by almost 30%
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“The magnitude of the decline is really tremendous,” said Jersey Chen, MD, MPH, of the Yale University School of Medicine in New Haven, Conn. “The caveat is that it hasn’t occurred evenly across groups of patients, like black men, or by states. Even though the one-year mortality dropped a little bit, it is still high. This outlines where we have to make progress.”
Chen and colleagues noted that heart failure is a leading cause of hospitalizations and rehospitalizations for elderly Americans, with estimated direct and indirect costs of more than $39 billion in 2010. They speculated that with the growing number of older Americans, the HF hospitalization rate might increase. At the same time, they wondered if factors such as recent declines in the incidence of heart disease, improvement in preventive care and a shift toward outpatient care might decrease HF hospitalization rates.
Chen said that while heart failure rates had trended up several decades ago, recent studies outside the U.S. showed a reversal.
To examine whether a similar decline was occurring in the U.S., Chen and colleagues used claims files from the Centers for Medicare & Medicaid Services (CMS) to identify fee-for-service beneficiaries whose diagnostic codes reflected a heart failure admission between 1998 and 2008. The files also contained information on sex, age or race and admission and discharge dates.
They identified more than 55 million unique individual fee-for-service Medicare beneficiaries with a principal discharge code for HF, for a total of more than 312 million person-years of observation for the 10-year period. The large nationwide sample allowed them also to examine trends across geographic regions and by patient characteristics.
They found that the overall HF hospitalization rate declined from 2,845 per 100,000 person-years in 1998 to 2,007 per 100,000 person-years in 2008, for a relative decline of 29.5 percent. The number of unique Medicare beneficiaries who were hospitalized at least once for HF in any given year decreased from 2,014 per 100,000 person-years to 1,462 per 100,000 person-years over the 10-year period.
“In absolute terms, this implies that if the 2008 Medicare fee-for-service population of 27.3 million had an HF hospitalization rate similar to that of 1998, an additional 229,000 HF hospitalizations would have been expected that did not occur,” the authors wrote. “With a mean HF hospitalization cost of $18,000 in 2008, this decline represents a savings of $4.1 billion in fee-for-service Medicare.”
Risk adjusted one-year mortality decreased from 31.7 percent in 1999 to 29.6 percent in 2008. But an analysis by sex showed that unadjusted one-year mortality actually increased for women, from 30.4 percent to 31.1 percent compared with a dip for men, who saw a 0.5 percentage point decline during the study period.
Nor were the improvements in the overall hospitalization rate evenly distributed by race-sex or region. In analyses by categories, the researchers found that black men had the lowest rate of decline, from 4,142 per 100,000 person-years in 1998 to 3,201 per 100,000 person-years in 2008. Chen said the fact that the decline was lagging for black men was a concern.
Risk-standardized HF hospitalizations and risk-standardized one-year mortality rates varied greatly by state during the study period. A total of 16 states recorded declines in HF hospitalization rates that were significantly higher than the change in the national rate, while three were significantly lower. Four states recorded a significant decline in the one-year mortality rate while five states had a statistically significant increase.
Chen said that geographic variation was expected but he nonetheless did not anticipate that some states would have stagnated during the 10-year period. “There were a few states that were essentially standing still,” he observed.
The researchers pointed to several recent trends that could explain the decline in HF hospitalizations: a decrease in risk factors for developing HF; changes in secondary prevention, such as an increase in the use of treatments and therapies for HF; and a shift from management of HF patients from an inpatient to an outpatient setting.
The authors pointed out that the fee-for-service Medicare population is likely sicker than its Medicare Managed Care counterparts, making the decline in the HF hospitalization rates “that much more dramatic,” they wrote. On the other hand, they noted that their study may underestimate overall HF incidence rates because it lacked outpatient data.
“Having heart failure care move from the hospital to outpatient setting is good news, too,” Chen said. “Maybe the number of patients who have heart failure is the same, but it is much less costly to see patients out of the hospital than in the hospital.”
Writers of the accompanying editorial, Mihai Gheorghiade, MD, of the Center for Cardiovascular Innovation at Northwestern University Feinberg School of Medicine in Chicago, and Eugene Braunwald, MD, of the Division of Cardiovascular Medicine at Brigham and Women’s Hospital in Boston, called the paper by Chen et al a “substantial contribution” to the literature and added that the post-discharge event rate for HF patients is still “unacceptably high and requires immediate attention.”
They listed several possible strategies for improving patient outcomes: aggressive treatment for subclinical congestion; an assessment of cardiac abnormalities; treatment for noncardiac comorbidities; incorporation of underused therapies; and scheduling a post-discharge visit for high-risk patients.
Chen added that the study was descriptive and not designed to determine causality. He said the researchers already are developing a follow-up study to better understand the reasons for the trends they observed.