Heart failure

Heart failure outcomes have improved despite inaction on readmission rates

Heart failure outcomes in Australia and New Zealand improved between 2010 to 2015 despite the absence of specific policy interventions such as the Hospital Readmissions Reduction Program (HRRP) introduced in the US.

Local hospitalisation data over the full study period showed about 10.7% of the 153,592 patients died within 30-days of their admission.

The mortality rate decreased substantially from a high of 12.5% in 2010 to 8.1% in 2015 with the trend seen in both the in-hospital deaths and to a lesser extent in post-discharge deaths.

The study, published in the European Journal of Heart Failure, also found 30-day unplanned readmissions occurred in about 22.3% of 148,704 patients over the full study period.

However there was a much more modest decline in the readmission rate from 23.2% in 2010 to 21.9% in 2015.

Heart failure was the most common reason for readmission (33.9%) but other reasons included a different cardiovascular diagnosis (14.7%), COPD (4.1%), pneumonia (3.2%) and AF (2.9%).

The study, which sourced data from 835 hospitals, noted a wide variation in outcomes between the sites.

For example, in a subset of almost 400 hospitals with at least 25 HF hospitalisations, the median risk-standardised mortality rate ranged from 6.1% to 17.3% and risk-standardised readmission rate ranged from 17.7% to 27.1%.

“The variation in HF outcomes also implies disparities in care quality among hospitals and the need for well-designed quality improvement efforts to standardise care,” the investigators said.

“Nevertheless, in contrast with the recent trends in HF outcomes seen in the US, we observed a 35% relative decline in 30-day all-cause mortality over the study period, accompanied by a modest reduction in the readmission rate, despite the absence of broad policy efforts to improve HF outcomes.”

The study said the excess of post-discharge deaths may indicate the need for greater emphasis on patient enrolment in community HF management programs that have been shown to reduce all-cause mortality and re-hospitalisations.

“Access to such programs remain suboptimal with recent findings suggesting differences in access may explain differences in readmission rates among Australian hospitals.”

“Fewer in-hospital deaths may also build a reservoir of surviving patients at higher risk of readmission and may explain the limited reduction in readmission rate over time.”

An editorial in the journal said the decline in mortality over time was likely explained by factors such as novel therapies, earlier diagnosis and intervention, better treatment of comorbid conditions as well as increased focus on patient education.

Despite some limitations in the study, they noted that the findings add to the global evidence on early outcomes after a HF hospitalisation.

“It shows early post-hospital mortality rates have declined substantially between 2010 and 2015, seemingly independent of readmission rates. This finding, in turn, underscores that the road to improved survival in HF is not necessarily paved with avoidance of hospitalisations.”

The controversial HRRP in the US applied financial penalties to hospitals with 30-day readmission rates higher than expected.

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