Evidence-based beta blocker use associated with lower heart failure readmission and mortality, but not all-cause readmission, among Medicare beneficiaries hospitalized for heart failure with reduced ejection fraction.

Matthew Shane Loop,Todd M Brown,Monika M Safford,Melissa K Van Dyke,Emily B Levitan,Raegan W Durant,Ligong Chen,Hans-Peter Brunner-La Rocca

doi:10.1371/journal.pone.0233161

Abstract

The beta blockers carvedilol, bisoprolol, and sustained-release metoprolol succinate reduce readmissions and mortality among patients with heart failure with reduced ejection fraction (HFrEF), based upon clinical trial and registry studies. Results from these studies may not generalize to the typical patient with HFrEF. We conducted a retrospective cohort study of beneficiaries in the Medicare 5% sample hospitalized for HFrEF between 2007 and 2013 and were discharged alive. We compared the 30-day and 365-day heart failure (HF) readmission, all-cause readmission, and mortality rates between beneficiaries who filled a prescription for an evidence-based beta blocker and those who did not after being hospitalized for HFrEF. Out of 12,127 beneficiaries hospitalized for HFrEF, 20% were readmitted for HF, 62% were readmitted for any cause, and 27% died within 365 days. In competing risk models adjusted for demographics, healthcare utilization, and comorbidities, beta blocker use was associated with a lower risk of HF readmission between 8-365 days post discharge (hazard ratio 0.79 [95% confidence interval 0.76, 0.82]), but was not significantly associated with all-cause readmission (1.02 [0.97-1.07]). In Cox models adjusted for the same covariates, beta blocker use was associated with lower mortality 8-365 days post discharge (0.65 [0.60-0.71]). Results were similar when follow up was truncated at 30 days post discharge. Increasing the use of beta blockers following HFrEF hospitalization may not decrease all-cause readmissions among Medicare beneficiaries, but may reduce HF-specific readmissions and mortality.

Highlights

The beta blockers carvedilol, bisoprolol, and sustained-release metoprolol succinate have been shown to reduce readmissions and mortality for patients with heart failure with reduced ejection fraction (HFrEF)
We conducted a retrospective cohort study of the Medicare 5% random sample to determine the relative risk for heart failure (HF) readmission, all-cause readmission, and mortality associated with use of these evidence-based beta blockers among beneficiaries hospitalized for HFrEF
This study was approved by the University of Alabama at Birmingham Institutional Review Board and the Centers for Medicare and Medicaid Services Privacy Board. These inclusion / exclusion criteria led to a final sample size of 12,127 beneficiaries hospitalized for HFrEF

Summary

Introduction

The beta blockers carvedilol, bisoprolol, and sustained-release metoprolol succinate have been shown to reduce readmissions and mortality for patients with heart failure with reduced ejection fraction (HFrEF). These findings have led to the use of beta blocker prescriptions at hospital discharge as an indicator of quality of care [1,2]. The evidence for their benefit is based largely upon patients enrolled in randomized controlled trials (RCTs) and heart failure registries [3,4,5,6] Participants in these studies were likely different from the typical patient hospitalized for HFrEF, potentially limiting the generalizability of these results. We conducted a retrospective cohort study of the Medicare 5% random sample to determine the relative risk for heart failure (HF) readmission, all-cause readmission, and mortality associated with use of these evidence-based beta blockers among beneficiaries hospitalized for HFrEF

Methods

Results

Conclusion