Index Heart Failure Hospitalization Research Articles

Predicting Costs Among Medicare Beneficiaries With Heart Failure

Disease management programs that target patients with the highest risk of subsequent costs may help payers and providers control health care costs, but identifying these patients prospectively is challenging. We hypothesized that medical history and clinical data from a heart failure registry could be used to prospectively identify patients with heart failure most likely to incur high costs. We linked Medicare inpatient claims to clinical registry data for patients with heart failure and calculated total Medicare costs during the year after the index heart failure hospitalization. We defined patients as having high costs if they were in the upper 5% (>$76,500) of the distribution. We used logistic regression models to identify patient and clinical characteristics associated with high costs. Costs for 40,317 patients in the study varied widely. Patients in the upper 5% of the cost distribution incurred mean costs of $117,193 ± 55,550 during 1 year of follow-up compared to $17,086 ± 17,792 for the lower-cost group. Demographic and clinical characteristics associated with high costs included younger age and black race; history of anemia, chronic obstructive pulmonary disease, ischemic heart disease, diabetes mellitus, or peripheral vascular disease; serum creatinine level; and systolic blood pressure at admission. Mean 1-year Medicare costs for patients whom the model predicted would exceed the high-cost threshold were >2 times the costs for patients below the threshold. In conclusion, a model based on variables from clinical registries can identify a group of patients with heart failure who on average will incur higher costs in the first year after hospitalization.

Understanding changing patterns of survival and hospitalization for heart failure over two decades in New Zealand: utility of ‘days alive and out of hospital’ from epidemiological data

To describe changes in heart failure (HF) epidemiology in New Zealand between 1988 and 2008 using the number of days alive and out of hospital after a first hospitalization for HF, and to use these data to evaluate the overall impact of changing patterns of hospitalization and survival. We performed a population analysis of all HF hospitalization and mortality data from 1 January 1988 to 31 December 2008 in New Zealand. The main outcome measures were: days alive and out of hospital, age standardized hospitalization rates, and mortality after an index hospitalization for HF. The number of days alive and out of hospital at 2 years increased by 2 months over the two decades of the study (from 448.8 to 511.3 days). Age standardized index HF hospitalization rates increased from 1988 to 1999, and declined thereafter, current rates are 106.9/100 000 for women and 174.3/100 000 for men. Patient age at index admission progressively increased, and hospital length of stay decreased. Mortality rates progressively decreased until 2000, but there has been no further decrease since then. Total hospital days have decreased up to 2008. There have been major changes in the epidemiology of HF in New Zealand between 1988 and 2008, during which time there have been important changes in HF management. Despite increasing age, hospitalization rates are now declining and patients with HF are surviving longer out of hospital and with fewer hospital days. These results support the need for continued emphasis on delivery of effective community-based care for patients with this long-term condition.

Costs of Inpatient Care Among Medicare Beneficiaries With Heart Failure, 2001 to 2004

Inpatient care is the primary driver of costs for patients with heart failure. It is unclear whether recent advances in heart failure care have reduced the costs to Medicare for the care of inpatients with heart failure. In a retrospective cohort study of 1 363 977 elderly Medicare beneficiaries hospitalized with heart failure between January 1, 2001, and December 31, 2004, we examined costs to Medicare for all inpatient care, inpatient cardiovascular care, and inpatient heart failure care and the adjusted relationships between patient characteristics and costs. Among 1 363 977 Medicare beneficiaries with an index heart failure hospitalization, 901 885 (66%) had a subsequent inpatient claim during the following year. Noncardiovascular costs accounted for 57% of total inpatient costs, and costs associated with heart failure hospitalizations accounted for 15% of total inpatient costs. No significant changes occurred in total, cardiovascular, and heart failure inpatient costs over time. The costs of inpatient care for patients with heart failure are high, but most subsequent inpatient costs are attributable to noncardiovascular and non-heart failure admissions. Further research is needed to identify predictors of costs, so that patients can be stratified according to risk, and to evaluate strategies that target primary cost drivers for patients with heart failure.

Comparative Effectiveness of β-Blockers in Elderly Patients With Heart Failure

Whether beta-blockers (BBs) other than carvedilol, metoprolol succinate, and bisoprolol fumarate (evidence-based beta-blockers [EBBBs]) improve survival in patients with heart failure (HF) is unknown. We compared the effectiveness of EBBBs vs non-EBBBs on survival. Our study population included North Carolina residents at least 65 years old who were eligible for Medicare and Medicaid with pharmacy benefits and had had at least 1 hospitalization for HF during the period 2001 through 2004. Primary outcome was survival from 30 days to 1 year. Secondary outcomes included number and days of rehospitalizations for HF and number of outpatient visits. Cohorts were defined by BB class (EBBBs, non-EBBBs, or no BBs) in first 30 days after discharge from index hospitalization for HF. Outcomes were analyzed using inverse probability-weighted (IPW) estimators with propensity score adjustment. Of 11,959 patients, 40% were nonwhite, 79% were female, and 26% were at least 85 years old. Fifty-nine percent received no BB, 23% received EBBBs, and 18% received non-EBBBs. One-year adjusted mortality rates were 28.3% (no BBs), 22.8% (non-EBBBs), and 24.2% (EBBBs). The IPW-adjusted comparisons of 1-year mortality outcomes for either non-EBBBs or EBBBs compared with no BBs were statistically significant (P = .002 for both), but there was no statistical difference between the 2 BB groups (P = .43). The IPW-adjusted mean numbers of rehospitalizations for HF were 0.33 (no BBs), 0.29 (non-EBBBs), and 0.41 (EBBBs), with statistically more rehospitalizations in patients receiving EBBBs compared with no BBs (P = .002) and with non-EBBBs (P < .001). In this elderly population, the comparative effectiveness of EBBBs vs non-EBBBs was similar for 1-year survival, whereas the rehospitalization rate was higher for patients receiving EBBBs.

Measuring Quality in Heart Failure

As we approach the end of the first decade of the 21st century, it is evident that the epidemic of heart failure has not abated, nor have concerns about the quality of care received by patients with this condition. Recent data from the American Heart Association1 and the Centers for Disease Control and Prevention2 reaffirm that the number of patients hospitalized with heart failure has grown steadily over the past 30 years. With aging of the US population, this trend will undoubtedly continue, but it is also noteworthy that the increase in heart failure hospitalizations over the past few decades is not limited to the Medicare population.2 Moreover, the outcome of heart failure patients after hospital discharge is not improving. Despite evidence-based guidelines, performance measures, quality improvement programs, and public reporting of hospital-level performance data, the number of patients dying or readmitted to hospitals within 30 days of hospital discharge has not declined3–6 and is equivalent in patients with depressed and those with preserved left ventricular systolic function.7 Hospital readmission is expensive and contributes to the increasing economic burden of heart failure, but this is often a preventable event. However, the characteristics of patients who will require rehospitalization have not been identified,5 and it is impossible to predict which patients will be readmitted. In many cases it is not the patient, but the healthcare system involving multiple providers and transitions of care, that makes the conditions ripe for high readmission rates. Article See p 29 The fundamental first step in identifying and correcting gaps in healthcare quality is setting standards of care through development of evidence-based clinical practice guidelines. From quality indicators emphasized in guidelines, clinical performance measures can be derived to evaluate the quality of care provided by hospitals and by individual practitioners. …

Relating quality of care to clinical outcomes in heart failure: In search of the missing link

As heart failure becomes an increasingly important public health problem in the aging population, all avenues continue to be sought toward improving clinical outcomes among patients with this condition. From the perspective of clinical care, this process most appropriately begins with the demonstration of a significant treatment effect within a randomized clinical trial. Drawing upon such information, uniform guidance must be provided to the practitioner, defining a consensus view of optimal quality of care. Such guidance, in the form of clinical practice guidelines, has reached beyond the realm of randomized clinical trial evidence, drawing from multiple sources of information, often with weak or absent documentation of linkage between the clinical process being advocated and the outcome being sought. Polanczyk et al (1) in this issue of the Journal of Cardiac Failure provide some of this linkage by examining correlation between indices of quality of care for patients hospitalized with heart failure and the important clinical outcome of hospital readmission. Krumholz et al (2) recently reviewed quality measures in heart failure. They reported characteristics of guideline recommendations that are most appropriately translated into measures to judge the quality of care delivery, including 1) strong process-outcome linkage, 2) wide applicability to a well-defined patient population, and 3) amenability to measurement based on existing or readily adapted documentation standards. At present, few recommendations meet these rigorous requirements. The Centers for Medicare and Medicaid Services (previously the Health Care Finance Administration) in an effort to improve quality of care in heart failure have adapted 2 measures that come close to meeting these standards: measurement of left ventricular function and prescription of angiotensin-converting enzyme (ACE) inhibitors. In contrast, Polanczyk et al explored an instrument based on a wide variety of quality measures for inhospital management, including criteria for 1) admission work-up, 2) evaluation and treatment during hospitalization, and 3) readiness for discharge. They correlated scores on the various components of this instrument with the likelihood of rehospitalization for heart failure during 3 months of follow-up in 200 patients discharged alive after index hospitalization for heart failure. Using a multivariate model that included both clinical characteristics and quality criteria, the investigators observed that a low score for evaluation and treatment independently predicted readmission. Patients meeting 50% of the evaluation and treatment criteria were 2.5 times more likely to be readmitted for heart failure than the remaining population. The frequency of 1) performing any diagnostic evaluation, 2) performing echocardiography in patients with an unknown ejection fraction, and 3) treatment with an ACE inhibitor differed significantly between patient groups with and without readmission. Although the precise mechanism for linkage between the diagnostic evaluation, including echocardiography, and readmission is uncertain, these findings bring us a step closer to documenting that improvement in clinical practice, based on established quality standards, yields improved clinical outcomes in patients with heart failure. Readmission after a hospitalization for heart failure is common, estimated as 44% at 6 months within the Medicare population (3). Reduction in heart failure hospitalizations is an appropriate goal for treatment modalities and quality improvement strategies because hospitalization impacts adversely on both sides of the cost-effectiveness equation. On the cost side, hospitalization is the principal component of the high cost of care for patients with heart failure, representing 70% to 75% From the Division of Cardiology, Department of Medicine, New England Medical Center and Tufts University School of Medicine, Boston, MA. Reprint requests: Marvin A. Konstam, MD, Hospital Box 108, New England Medical Center, 750 Washington St, Boston, MA 02111. Copyright © 2001 by Churchill Livingstone 1071-9164/01/0704-0004$35.00/0 doi:10.1054/jcaf.2001.30132 Journal of Cardiac Failure Vol. 7 No. 4 2001