HF hospitalizations among Medicare patients have declined substantially

From 1998 to 2008, HF-related hospitalizations declined substantially for fee-for-service Medicare beneficiaries; however, 1-year mortality rates declined slightly and remain high, researchers wrote in a new study published in the Journal of the American Medical Association.

“Although the HF hospitalization rate has decreased nationally, our results demonstrate this has occurred unevenly across race-sex categories, especially for black men, who had the lowest rate of decline,” researchers wrote. “Similarly, 1-year mortality declined for all race-sex categories except for non-white non-black women.”

Hospitalization data

CMS National Claims History files, which included patient demographics, admission and discharge dates, and principal and secondary diagnosis codes, were used to identify all fee-for-service Medicare beneficiaries hospitalized for HF from 1998 to 2008 in the US and Puerto Rico. Overall, 55,097,390 patients were identified and had clinical characteristics examined. Participants were stratified according to age (65-74 years; 75-84 years; 85 years or older), sex and race (white, black, other).

The researchers found a relative decline of 29.5% of the overall risk-adjusted HF hospitalization rate from 1998 (2,845 per 100,000 person-years) to 2008 (2,007 per 100,000 person-years; P<.001). During the study period, HF patients who were hospitalized at least once in a given year decreased from 2,014 per 100,000 person-years to 1,462 per 100,000.

Age-adjusted HF hospitalization rates declined over the study period for all race-sex categories, with black men having the lowest rate of decline, according to a press release. Black men had the lowest rate of decline (4,142 to 3,201 per 100,000 person-years) of all race-sex categories; this persisted after the researchers adjusted for age (incidence rate ratio=0.81; 95% CI, 0.79-0.84).

In addition, risk-adjusted 1-year mortality decreased from 31.7% to 29.6% between 1999 and 2008, a relative decline of 6.6%, with substantial variation by state. For example, four states had a statistically significant decline in 1-year risk-standardized mortality between 1998 and 2008 and five states had a statistically significant increase. Moreover, decreases in unadjusted 1-year mortality occurred in patients aged 65-74 years (23.8% to 22%) and 75-84 years (31.1% to 30.3%); however, there was an increase in 1-year mortality among patients aged 85 years and older (42.3% to 42.7%; P<.001).

Overall, risk-standardized HF hospitalization rates in 1998 and 2008 varied significantly by state. The decline in this rate was significantly higher than the change in the national rate in 16 states and significantly lower in three states (Wyoming, Rhode Island and Connecticut).

The researchers said the overall decline in HF hospitalization rate was primarily because of fewer individuals being hospitalized with HF rather than a reduction in the frequency of HF hospitalizations. Also, they noted that the substantial geographic variation in HF hospitalization and 1-year mortality rates represent marked differences in outcomes that cannot be explained by insurance status, according to the press release.

A sign of hope

In an accompanying editorial, Mihai Gheorghiade, MD, from the Center for Cardiovascular Innovation at Northwestern University School of Medicine, and Eugene Braunwald, MD, from the TIMI study group division of cardiovascular medicine at Brigham and Women’s Hospital, wrote: “This report is a substantial contribution to existing HF epidemiological literature because it is the first to document an improvement in hospitalization rates in HF in the US. These improvements appear to be more evident in recent years during which major progress has been made in promoting evidence-based therapies for CAD.”

Chen J. JAMA. 2011;306:1669-1678.

Gheorghiade M. JAMA. 2011;306:1705-1706.

Disclosures: The researchers report no relevant financial disclosures. Dr. Gheorghiade received consulted fees from Bayer, Novartis, Sigma Tau, Johnson & Johnson, Takeda, Otsuka and Medtronic. Dr. Braunwald reports no relevant financial disclosures.

Douglass Mann

The authors report that both heart failure hospitalizations and heart failure mortality declined from 1998 to 2008, in white and black patients, as well as in male and female patients, although black men had the lowest decline in hospitalization rates among all race and sex categories. Although the overall one year mortality rate declined significantly over the past decade it still remains high at 30% for hospitalized patients… Despite the encouraging nature of the report by Chen et al there were some potentially disturbing trends that were observed. In particular, there was an increase in the prevalence of hypertension from 48% to 61%, and renal failure from 8% to 20% from 1998 - 2008. Increases in the prevalence of hypertension and renal insufficiency may tend to dampen improvements in HF hospitalization and mortality in the coming years. Nonetheless, the report by Chen and colleagues is exciting because it implies that many of the new therapies and models of care for HF are having a significant benefit nationwide.

– Douglass Mann, MD
Cardiology Today Editorial Board member

Disclosures: Dr. Mann reports no relevant financial disclosures.

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