Have We Improved Outcomes for Elderly Patients Admitted with Heart Failure?

Hospitalization for heart failure is exceedingly common, accounting for more than 1.1 million hospitalizations in 2006. It is also the leading cause of hospitalization in patients older than 65 years of age, accounting for at least 20% of all hospital admissions in this age group. The good news, according to a new paper by Bueno and colleagues published in JAMA today, is that we are doing a great job in the hospital of making them better and shipping them out. The bad news is that patients are more likely to end up in a skilled nursing facility or be readmitted within 30 days.

The JAMA study analyzed 6,955,461 Medicare fee-for-service hospitalizations for heart failure from 1993 and 2006, and importantly also looked at a 30-day post-discharge follow-up period. What they found was that length of stay decreased from 8.8 days to 6.3 days between 1993 and 2006. In hospital mortality was cut in half from 8.5% to 4.3% and overall 30 days mortality dropped as well from 12.8% to 10,7%. We rock, right? Well, not really. The study also saw discharges to skilled nursing facilities jump up by half (13% to 17%) and 30 day readmission rates increase from 17% to 20%. Post-discharge mortality also increased from 4.3% to 6.3%.

These findings are similar to a study by Curtis and colleagues published in the Archives of Internal Medicine in 2008. This study looked at 2.5 million Medicare beneficiaries hospitalized with heart failure between 2001 and 2005 and showed a reduction in in-hospital mortality from 5.1% to 4.2%, however re-hospitalizion within 30 days of discharge remained at 23%. By 6 months more than half of patients were readmitted to the hospital, and by one year more than 2/3rds were readmitted. The mortality data was even more striking. Within 30 days of hospitalization for heart failure more than 1 in 10 Medicare beneficiaries died. Six months out from hospitalization more than 1 in 4 patients died, and at one year one in three were dead.

How should we put this data together? Well, in 2006 the United States spent $30 billion dollars to treat patients with heart failure; $18 billion of which was related to in-hospital care. All this money spent in the hospital seems to be doing something, at least in the hospital. The problem is that we still remain abysmal at care transitions.

How can we improve? The literature supports some type of interdisciplinary support team for these patients, both at the time of discharge and post-discharge. One randomized, controlled study of 223 patients with systolic heart failure found that a 1-hour teaching session with a nurse educator led to a 35% reduction in the combined end point of re-hospitalization or death in a 180-day follow-up period. Costs of care, including that of the intervention, were shown to be lower in patients receiving the education intervention group than in control group by $2823 per patient.

Adding some form of interdisciplinary post-discharge support to inpatient discharge planning for older patients hospitalized with heart failure can also significantly reduce readmission rates, as well as improve quality of life and functional status. A 2004 meta-analysis of 18 studies that involved 3304 older inpatients with heart failure found that there was a 25% relative reduction in the risk of readmission, a trend toward 13% relative reduction in mortality, and an improvement in quality of life scores in studies in which a post-discharge support system was in place.

It is time for our health care system to change.  We can't continue to ignore that patients do poorly once discharged due to our fragmented care delivery model.  Studies, like the one by Bueno, are a great step in moving us forward.

by: Eric Widera