Heart failure admissions decline in U.S.

U.S. heart failure (HF) hospitalizations decreased by 29.5% during the past decade, data from a fee-for-service Medicare claims analysis conducted from 1998 to 2008 indicate.

Risk-adjusted HF hospitalizations dropped from 2,845 to 2,007 per 100,000 person-years from 1998 to 2008 (P<0.001) – the first ever decline of this type documented in the United States, according to study researchers, Jersey Chen, MD, MPH, of Yale University and colleagues.

The number of unique HF patients hospitalized was down to 1,462 per 100,000 in 2008 from 2,014 per 100,000 in 1998, with declines occurring across all racial and ethnic groups during the 10-year study period.

“In absolute terms, this implies that if the 2008 Medicare fee-for-service population of 27.3 million had an HF hospitalization rate similar to that of 1998, an additional 229,000 HF hospitalizations would have been expected that did not occur,” the researchers wrote in the Journal of the American Medical Association.

This decrease is projected to have saved $4.1 billion in Medicare costs since 1998, the researchers reported in the Journal of the American Medical Association.

Factors contributing to the declines include lower incidence of HF risk factors, modest improvements in BP control and better use of evidence-based therapies the researchers suggested, noting that a shift towards managing HF in outpatient settings may also have made a difference.

Despite these improvements, declines were not equal among all racial and ethnic groups. Black men experienced the smallest changes, with HF hospitalization rates falling from 4,142 to 3,201 per 100,000 person-years. This was 19% less than improvements observed in other groups after adjusting for age.

Disparities were observed among states as well. Changes occurred slower than the national average in Connecticut, Rhode Island and Wyoming, and five states —Alaska, Arizona, Louisiana, Kentucky and South Dakota — even reported increases in one-year mortality rates.

“Administrative data do not identify reasons for these disparities but demonstrate important areas for future investigation into differences in clinical presentation and treatment patterns,” the researchers wrote.

Study limitations included inability to establish causality for any of the findings, lack of generalizability beyond the Medicare population and reliance on  administrative codes to determine outcomes.

In an accompanying editorial, Mihai Gheorghiade, MD, and Eugene Braunwald, MD, of of Northwestern University, and Eugene Braunwald, MD, of Brigham and Women's Hospital and Harvard in Boston, point out that although the report offers a sign of hope for HF management, there is still room for improvement.

“The overall mortality and readmission rate for HF continue to remain unacceptably high,” Gheorghiade and Braunwald wrote. They suggested the following strategies for improvement:

  • More aggressive treatment for subclinical congestion
  • More systemic assessment and treatment of the varying cardiac abnormalities that contribute to HF
  • Better management of noncardiac comorbidities such as diabetes, COPD and sleep apnea
  • Facilitating better use of underused agents such as digoxin and mineralocorticoid antagonists
  • Scheduling post-discharge visits earlier

Chen J et al. JAMA. 2011;306(15):1669-1678.

Gheorghiade M, Braunwald E. JAMA. 2011;306(15):1705-1706.

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