Hospitalizations for Heart Failure in the United States—A Sign of Hope
Authors: Mihai Gheorghiade, Eugene Braunwald
Journal: JAMA (2011)

HEART FAILURE (HF) IS THE MOST COMMON CAUSE OF hospitalization in patients older than 65 years in the United States. In the early 1990s, data from clinical trials and registries demonstrated that in patients hospitalized with HF, mortality and rehospitalization rates could be as high as 15% and 30%, respectively, at 60 to 90 days after discharge. During this period, major efforts were directed toward reducing the length of stay in patients hospitalized with HF. Performance measures were developed and later adopted by the Centers for Medicare & Medicaid Services (CMS) with the intent to improve postdischarge outcomes. Although these measures were implemented across the country, the rehospitalization rate for patients with HF did not appear to decrease. Recently, because of changes in CMS reimbursement patterns, the focus has shifted toward 30-day postdischarge readmission rates as a measure of care. In this issue of JAMA, Chen et al reviewed administrative data of more than 55 million Medicare fee-for-service beneficiaries,withameanageof79years,whowerehospitalizedwith a discharge diagnosis of HF. Black patients represented 11% of the total studypopulation.Theoverall ratesof risk-adjusted hospitalizationforHFdeclined30%over thestudyperiodfrom 2845 per 100 000 person-years in 1998 to 2007 per 100 000 person-years in2008.Theauthorsattribute thisdecline inhospitalizations to reductions in the incidence of coronary artery disease, improved control of blood pressure, increased use of evidence-based therapies, and possibly changes in admission thresholds. In contrast to this significant reduction in hospitalizations forHF,1-year risk-adjustedall-causemortality rate declined minimally but remained high at approximately 30%. This report is a substantial contribution to existing HF epidemiological literature because it is the first to document an improvementinhospitalizationrates inHFintheUnitedStates. These improvementsappear tobemoreevident inrecentyears during which major progress has been made in promoting evidence-basedtherapies forcoronaryarterydisease.However, thissubstantialdecline inhospitalizationrateswassignificantly less in black men than in white men. Another important observation was that the decreases in hospitalization rates across states were not uniform. The authors also noted that comorbidities such as hypertension and renal dysfunction increased over time. Approximately 40% of these patients had diabetes and 30% had chronic obstructive pulmonary disease. The general reduction in admission rates may reflect improvements in overall management of HF risk factors, as suggested by Chen et al, but the persistently high 1-year mortality rates suggest that postdischarge practices for patients with HF have not been as effective. Although the admission rates for HF have decreased based on Medicare data reported by Chen et al, the available data suggest that rehospitalization rates after an index admission for HF have remained unchanged or have even increased over a similar time frame. It is important to recognize that among patients discharged following hospital admission for HF, a significant number of rehospitalizations are not related to HF. In the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome StudywithTolvaptan) trial conducted inpatientsadmitted for worsening HF with reduced ejection fraction, the total rehospitalizationrateexceeded50%at9.9months,andless thanhalf of rehospitalizations were due to HF. This occurred despite the studypopulationbeing relativelyyoung forHF(meanage, 62years),withfewmajorcomorbidconditions.IntheDIG(Digitalis Investigation Group) ancillary trial that studied outpatients with HF and preserved ejection fraction, the total hospitalization rate exceeded 65% during a mean follow-up of 37 months.Ofthesehospitalizations,only35%wererelatedtoHF. Inbothstudies,totalcardiovascularhospitalizationsrepresented a large proportion of the hospitalizations. Targeting total rehospitalization rather than rehospitalization for HF rates may be especially important given the aging population and their associated cardiac and noncardiac comorbid conditions. Chen et al suggested that the reduction in HF admissions may be related to changes in the threshold for admission in emergency departments. Lee et al reported that patients with HF who were discharged home directly from the emergency department, representing 30% of total HF presentations in their cohort, had a high risk-adjusted early death compared with patients who were admitted. If the reduction in number of hospitalizations noted by Chen et al is