Hospitalizations for Heart Failure in the United States—A Sign of Hope

Abstract

EART FAILURE (HF) IS THE MOST COMMON CAUSE OF hospitalization in patients older than 65 years in the United States. 1 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.2,3 During this period, major efforts were directed toward reducing the length of stay in patients hospitalized with HF.4 Performance measures were developed and later adopted by the Centers for Medicare & Medicaid Services (CMS) with the intent to improve postdischarge outcomes.5 Although these measures were implemented across the country, the rehospitalization rate for patients with HF did not appear to decrease. 4,6 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 7 reviewed administrative data of more than 55 million Medicare fee-for-service beneficiaries, with a mean age of 79 years, who were hospitalized with a discharge diagnosis of HF. Black patients represented 11% of the total study population. The overall rates of risk-adjusted hospitalization for HF declined 30% over the study period from 2845 per 100 000 person-years in 1998 to 2007 per 100 000 person-years in 2008. The authors attribute this decline in hospitalizations 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 for HF, 1-year risk-adjusted all-cause mortality 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 improvement in hospitalization rates in HF in the United States. These improvements appear to be more evident in recent years during which major progress has been made in promoting evidence-based therapies for coronary artery disease. However, this substantial decline in hospitalization rates was significantly 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, 7 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 ev...

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