Circ: In elderly HF patients, mortality down, readmissions up

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Although mortality within the elderly heart failure (HF) population (age 80 and over) has improved over the last two decades, 30-day readmission rates remain lofty, according to the results of a study published online April 5 in Circulation: Heart Failure. Researchers urged that future studies must recognize interventions that can help reduce these cardiac and non-cardiac readmissions.

Because studies assessing elderly HF patients have been limited to Europe, to better understand the characteristics of the elderly HF population, Rashmee U. Shah, MD, of Stanford University in Palo Alto, Calif., and colleagues used the Veteran’s Administration (VA) National Patient Care Database from 1999 to 2008 to evaluate 30-day and one-year mortality and 30-day hospital readmissions in 21,397 elderly veterans with a first HF hospitalization.

Patients aged 80 to 84 made up 62.9 percent of the 21,387 patients and 8.1 percent of the cohort were aged 90 or older.

Between 1998 and 2008 Shah et al reported that 30-day mortality rates decreased by almost half, from 14.4 percent to 7.3 percent. The rates of one-year mortality decreased from 48.8 percent to 27.2 percent. Patients over the age of 90 saw the greatest improvement in one-year mortality (an improvement of 26 percent). This rate was 23.2 percent for those aged 80 to 84 and 19.2 percent for those aged 85 to 89.

For patients aged 80 to 84 and those aged 85 to 89, 30-day mortality decreased by 6.7 percent and 7.2 percent, respectively.

Thirty-day all-cause readmissions were reported to be similar for all age groups (ages 80-84, 85-89 and 90 and older). However, the rates of all-cause HF readmissions ranged from 16 percent to 25 percent across all age groups within 30 and 90 days.

At the end of the study period in 2008, 16.7 percent of all patients, despite their age, were readmitted for the hospital for any cause.

The researchers offered that in the late '90s, the VA restructured its care system to provide a continuity of care over the entire acute care episode, rather than simply the hospital encounter. This has led to quality improvement from the use of EMRs, improved cardiac catheterization facilities and quality assurance. These efforts combined with others have led to the decrease in mortality after acute MI, and these elderly HF patients have also benefited, the authors noted.

“Healthcare providers may be able to prevent certain non-cardiac readmissions by careful drug selection and close monitoring,” the authors wrote.

Additionally during the study the authors found that more than 80 percent of HF patients were discharged home compared to only 50 percent of Medicare HF patients. This may be due to the fact that the VA payment system uses the same funds for both acute and post-acute care giving them more incentive to discharge patients home.

The authors noted that the healthcare reform bill may change the Medicare payment system to link these two outlets—acute and post-acute care—by bundling payments, which would encourage the system to discharge patients home.

“This finding highlights the challenge of identifying interventions to reduce readmissions that are often due to non-cardiac conditions, particularly in light of the pending changes to Medicare reimbursement for 30-day readmissions,” the authors concluded.

“Future investigations into delineating outcome predictors and identifying effective management of very elderly HF patients are warranted.”