Clinical Heart and Vascular Center
An Evaluation of Post-Discharge Acute Care and Mortality in Heart Failure
By Rohan Khera, M.D., Cardiology Fellow
Among Medicare beneficiaries hospitalized for heart failure, mortality in the 30-day post-discharge period has been increasing over the past several years. During this period, there has concurrently been a focus on reducing readmissions. Moreover, the increase in mortality has been manifested in patients who did not get readmitted, raising concerns about the inappropriate use of observation units and the emergency departments (EDs) to provide post-discharge care and deferring of required readmissions.
In our study presented at the AHA Scientific Sessions, we determined whether patients with hospitalizations for conditions covered by national readmission programs who received care in the ED or observation units but were not hospitalized within 30 days had an increased risk of death. We also evaluated temporal trends in post-discharge acute care utilization in inpatient units, the ED, and observation units for these patients.
“[T]he increasing post-discharge mortality in high-risk heart failure patients occurred in those who did not seek any post-discharge care, many of whom appear to have been appropriately transitioned to hospice care at hospital discharge.”
In national Medicare data for the study period spanning 2008 through 2016, there were 3.7 million hospitalizations for heart failure and 1.6 million hospitalizations for myocardial infarction among Medicare beneficiaries 65 years of age and older. During the same time span, concurrent with a reduction in 30-day readmission rates, 30-day observation stays and visits to the ED increased across all conditions included in the HRRP. The use of observation units and the ED also increased beyond the post-discharge 30-day period.
We found that among conditions targeted in the HRRP, patients with heart failure, but not those with myocardial infarction, experienced an increase in post-discharge 30-day mortality. However, this increase preceded the announcement of the program and was concentrated among individuals who sought no post-discharge acute care. Among those not seeking post-discharge care, a rising proportion had been discharged to hospice. Indeed, half of the deceased who had not sought post-discharge care had been discharged to hospice. Therefore, it appears that the increasing utilization of observation units and the ED in the post-discharge period for patients with heart failure is not the mediator of the rise in post-discharge 30-day mortality in this patient population. Rather, the increasing post-discharge mortality in high-risk heart failure patients occurred in those who did not seek any post-discharge care, many of whom appear to have been appropriately transitioned to hospice care at hospital discharge.