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Readmission for Heart Failure

Heart failure is a chronic syndrome associated with frequent exacerbations often resulting in hospitalization and death.¹ Readmission for heart failure occurs within 30 days following 20 percent of discharges from the VA system with similar rates in the Medicare health care system. The high rate of hospitalization has led to cost estimates of over $37 billion for heart failure care in the United States for 2009.²

Given the high cost and morbidity associated with heart failure hospitalization, recent research has focused on preventing admissions and readmissions in particular. Accordingly, preventing readmissions is now a focus of heart failure studies including studies related to comparative effectiveness. The rate of heart failure readmission has been discussed as a possible performance measure by the VA, Joint Commission, and Centers for Medicare and Medicaid Services. The latter plans to release to the general public risk-adjusted 30-day heart failure readmission rates for all nongovernment hospitals in summer 2009.

A heart failure readmission may be defined in multiple ways. It can be the primary cause of admission (coded as a principal diagnosis), a contributing factor (coded as one of the secondary diagnoses), or it may be unrelated to heart failure but occurring within a certain time period following a heart failure discharge. Using the principal diagnosis criteria, readmission occurs in 10 percent of patients at 30 days following discharge compared to 20 percent if one defines heart failure as a primary or secondary diagnosis. An admission for any cause occurs in approximately 25 percent of heart failure patients at 30 days following discharge.

Readmission as a Measure of Health Outcome and Quality of Care

While a heart failure readmission clearly increases cost, its use as a measure of health outcome is less clear. One of the principles of care coordination is delivering the optimal care in the optimal setting. Occasionally this setting is in the hospital, and trying to keep some patients out of the hospital may result in inferior care.

If readmission is a valid measure of the quality of heart failure care, it should satisfy several criteria. First, a significant fraction of readmissions should be due to preventable causes. Unfortunately, heart failure as the primary diagnosis accounts for only about a third of readmissions. Half of all readmissions are due to non-cardiac causes (as the principal diagnosis), and the remainder of readmissions (one sixth) is due to non-heart failure cardiac causes.

Second, one should be able to distinguish elective from non-elective readmissions. Presumably the non-elective admissions are more indicative of quality of care. Patients may be readmitted for elective device placement (e.g., defibrillator or resynchronization therapy) and the diagnosis may be coded as heart failure.

Third, all relevant admissions should be captured. Often, readmissions for Veterans are not captured using VA records because many Veterans receive cardiology care for heart failure outside of the VA system. This dual use may bias results of comparative effectiveness and cost-effectiveness studies.

Finally, variation in case mix should be minimal or measurable so that appropriate adjustments can be made. VA hospitals show moderate differences (e.g., age, income) in the patient population they admit with heart failure and such differences are likely to impact readmission rates.

Heart Failure Readmissions and Cost-Effectiveness

Since heart failure admissions account for up to 80 percent of the cost of heart failure care, knowing the impact on heart failure admissions is important for all cost-effectiveness analyses of heart failure interventions. As a general rule, any treatment that reduces heart failure hospitalizations (or mortality) is likely to be cost-effective compared to other accepted health interventions. Many disease management programs have reduced heart failure readmissions, though recent trials have had difficulty showing significant reductions, perhaps due to the improvement in usual care for heart failure.

Data from VA, non-VA U.S., and non-U.S. countries have demonstrated that as recommended medication use has increased so has survival following a hospitalization for heart failure. Unfortunately, readmission rates have not similarly improved in the VA and data from the U.S. National Hospital Discharge Survey indicate a slight increase in hospitalization rates from 1995-2004. While a heart failure admission is a clear contributor to the cost of care, using it as an outcome or quality measure is challenging. Cost-effectiveness and comparative effectiveness studies should not limit their outcome assessments to readmission when evaluating heart failure treatments.

References

1. Hunt SA, Abraham WT, et al. 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. Mar 26 2009.
2. Lloyd-Jones D, Adams R, et al. Heart Disease and Stroke Statistics -- 2009 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119(3):480-6.