November 3rd, 2011
Success in Heart Failure? Hospitalizations Decline
We welcome Jersey Chen to answer questions about his recent study in JAMA documenting that heart failure hospitalization rates declined nearly 30% between 1998 and 2008. Risk-adjusted 1-year mortality in patients hospitalized for heart failure also fell, but by a more modest 6.6%. CardioExchange editor Harlan Krumholz was senior author on the paper.
CardioExchange: How can you be sure that these are real changes and don’t result from, say, changes in coding practices?
Dr. Chen: There has not been substantive changes in hospital reimbursement for HF, so coding practice is unlikely to be major factor. That the rate of myocardial infarction has declined substantially in the US (an important precursor of HF) during this time period suggests that these HF hospitalizations changes were real.
CardioExchange: Can you place these declines in heart failure hospitalizations in context? How dramatic are they compared with overall declines in ischemic heart disease?
Dr. Chen: MI hospitalization rates have dropped by 23% in the Medicare population from 2002-2007, so HF hospitalization declines are comparable.
CardioExchange: With the caveat that this was an epidemiologic study, do the data give us any indication of what may or may not be driving these changes?
Dr. Chen: Major drivers very likely are:
- improved primary prevention of HF risk precursors such as CAD and hypertension,
- improved secondary prevention such as increased use of ACE inhibitors, ARBs, and beta-blockers in patients with existing HF, and
- improved transition of HF care from inpatient to outpatient settings.
CardioExchange: HF hospitalization rates did decline for black men in your study, but at a slower rate than for the population as a whole. Any hints as to the underlying cause for this disparity? What of other disparities?
Dr. Chen: A similar pattern of racial disparity has also been documented with acute myocardial infarction. Studies show that black men have less primary prevention screening, so this may be a reason. Genetics may explain why black patients have higher prevalence of HF but not the change over time. We also noted some substantial geographic variations across states, both in HF hospitalizations and mortality. These data may reflect differences in primary prevention, public health efforts regarding risk factors, or patterns in care for inpatient versus outpatient treatment for patients at the threshold of admission.