AJM Theme Issue: Cardiology
AJM online: Clinical research study
National Trends in Outcomes Among Elderly Patients with Heart Failure

https://doi.org/10.1016/j.amjmed.2005.11.019Get rights and content

Abstract

Purpose

Despite dramatic changes in heart failure management during the 1990s, little is known about the national heart failure mortality trends during this time period, particularly among the elderly. The purpose of this study was to determine temporal trends in outcomes of elderly patients with heart failure between 1992 and 1999.

Subjects and methods

We analyzed a national sample of 3,957,520 Medicare beneficiaries aged 65 years or more who were hospitalized with heart failure between 1992 and 1999, assessing temporal trends in 30-day and 1-year all-causemortality and 30-day and 6-month all-cause hospital readmission. In risk-adjusted analyses, mortality and readmission for each year between 1994 and 1999 were compared with the referent year of 1993.

Results

Crude 30-day and 1-year mortality decreased slightly (range for 1992-1999: 11.0%-10.3% and 32.5%-31.7%, respectively), whereas 30-day and 6-month readmission increased (10.2%-13.8% and 35.4%-40.3%, respectively). After risk adjustment, there was no change in 30-day mortality between 1993 and 1999 (eg, for 1999 vs 1993, odds ratio [OR] 1.01, 95% confidence interval [CI], 1.00-1.02). One-year mortality was lower in 1994 compared with 1993 (OR 0.91, 95% CI, 0.90-0.92), but data from subsequent years suggested no continuous improvement after 1994 (1999 vs 1993: OR 0.93, 95% CI, 0.92-0.94). Thirty-day readmission increased (1999 vs 1993: OR 1.09, 95% CI, 1.07-1.10), but there was no change in 6-month readmission (1999 vs 1993: OR 1.00, 95% CI, 0.99-1.01).

Conclusion

We found no substantial improvement in mortality and hospital readmission during the 1990s among elderly patients hospitalized with heart failure. These findings suggest that recent innovations in heart failure management have not yet translated into better outcomes in this population.

Section snippets

Study Cohort

The study sample was derived from the Centers for Medicare and Medicaid Services’ administrative records and included all fee-for-service Medicare beneficiaries aged 65 years or more who were hospitalized with heart failure in acute care facilities between 1992 and 1999. Cohorts were identified for each calendar year from the Centers for Medicare and Medicaid Services’ Inpatient Standard Analytic Files using International Classification of Diseases, Ninth Revision, Clinical Modification

Results

The demographic characteristics of the patients did not change substantially during the study period (1992-1999 [age 79.3-79.9 years; female, 57.3%-59.1%; white, 85.9%-84.5%]). We found a considerable increase, however, in the proportion of patients with comorbidities such as diabetes (26.2%-36.7%), hypertension (26.6%-44.4%), and dementia (2.8%-5.0%). The proportion of patients with a Deyo comorbidity score of 3 or more also increased from 14.2% to 30.7% (Table 1).

Crude rates of

Major Findings

In this analysis of national administrative Medicare data, we demonstrate that overall, little progress was made in improving outcomes for elderly patients hospitalized with heart failure during the 1990s. Specifically, there has been no change in short-term mortality and only minor improvement in long-term mortality, whereas short-term hospital readmission rates have increased.

Although these results contrast remarkably with the 20% to 30% relative reduction in mortality and the 30% to 40%

Prior studies of temporal trends in heart failure survival and hospital readmission

The results of several studies that examined recent trends in heart failure outcomes have been conflicting. Prospective cohort-based data from both the Framingham Heart Study and the Rochester Epidemiology Project have demonstrated improvements in long-term heart failure survival during the 1990s compared with the period from 1950 to 1969 and 1979 to 1984, respectively.18, 19 However, those studies predominantly contrasted mortality during the 1990s with that of earlier decades and did not

Translating medical progress into practice

The lack of substantial improvement in outcomes seen in our study underscores the complexity of applying medical progress to actual practice. Future efforts to improve outcomes in elderly patients with heart failure will likely need to be directed toward several key objectives: improving use of and adherence to lifesaving therapies in patients who are eligible to receive them, generating knowledge about appropriate therapies in patients with heart failure with preserved systolic function, and

Summary

Despite significant advances in heart failure management, our results show a lack of substantial improvement in outcomes among elderly patients hospitalized with this condition during the 1990s. These data underscore the complexity of translating medical progress into clinical practice and emphasize the importance of coordinated efforts designed to improve outcomes in this patient group.

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    This publication was supported by grant number 1 K01 DP000085-01 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.

    The Centers for Medicare and Medicaid Services (CMS) reviewed and approved the use of its data for this work, and approved submission of the manuscript; this approval is based on data use only, and does not represent a CMS endorsement of or comment on the manuscript content.

    Neither CDC nor CMS played a role in the design and conduct of the study, or in the analysis and interpretation of the data. All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the analysis.

    1

    Dr. Kosiborod was a fellow in the Robert Wood Johnson Clinical Scholars Program at Yale University School of Medicine during the time this work was conducted.

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