Impact of Prior Admissions on 30-Day Readmissions in Medicare Heart Failure Inpatients

doi:10.1016/j.mayocp.2013.12.018

Mayo Clinic Proceedings

Volume 89, Issue 5, May 2014, Pages 623-630

https://doi.org/10.1016/j.mayocp.2013.12.018 Get rights and content

Abstract

Objective

To determine how all-cause hospitalizations within 12 months preceding an index heart failure (HF) hospitalization affect risk stratification for 30-day all-cause readmission.

Patients and Methods

Early readmission of inpatients with HF is challenging to predict, yet this outcome is used to compare hospital performance and guide reimbursement. Most risk models do not consider the potentially important variable of prior admissions. We analyzed Medicare inpatients with HF aged 66 years or older admitted to 14 Michigan community hospitals from October 1, 2002, to March 31, 2003, and from January 1 to June 30, 2004. Clinical data were obtained from admission charts, hospitalization dates from Centers for Medicare & Medicaid Services (CMS) claims, and mortality dates from the Social Security Death Index. We used mixed-effects logistic regression and reclassification indices to evaluate the ability of a CMS chart-based readmission risk model, prior admissions, and their combination to predict 30-day readmission in survivors of the index HF hospitalization.

Results

Of 1807 patients, 43 (2.4%) died during the index admission; 476 of 1764 survivors (27%) were readmitted 30 or fewer days after discharge. Adjusted for the CMS readmission model, prior admissions significantly increased the odds of 30-day readmission (1 vs 0: odds ratio, 4.67; 95% CI, 3.37-6.46; ≥2 vs 0: odds ratio, 6.49; 95% CI, 4.93-8.55; both P<.001), improved model discrimination (c statistic, 0.61-0.74, P<.001), and reclassified many patients (net reclassification index, 0.40; integrated discrimination index, 0.12).

Conclusion

In Medicare inpatients with HF, prior all-cause admissions strongly increase all-cause readmission risk and markedly improve risk stratification for 30-day readmission.

Section snippets

Definition of Variables Used

We used data from the Mid-Michigan Guidelines Applied in Practice – Heart Failure (GAP-HF) study for our analyses; additional details on this study are available in our other articles.2, 13, 14 In brief, GAP-HF was a collaborative partnership of 15 Michigan community hospitals to assess and improve the quality of inpatient HF care. Each hospital enrolled patients admitted with primary diagnosis of HF during two 6-month periods (from October 1, 2002, to March 31, 2003, and from January 1 to June

Patient Characteristics

The GAP-HF cohort contained index hospitalizations in 1807 unique Medicare inpatients with HF aged 66 years or older. The baseline characteristics (Table 1) were similar to the National Heart Failure Project¹⁸ and more recent Medicare HF cohorts.8, 9 In GAP-HF, 1018 patients (56.3%) had not been recently hospitalized, 254 (14.1%) had been admitted once, and 535 (29.6%) had been admitted 2 or more times within the prior 12 months. The median number of patients across the 14 GAP-HF hospitals was

Discussion

We found that in Medicare inpatients with HF, hospitalizations within the prior 12 months strongly increased the odds for 30-day all-cause readmission, improved the discrimination of a widely recommended HF readmission risk model, and clearly separated patients with HF into high-risk and low-risk categories for early rehospitalization.

Conclusion

In Medicare inpatients with HF, all-cause prior admissions within 12 months strongly increased the risk for 30-day all-cause readmission, improved the performance of a widely recommended risk model, and clearly separated patients into high-risk and low-risk categories for early rehospitalization. This easily obtained information could help focus readmission-prevention efforts in older patients with HF.

References (30)

N.V. Kommuri et al.
The impact of prior heart failure hospitalizations on long-term mortality differs by baseline risk of death
Am J Med
(2012)
S. Setoguchi et al.
Repeated hospitalizations predict mortality in the community population with heart failure
Am Heart J
(2007)
Z.J. Eapen et al.
Validated, electronic health record deployable prediction models for assessing patient risk of 30-day rehospitalization and mortality in older heart failure patients
JCHF
(2013)
H.M. Krumholz et al.
Predictors of readmission among elderly survivors of admission with heart failure
Am Heart J
(2000)
G.M. Felker et al.
Risk stratification after hospitalization for decompensated heart failure
J Card Fail
(2004)
S.L. Hummel et al.
Prolonged electrocardiogram QRS duration independently predicts long-term mortality in patients hospitalized for heart failure with preserved systolic function
J Card Fail
(2009)
S.L. Hummel et al.
Recommendation of low-salt diet and short-term outcomes in heart failure with preserved systolic function
Am J Med
(2009)
K.A. Eagle et al.
Guideline-based standardized care is associated with substantially lower mortality in Medicare patients with acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice (GAP) projects in Michigan
J Am Coll Cardiol
(2005)
E.P. Havranek et al.
Spectrum of heart failure in older patients: results from the National Heart Failure Project
Am Heart J
(2002)
A.G. Au et al.
Predicting the risk of unplanned readmission or death within 30 days of discharge after a heart failure hospitalization
Am Heart J
(2012)

P.A. Heidenreich et al.

Divergent trends in survival and readmission following a hospitalization for heart failure in the Veterans Affairs health care system 2002 to 2006

J Am Coll Cardiol

(2010)

S. Stewart et al.

Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study

Lancet

(1999)

P.S. Keenan et al.

An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure

Circ Cardiovasc Qual Outcomes

(2008)

D.S. Lee et al.

“Dose-dependent” impact of recurrent cardiac events on mortality in patients with heart failure

Am J Med

(2009)

S.D. Solomon et al.

Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure

Circulation

(2007)

Cited by (24)

Insufficient Calorie Intake Worsens Post-Discharge Quality of Life and Increases Readmission Burden in Heart Failure
2020, JACC: Heart Failure
Citation Excerpt :
Discrimination for all-cause readmission was assessed with and without NRI and caloric intake. For number of days of rehospitalization, which represent overly dispersed count data, negative binomial regression was used, adjusted for NRI category, OPTIMIZE-HF score, randomization to meals versus usual care, and the number of cardiovascular hospitalizations within the previous year (categorized as 0, 1, 2, or more) (23). Among the 57 randomized GOURMET-HF participants with completed FFQ, the median sodium intake was 2,987 mg/day (interquartile range [IQR]: 2,160 to 3,540 mg/day), and the median calorie intake was 1,602 kcal/day (IQR: 1,201 to 2,142 kcal/day); 29 of 57 participants (53%) had insufficient caloric intake (as defined above, <90% of estimated TEE).
The purpose of this study was to evaluate the relationship between calorie intake and post-discharge outcomes in hospitalized patients with heart failure (HF).
Malnutrition increases adverse outcomes in HF, and dietary sodium restriction may inadvertently worsen nutritional intake.
In a dietary intervention trial, baseline nutritional intake in HF inpatients was estimated using the Block Food Frequency Questionnaire (FFQ), and the Nutritional Risk Index (NRI) was calculated. Insufficient calorie intake was defined as <90% of metabolic needs, and a 15-point micronutrient deficiency score was created. Adjusted linear, logistic, and negative binomial regression were used to evaluate associations between insufficient calorie intake and quality of life (using the Kansas City Cardiomyopathy Questionnaire Clinical Summary [KCCQ-CS]), readmission risk, and days rehospitalized over 12 weeks.
Among 57 participants (70 ± 8 years of age; 31% female; mean body mass index 32 ± 8 kg/m²); median sodium and calorie intake amounts were 2,987 mg/day (interquartile range [IQR]: 2,160 to 3,540 mg/day) and 1,602 kcal/day (IQR: 1,201 to 2,142 kcal/day), respectively; 11% of these patients were screened as malnourished by the NRI. All patients consuming <2,000 mg/day sodium had insufficient calorie intake; this group also more frequently had dietary micronutrient and protein deficiencies. At 12 weeks, patients with insufficient calorie intake had less improvement in the KCCQ-CS score (β = −14.6; 95% confidence interval [CI]: −27.3 to −1.9), higher odds of readmission (odds ratio: 14.5; 95% CI: 2.2 to 94.4), and more days rehospitalized (incident rate ratio: 31.3; 95% CI: 4.3 to 229.3).
Despite a high prevalence for obesity and rare overt malnutrition, insufficient calorie intake was associated with poorer post-discharge quality of life and increased burden of readmission in patients with HF. Inpatient dietary assessment could improve readmission risk stratification and identify patients for nutritional intervention. (Geriatric Out of Hospital Randomized Meal Trial in Heart Failure [GOURMET-HF] NCT02148679)
Latent topic ensemble learning for hospital readmission cost optimization
2020, European Journal of Operational Research
Citation Excerpt :
However, studies which use LACE on different datasets are often unable to obtain a c-statistic near 0.7 (Philbin & DiSalvo, 1999), and can be as low as 0.55 (Cotter, Bhalla, Wallis, & Biram, 2012). Other models which use similar methods also perform poorly (Hummel, Katrapati, Gillespie, DeFranco, & Koelling, 2014). Little consensus is reached regarding best approaches and many systems are very similar to early works nearly 30 years old.
Unplanned hospital readmission is a costly problem in the United States, and in 2013 the U.S. federal government began to reduce payments to hospitals with preventable patient readmissions. Predictive modeling using machine learning and data analytics can be a useful decision support tool to help identify patients most likely to be readmitted. However, current systems have several shortcomings, such as difficulties in utilizing unstructured data and combining data from multiple hospitals. In this paper, we propose Latent Topic Ensemble Learning, which uses an ensemble of topic specific models to leverage data from multiple hospitals, as key data analytic algorithm for predicting hospital readmission. Models are built and evaluated incorporating federal financial penalties and tested using dataset containing data collected from 16 regional hospitals. It is found that LTEL significantly outperforms the best performing baseline method for readmission cost optimization.
Economic Impact of Chronic Heart Failure Management in Today's Cost-Conscious Environment
2019, Cardiac Electrophysiology Clinics
Citation Excerpt :
As a result, data from 3387 hospitals between 2007 and 2015 have demonstrated significant reductions in readmissions in target and nontarget conditions.46 A study of Medicare patients indicates that prior all-cause admissions within 12 months of an index admission for HF is a strong predictor of 30-day all-cause readmission.47 A 3-phase terrain of readmission risk after index HF hospitalization has been proposed by Chun and colleagues20 with the highest risk of readmissions the first 4 months after discharge and the last months of life.48
Lower Extremity Function Is Independently Associated With Hospitalization Burden in Heart Failure With Preserved Ejection Fraction
2019, Journal of Cardiac Failure
Citation Excerpt :
The variables comprising the HFPSI include blood urea nitrogen; B-type natriuretic peptide; NYHA class; the presence of diabetes or atrial arrhythmias; and prior all-cause hospitalizations, the strongest predictor of hospital admission in patients with HF. A simple integer score effectively divides patients with HF into 4 risk strata.19 For this analysis, we calculated the HFPSI score using data available at the time of SPPB assessment in the HFpEF clinic (Supplementary Table S3 provides a score calculation).
Frailty reflects decreased resilience to physiological stressors; its prevalence and prognosis are not fully defined in heart failure with preserved ejection fraction (HFpEF).
The Short Physical Performance Battery (SPPB) was prospectively obtained in 114 outpatients with HFpEF. The SPPB tests gait speed, tandem balance, and timed chair rises, each scored from 0 to 4 points. Severe and mild frailty were respectively defined as an SPPB score ≤6 and 7–9 points. We used risk-adjusted logistic, Poisson, and negative binominal regression, respectively, to assess the relationship between SPPB score and risk of death or all-cause hospitalization, number of hospitalizations, and days hospitalized or dead longer than 6 months.
Patients were similar to other HFpEF cohorts (age 68 ± 13 years, 58% female, body mass index 36 ± 8 kg/m², multiple comorbidities). Mean SPPB score was 6.9 ± 3.2, and 80% of patients were at least mildly frail. Over a 6-month period, the SPPB score independently predicted death or all-cause hospitalization (odds ratio 0.81 per point, 95% confidence interval [CI] 0.69–0.94, P = .006), number of hospitalizations (incidence rate ratio 0.92 per point, 95% CI 0.86–0.97, P = .006), and days hospitalized or dead (incidence rate ratio 0.85 per point, 95% CI 0.73–0.99, P = .04).
Lower extremity function, as measured by the SPPB, independently predicts hospitalization burden in outpatients with HFpEF. Additional studies are warranted to explore shared mechanisms and treatment implications of frailty in HFpEF.
Implementation of a Multidisciplinary Inpatient Cardiology Service to Improve Heart Failure Outcomes in Guyana
2018, Journal of Cardiac Failure
Citation Excerpt :
This program was created with the goal of improving cardiovascular outcomes through systematic implementation of evidence-based cardiac interventions with emphasis on sustainability and effective resource utilization. Despite evidence supporting the value of multidisciplinary cardiovascular care services for improving clinical outcomes,7–13 the impact in developing countries has not been well studied. The objective of the present study was to determine the effectiveness of a dedicated inpatient cardiac care program in a resource-poor setting for improving practitioner adherence to guideline-directed HF medical therapy (GDMT) and reducing hospital length of stay, readmission rates, and mortality.
Guyana is a small developing country with a high burden of cardiovascular disease and extensive barriers to optimal care delivery. We investigated the effectiveness of a newly established multidisciplinary inpatient cardiology service in this setting.
We performed an interrupted time-series cohort study of heart failure (HF) patients admitted to the Georgetown Public Hospital Corporation from January to December 2015 and July 2016 to December 2017. The primary outcome was discharge on guideline-directed medical therapy (GDMT). Secondary outcomes included length of hospitalization and all-cause mortality.
We identified 740 patients, 347 (46.9%) of whom were admitted after service implementation. The postimplementation cohort was more likely to be discharged on a beta-blocker (66.6% vs 41.7%; P < .01) and mineralocorticoid receptor antagonist (31.7% vs 15.3%; P = .01). They were also more likely to undergo echocardiography (60.8% vs 40.5%; P < .01) and chest x-rays (70.6% vs 46.6%; P < .01). Hospitalization length (10.0 ± 13.1 vs 9.8 ± 10.1 days) and readmissions within 90 days (19.0% vs 19.1%) were not significantly different. There were fewer deaths in the postimplementation cohort compared with the preimplementation cohort (12/347 vs 28/393).
Establishment of a multidisciplinary inpatient cardiology service demonstrated increased adherence to GDMT without extending length of hospitalization.
Dietary sodium restriction in heart failure: A recommendation worth its salt?
2016, JACC: Heart Failure

View all citing articles on Scopus

: Grant Support: The Mid-Michigan GAP-HF study was conducted in conjunction with the Greater Flint Health Coalition and was funded by unrestricted grants from AstraZeneca Pharmaceuticals, Pfizer, Inc, GlaxoSmithKline, and the Blue Cross Blue Shield of Michigan Foundation. The funding organizations had no role in the design and conduct of this study, the analysis of data, or the preparation of this article. Dr Hummel was supported by a grant from the National Institutes of Health (grant no. NIH/NHLBI K23HL109176). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Original articleImpact of Prior Admissions on 30-Day Readmissions in Medicare Heart Failure Inpatients

Abstract

Objective

Patients and Methods

Results

Conclusion

Section snippets

Definition of Variables Used

Patient Characteristics

Discussion

Conclusion

Am J Med

Am Heart J

JCHF

Am Heart J

J Card Fail

J Card Fail

Am J Med

J Am Coll Cardiol

Am Heart J

Am Heart J

J Am Coll Cardiol

Lancet

An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure

Circ Cardiovasc Qual Outcomes

“Dose-dependent” impact of recurrent cardiac events on mortality in patients with heart failure

Am J Med

Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure

Circulation

Original article
Impact of Prior Admissions on 30-Day Readmissions in Medicare Heart Failure Inpatients