Differences in health care use and outcomes by the timing of in-hospital worsening heart failure

Abstract

Background: Patients hospitalized with acute heart failure may experience worsening symptoms requiring escalation of therapy. In-hospital worsening heart failure is associated with worse in-hospital and postdischarge outcomes, but associations between the timing of worsening heart failure and outcomes are unknown.

Methods: Using data from a large clinical registry linked to Medicare claims, we examined characteristics, outcomes, and costs of patients hospitalized for acute heart failure. We defined in-hospital worsening heart failure by the use of inotropes or intravenous vasodilators or initiation of mechanical circulatory support, hemodialysis, or ventilation. The study groups were early worsening heart failure (n = 1,990), late worsening heart failure (n = 4,223), complicated presentation (n = 15,361), and uncomplicated hospital course (n = 41,334).

Results: Among 62,908 patients, those with late in-hospital worsening heart failure had higher in-hospital and postdischarge mortality than patients with early worsening heart failure or complicated presentation. Those with early or late worsening heart failure had more frequent all-cause and heart failure readmissions at 30 days and 1 year, with resultant higher costs, compared with patients with an uncomplicated hospital course.

Conclusion: Although late worsening heart failure was associated with the highest mortality, both early and late worsening heart failures were associated with more frequent readmissions and higher health care costs compared to uncomplicated hospital course. Prevention of worsening heart failure may be an important focus in the care of hospitalized patients with acute heart failure.

Figure

Kaplan-Meier Estimates of All-Cause Mortality, All-Cause Readmission, and Heart Failure Readmission Among Patients With Early or Late In-Hospital Worsening Heart Failure Panel A shows the Kaplan-Meier estimates of all-cause mortality at 1 year after admission from the index hospitalization for patients with early in-hospital worsening heart failure and late in-hospital worsening heart failure (P < .001). Panel B shows the Kaplan-Meier estimates of all-cause readmission at 1 year after discharge from the index hospitalization for patients with early in-hospital worsening heart failure and late in-hospital worsening heart failure (P = .03 for the unadjusted analysis; P = .60 for the adjusted analysis). Panel C shows the Kaplan-Meier estimates for heart failure readmission at 1 year after discharge from the index hospitalization for patients with early in-hospital worsening heart failure and late in-hospital worsening heart failure (P = .54 for the unadjusted analysis; P = .30 for the adjusted analysis).