Length of stay, mortality rate drops in elderly HF but not younger patients

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Younger patients have not experienced comparable declines in heart failure (HF) hospital stay, length of stay and in-hospital mortality as older patients, and black men remain a vulnerable population for HF hospital stay, according to a study published March 12 in the Journal of the American College of Cardiology.

The HF hospital stay rate has dropped substantially over the past decade in the Medicare population—nearly 30 percent from 1998 to 2008—implying some success in preventive efforts (JAMA 2011;306:1669-1678).

However, the etiology of HF often differs between younger adults and older Medicare beneficiaries, according to Jersey Chen, MD, MPH, of the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital in New Haven, Conn., and colleagues. They conducted the study to analyze recent trends over time in HF hospital stay rates, length of stay and in-hospital mortality by age groups with a large national dataset of U.S. hospital discharges.

Accordingly, they analyzed data from the National Inpatient Sample (NIS), a nationwide dataset of acute care hospital stays that includes all age groups and all types of health insurance coverage to examine changes across patient age categories in HF hospital stay rates, length of stay and in-hospital mortality between 2001 and 2009. Secondary analyses examined trends in HF hospital stay by race-sex categories.

The researchers identified hospital stays (1.69 million) with a primary discharge diagnosis of HF from NIS data between 2001 and 2009. The overall nationwide hospital stay rate decreased by 26.9 percent, from 633 to 463 hospital stays per 100,000 persons.

The authors wrote that their study adds to prior work by demonstrating the HF hospital stay rate did not decrease significantly for patients 18 to 44 years and 45 to 55 years of age, indicating that trends for HF hospital stay rate observed for older Medicare patients do not necessarily apply to younger populations.  

However, Chen et al observed statistically significant declines only for patients 55 to 64 years of age (36.5 percent), 65 to 74 years (37.4 percent) and 75 years and older (28.3 percent). While declines occurred in the younger populations, they were not statistically significant for patients 18 to 44 years of age (12.8 percent) or 45 to 55 years (16.2 percent). Likewise, statistically significant declines in length of stay were observed only for patients 65 years of age and older.

“Understanding the reasons for the lack of decline in length of stay in younger patients will ultimately require clinical data, but we speculate that it might be related in some part to differences in comorbidity burden,” they wrote. "Older patients typically have multiple comorbidities and perhaps more opportunities to reduce LOS [length of stay] through more intensive use of skilled nursing facilities or increased referral to hospice, both of which have increased in the Medicare population over the past decade.”

Overall in-hospital mortality fell from 4.5 percent to 3.3 percent, a relative decline of 27.4 percent, but patients 18 to 44 years of age did not exhibit a significant decline (8.1 percent). In secondary analyses, they observed significant declines in HF hospital stay rate over time for white men, white women and black women but not for black men—who saw a decline of only 9.5 percent. The authors speculated that black men had a slower rate of decline in HF hospital stays in part due to differences in risk factor management.

“Although the overall reduction in the HF hospital stay rate represents a success, our findings illustrate that challenges remain for ensuring comparable improvements for younger patients,” wrote the study authors. “One possible explanation for the lack of decline in HF hospital stay for younger patients is that HF risk factor control might have improved more in older patients.”