Circulation: Hospital ratings for elderly heart failure should look beyond death records

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Looking only at the costs of treatment for elderly patients who died from heart failure ignores important differences between hospitals—such as survival rates—and overlooks potential associations between more resource use and better survival rates, according to a study published online Oct. 13 in Circulation: Cardiovascular Quality and Outcomes.

Researchers analyzed 3,999 people, average age 80, hospitalized with a principal diagnosis of heart failure at six California teaching hospitals between Jan. 1, 2001 and June 30, 2005. They assessed total hospital days, total hospital direct costs and death within 180 days after initial admission—called the “Looking Forward” method.

The study used a "Looking Forward" approach that examined the complete hospitalization process for heart failure patients; this approach compares with the "Looking Back" approach used in prior studies—an approach that examines only hospitalized individuals in the last six months of life.

Michael K. Ong, MD, PhD, from the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues analyzed a subset of 1,639 individuals, average age 82, who died during the study period for total hospital days and total hospital direct costs within 180 days before death (“Looking Back”).

The study found variation among California teaching hospitals in survival for patients hospitalized with heart failure. This variation would have been overlooked by a “Looking Back” study that only examined heart failure patients who died, according to the authors.

The investigators also found that:

  • Analyzing all patients hospitalized for heart failure showed that California teaching hospitals that used more resources (financial, personnel, etc.) had lower death rates.
  • Analyzing all patients hospitalized for heart failure showed that when “Looking Forward” the variation in resource use among California teaching hospitals was 27 percent to 44 percent less than the variation observed when “Looking Back” (analyzing only heart failure patients who died).

The "Looking Forward” risk-adjusted hospital means ranged from 17 percent to 26 percent for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs, according to Ong and colleagues. However, they reported that the “Looking Back" risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs.

The researchers concluded that focusing only on patients who died may overlook important associations. They wrote that “the ‘Looking Back’ method ignores the possibility that resource-intensive care may improve survival, and therefore identifies resource-intensive care as inherently inefficient.”