Predictors of Early Readmission in Heart Failure Patients in an Inner-City Community Hospital

Fafa Xexemeku, Arti Singh, Yaw Amoateng Adjepong, Stuart Zarich

Department of Medicine, Bridgeport Hospital, Yale University, Bridgeport, USA.
Division of Cardiology, Department of Medicine, Bridgeport Hospital, Yale University, Bridgeport, USA.

DOI: 10.4236/wjcd.2014.49057                

Abstract

Heart failure (HF) is the most common hospital discharge diagnosis among the elderly. It accounts for nearly 1.4 million hospitalizations and $21 billion in spending per year in the United States. Readmission rates remain high with estimates ranging from 15-day readmission rates of 13%, 30- day readmission rates of 25%, to 6-month readmission rates of 50%. The Center for Medicare and Medicaid Services (CMS) has started penalizing hospitals with higher than expected readmission rates. Objective: To identify factors associated with increased 30-day readmission among heart failure patients in an inner-city community-based teaching hospital. Methods: A retrospective cohort study of patients with principal discharge diagnosis of acute Heart Failure between 2008 and 2010. Demographic, clinical characteristics, length of stay, discharge medications, disposition and all-cause 30-day readmission were abstracted from the hospital’s administrative database and analyzed. Results: Almost 8 out of 10 patients were 65 years or older (mean age 75.4 ± 14.3) and 51% were female. The in-hospital mortality rate was 2.7% (95% confidence interval [CI], 1.6% - 4.3%) with a median length of stay of 5.0 days (Interquartile range of 3 - 7). The all-cause 30-day readmission rate was 17.7% (95% CI 14.9% - 20.8%). By univariate analysis, readmissions were predicted by black race, prior history of HF, length of stay of more than 7 days and discharge to extended care facility (ECF). By logistic regression analysis, black race (OR 2.4, 95% CI 1.4 - 3.8), prior history of HF (OR 1.7, 95% CI 1.5 - 2.6) and discharge to an ECF (OR 2.4, 95% CI 1.5 - 3.7) were the independent predictors of 30-day readmission. HF accounted for 43.7% of the readmissions. Conclusion: Prior diagnosis of HF, black race, and discharge to an ECF were independent predictors of 30-day readmission in this cohort, and over half of the readmissions were for reasons other than HF.

Keywords

Heart Failure, Readmissions, Predictors

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Bueno, H., Ross, J.S., Wang, Y., Chen, J., Vidán, M.T., et al. (2010) Trends in Length of Stay and Short-Term Outcomes among Medicare Patients Hospitalized for Heart Failure, 1993-2006. JAMA, 21, 2141-2147. http://dx.doi.org/10.1001/jama.2010.748
[2]	Rosamond, W., Flegal, K., Furie, K., Go, A., Greenlund, K., et al. (2008) Heart Disease and Stroke Statistics—2008 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 4, e25-e146.
[3]	Lloyd-Jones, D., Adams, R.J., Brown, T.M., Carnethon, M., Dai, S., et al. (2010) Heart Disease and Stroke Statistics—2010 Update: A Report from the American Heart Association. Circulation, 7, e46-e215.
[4]	Keenan, P.S., Normand, S.L., Lin, Z., Drye, E.E., Bhat, K.R., et al. (2008) An Administrative Claims Measure Suitable for Profiling Hospital Performance on the Basis of 30-Day All Cause Readmission Rates among Patients with Heart Failure. Circulation: Cardiovascular Quality and Outcomes, 1, 29-37. http://dx.doi.org/10.1161/CIRCOUTCOMES.108.802686
[5]	Jencks, S.F., Williams, M.V. and Coleman, E.A. (2009) Rehospitalizations among Patients in the Medicare Fee-forService Program. The New England Journal of Medicine, 360, 1418-1428. http://dx.doi.org/10.1056/NEJMsa0803563
[6]	Hackbarth, G.M. and Reischauer, R.D. (2007) Medicare Payment Advisory Commission (MedCAP). Report to the Congress: Creating Greater Efficiency in Medicare. http://www.medpac.gov/documents/Jun07_EntireReport.pdf
[7]	Bradley, E.H., Curry, L., Horwitz, L.I., Sipsma, H., Wang, Y., et al. (2013) Hospital Strategies Associated with 30-Day Readmission Rates for Patients with Heart Failure. Circulation: Cardiovascular Quality and Outcomes, 4, 444-450. http://dx.doi.org/10.1161/CIRCOUTCOMES.111.000101
[8]	Silverstein, M.D., Qin, H., Mercer, S.Q., Fong, J. and Haydar, Z. (2008) Risk Factors for 30-Day Hospital Readmission in Patients ≥65 Years of Age. Proceedings (Baylor University. Medical Center), 4, 363-372.
[9]	Krumholz, H.M., Parent, E.M., Tu, N., Vaccarino, V., Wang, Y., et al. (1997) Readmission after Hospitalization for Congestive Heart Failure among Medicare Beneficiaries. Archives of Internal Medicine, 1, 99-104. http://dx.doi.org/10.1001/archinte.1997.00440220103013
[10]	Ross, J.S., Chen, J., Lin, Z., Bueno, H., Curtis, J.P., et al. (2010) Recent National Trends in Readmission Rates after Heart Failure Hospitalization. Circulation: Heart Failure, 1, 97-103. http://dx.doi.org/10.1161/CIRCHEARTFAILURE.109.885210
[11]	Krumholz, H.M., Chen, Y.T., Wang, Y., Vaccarino, V., Radford, M.J. and Horwitz, R.I. (2000) Predictors of Readmission among Elderly Survivors of Admission with Heart Failure. American Heart Journal, 139, 72-77. http://dx.doi.org/10.1016/S0002-8703(00)90311-9
[12]	Philbin, E.F. and DiSalvo, T.G. (1999) Prediction of Hospital Readmission for Heart Failure: Development of a Simple Risk Score Based on Administrative Data. Rev Port Cardiol, 9, 855-856.
[13]	Chin, M.H. and Goldman, L. (1997) Correlates of Early Hospital Readmission or Death in Patients with Congestive Heart Failure. American Journal of Cardiology, 79, 1640-1644. http://dx.doi.org/10.1016/S0002-9149(97)00214-2
[14]	Felker, G.M., Leimberger, J.D., Califf, R.M., Cuffe, M.S., Massie, B.M., Adams Jr., K.F., Gheorghiade, M. and O’Connor, C.M. (2004) Risk Stratification after Hospitalization for Decompensated Heart Failure. Journal of Cardiac Failure, 10, 460-466. http://dx.doi.org/10.1016/j.cardfail.2004.02.011
[15]	Yamokoski, L.M., Hasselblad, V., Moser, D.K., Binanay, C., Conway, G.A., Glotzer, J.M., Hartman, K.A., Stevenson, L.W. and Leier, C.V. (2007) Prediction of Rehospitalization and Death in Severe Heart Failure by Physicians and Nurses of the ESCAPE Trial. Journal of Cardiac Failure, 13, 8-13. http://dx.doi.org/10.1016/j.cardfail.2006.10.002
[16]	Muzzarelli, S., Leibundgut, G., Maeder, M.T., Rickli, H., Handschin, R., Gutmann, M., et al. (2010) Predictors of Early Readmission or Death in Elderly Patients with Heart Failure. American Heart Journal, 160, 308-314. http://dx.doi.org/10.1016/j.ahj.2010.05.007
[17]	Goldenberg, I., Moss, A.J., Hall, W.J., McNitt, S., Zareba, W., Andrews, M.L., Cannom, D.S. for the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II Investigators (2006) Causes and Consequences of Heart Failure after Prophylactic Implantation of a Defibrillator in the Multicenter Automatic Defibrillator Implantation Trial II. Circulation, 113, 2810-2817. http://dx.doi.org/10.1161/CIRCULATIONAHA.105.577262
[18]	Damman, K., Navis, G., Voors, A.A., Asselbergs, F.W., Smilde, T.D., Cleland, J.G.F., van Veldhuisen, D.J. and Hillege, H.L. (2007) Worsening Renal Function and Prognosis in Heart Failure: Systematic Review and Meta-Analysis. Journal of Cardiac Failure, 13, 599-608. http://dx.doi.org/10.1016/j.cardfail.2007.04.008
[19]	Felker, G.M., Gattis, W.A., Leimberger, J.D., Adams, K.F., Cuffe, M.S., Gheorghiade, M. and O’Connor, C.M. (2003) Usefulness of Anemia as a Predictor of Death and Rehospitalization in Patients with Decompensated Heart Failure. American Journal of Cardiology, 92, 625-628. http://dx.doi.org/10.1016/S0002-9149(03)00740-9
[20]	Manzano-Fernández, S., Boronat-Garcia, M., Albaladejo-Otón, M.D., Pastor, P., Garrido, I.P., Pastor-Pérez, F.J., Martínez-Hernández, P., Valdés, M. and Pascual-Figal, D.A. (2009) Complementary Prognostic Value of Cystatin C, N-Terminal Pro-B-Type Natriuretic Peptide and Cardiac Troponin T in Patients with Acute Heart Failure. American Journal of Cardiology, 103, 1753-1759. http://dx.doi.org/10.1016/j.amjcard.2009.02.029
[21]	Alexander, M., Grumbach, K., Remy, L., Rowell, R. and Massie, B.M. (1999) Congestive Heart Failure Hospitalizations and Survival in California: Patterns According to Race/Ethnicity. American Heart Journal, 137, 919-927. http://dx.doi.org/10.1016/S0002-8703(99)70417-5
[22]	Joynt, K.E., Orav, E.J. and Jha, A.K. (2011) Thirty-Day Readmission Rates for Medicare Beneficiaries by Race and Site of Care. JAMA, 305, 675-681. http://dx.doi.org/10.1001/jama.2011.123
[23]	Philbin, E.F. and DiSalvo, T.G. (1999) Prediction of Hospital Readmission for Heart Failure: Development of a Simple Risk Score Based on Administrative Data. Journal of the American College of Cardiology, 33, 1560-1566. http://dx.doi.org/10.1016/S0735-1097(99)00059-5
[24]	Vinson, J.M., Rich, M.W., Sperry, J.C., Shah, A.S. and McNamara, T. (1990) Early Readmission of Elderly Patients with Congestive Heart Failure. Journal of the American Geriatrics Society, 38, 1290-1295.
[25]	Allen, L.A., Hernandez, A.F., Peterson, E.D., Curtis, L.H., Dai, D., Masoudi, F.A., Bhatt, D.L., Heidenreich, P.A. and Fonarow, G.C. (2011) Discharge to a Skilled Nursing Facility and Subsequent Clinical Outcomes among Older Patients Hospitalized for Heart Failure. Circulation: Heart Failure, 4, 293-300. http://dx.doi.org/10.1161/CIRCHEARTFAILURE.110.959171