Heart failure hospitalizations dropped 29.5 percent nationally over the past decade, largely because fewer patients were admitted rather than fewer admissions per patient, researchers found.
The risk-adjusted rate of heart failure hospitalization fell from 2,845 to 2,007 per 100,000 person-years from 1998 to 2008 in a fee-for-service Medicare claims analysis by Dr. Jersey Chen of Yale University and colleagues.
That decline -- the first ever documented in the U.S. -- likely saved $4.1 billion in Medicare costs since 1998, they reported in the Oct. 19 issue of the Journal of the American Medical Association.
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Lower incidence of heart failure risk factors; modest improvements in blood pressure control; better use of evidence-based therapies; and a shift toward outpatient management of heart failure may have been contributing factors, the group suggested.
The main reason for the drop in hospitalizations was fewer unique patients hospitalized for heart failure, down from 2,014 per 100,000 in 1998 to 1,462 per 100,000 in 2008.
One-year mortality after heart failure hospitalization also dropped modestly by a relative 6.6 percent over the same period, from a risk-adjusted rate of 31.7 percent to 29.6 percent.
An accompanying editorial pointed to the results as a sign of hope, though with plenty of room for improvement.
The "persistently" and "unacceptably" high one-year mortality rates suggested a need for immediate attention to heart failure postdischarge practices, wrote Dr. Mihai Gheorghiade of Northwestern University in Chicago and Dr. Eugene Braunwald of Brigham and Women's Hospital and Harvard in Boston.
They suggested using more aggressive treatment for subclinical congestion, taking a mechanistic approach to underlying cardiac abnormalities, boosting use of digoxin and mineralocorticoid antagonists and scheduling an early postdischarge visit.
"There is more work to be done," agreed Dr. Ralph Brindis, immediate past-president of the American College of Cardiology, in a statement. While overall trends are on the right track, not all groups benefited equally, he noted.
When Chen's group analyzed all heart failure hospitalizations nationally in a complete sample of Medicare fee-for-service claims from 1998 to 2008, they found that all sex and race groups showed reductions in heart failure hospitalizations.
But black men had the lowest rate of decline, with heart failure hospitalizations falling from 4,142 to 3,201 per 100,000 person-years over the study period. This improvement was a significant 19 percent less than other groups after adjusting for age.
The rates didn't fall evenly across states either.
Heart failure hospitalization changes happened significantly slower than the national mean in three states: Connecticut, Rhode Island, and Wyoming. One-year mortality rates actually increased in five states: South Dakota, Arizona, Alaska, Louisiana, and Kentucky.
"We must continue to work to understand the causes of these disparities in outcomes and continue to apply what we learn through research to improve care and prevention across the board," Brindis said in the statement.
The researchers cautioned that the study could not determine causality for any of the findings.
Other limitations were sole inclusion of a Medicare population, which may differ in heart failure hospitalization and mortality trends from a younger population with different insurance, and use of administrative codes not confirmed clinically.