Postdischarge Mortality Remains Unchanged Despite Advances in Heart Failure Care

Despite significant progress in heart failure care and a decrease in in-hospital deaths, mortality rates after hospitalization discharge have shown little improvement since 2010 among Medicare beneficiaries, according to a new study published in JAMA Network Open.¹

Researchers analyzed data from more than 1.25 million Medicare fee-for-service beneficiaries hospitalized with incident heart failure from 2008 to 2018, with a mean (SD) age of 83 (7.6) years and with most (86%) being White. They measured unadjusted and risk-adjusted mortality rates across several periods after heart failure hospitalization: in hospital, 30 days after discharge, short-term (31 days to 1 year), intermediate-term (1-2 years), and long-term (2-3 years).

While in-hospital deaths substantially decreased by 26%—23% when not adjusted—during the study period, postdischarge mortality ratios actually increased from 2008 to 2013, then decreased again until 2018, overall remaining largely unchanged.

Heart failure mortality rates after hospitalization discharge have shown little improvement since 2010 | Image credit: Spiroview Inc. – stock.adobe.com

When focusing on risk-adjusted mortality rates, the biggest reduction occurred within the first 30 days after discharge, with a 12% lower risk of death. However, this improvement gradually diminished over time, with the risk reduction dropping to 6% for both short-term and intermediate-term periods and further decreasing to just 5% for long-term mortality.

“Our results suggest that future efforts to improve HF [heart failure] care that are focused on longitudinal outpatient follow-up may represent the greatest opportunity for patient benefit,” the researchers said.

HFrEF and HFpEF Mortality

The percentage of patients diagnosed with unspecified heart failure dropped significantly, from 51% in 2008 to just 3.8% in 2018. Among patients with a more specific diagnosis, the ratio of those with heart failure with reduced ejection fraction (HFrEF) compared with those with heart failure with preserved ejection fraction (HFpEF) declined from 1.1 in 2008 to 0.8 in 2018.

Risk-adjusted mortality rates were generally similar between patients with HFrEF and those with HFpEF during each period studied, but there was a slightly larger but not statistically significant drop in in-hospital death rates for patients with HFpEF (14%) compared with HFrEF (8%). Patients with HFpEF also experienced a more pronounced decline in postdischarge mortality during the later years of the study.

“Although our study suggests a slightly larger decrease in in-hospital mortality for patients with HFpEF compared with patients with HFrEF, it was not designed to evaluate the causes of mortality findings,” the researchers noted. “The improvements in in-hospital mortality for patients with HFpEF may reflect improvements in care for noncardiovascular conditions, such as diabetes and pulmonary diseases, for which patients with HFpEF typically have a larger burden compared with patients with HFrEF.”

A previous study found that as patients with heart failure get older, a smaller percentage of deaths are caused by cardiovascular issues.² Specifically, in patients over 65 with HFpEF, less than half of the deaths were linked to cardiovascular causes. More research is needed to confirm and explore these potential differences in mortality between HFpEF and HFrEF.

What This Adds to Existing Research

Previous research has mainly focused on overall heart failure mortality within specific time frames, such as 30 days or 1 year, finding improvements in in-hospital mortality but potential increases in 30-day mortality between 2010 and 2013. One recent study reported a rise in heart failure–related deaths from 2012 to 2021, but its conclusions were limited by the use of death certificate data, which can sometimes misclassify causes of death.³

In contrast, the current study builds on existing knowledge in several ways. It assessed mortality changes across specific follow-up periods, extending the analysis up to 3 years after discharge, and focused on patients with an initial heart failure hospitalization, a critical period when multiple heart failure treatments are typically recommended. Additionally, by incorporating both unadjusted and risk-adjusted analyses, the study offers a clearer picture of mortality trends without the potential bias of changing diagnostic codes, according to the researchers.

Over the past 2 decades, advances in heart failure management, including new medications, technologies, and devices, have shown in clinical trials that they can significantly improve patient survival. For example, comprehensive treatment for HFrEF can extend an 80-year-old patient's life by over a year.

However, this study suggests that real-world outcomes for Medicare patients after an initial heart failure hospitalization don’t fully match these trial results. The researchers explained that while postdischarge mortality slightly increased in the early years of the study, likely due to factors like more severe illness or health care policy changes, modest improvements were seen from 2013 onward, possibly due to better use of guideline-directed therapies. Despite these advances, barriers such as low cardiac rehabilitation participation and underuse of advanced treatments may limit long-term benefits.

“The small mortality improvements observed for long-term mortality in the later years of our study may reflect greater recognition and use of these programs and treatments,” the researchers wrote.

References

1. Vohra AS, Moghtaderi A, Luo Q, et al. Trends in mortality after incident hospitalization for heart failure among Medicare beneficiaries. JAMA Netw Open. 2024;7(8):e2428964. doi:10.1001/jamanetworkopen.2024.28964
2. Nakamaru R, Shiraishi Y, Sandhu AT, et al. Cardiovascular vs. non-cardiovascular deaths after heart failure hospitalization in young, older, and very old patients. ESC Heart Fail. 2023;10(1):673-684. doi:10.1002/ehf2.14245
3. Sayed A, Abramov D, Fonarow GC, et al. Reversals in the decline of heart failure mortality in the US, 1999 to 2021. JAMA Cardiol. 2024;9(6):585-589. doi:10.1001/jamacardio.2024.0615