Is 30-Day Mortality after Admission for Heart Failure an Appropriate Metric for Quality?

Abstract

BACKGROUND:

The Centers for Medicare and Medicaid Services (CMS) model for publicly reporting national 30-day-risk-adjusted mortality rates for patients admitted with heart failure fails to include clinical variables known to impact total mortality or take into consideration the culture of end-of-life care. We sought to determine if those variables were related to the 30-day mortality of heart failure patients at Geisinger Medical Center.

METHODS:

Electronic records were searched for patients with a diagnosis of heart failure who died from any cause during hospitalization or within 30 days of admission.

RESULTS:

There were 646 heart-failure-related admissions among 530 patients (1.2 admissions/patient). Sixty-seven of the 530 (13%) patients died: 35 (52%) died during their hospitalization and 32 (48%) died after discharge but within 30 days of admission; of these, 27 (40%) had been transferred in for higher-acuity care. Fifty-one (76%) died from heart failure, and 16 (24%) from other causes. Fifty-five (82%) patients were classified as American Heart Association Stage D, 58 (87%) as New York Heart Association Class IV, and 30 (45%) had right-ventricular systolic dysfunction. None of the 32 patients who died after discharge met recommendations for beta-blockers. Criteria for prescribing angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor blockers were not met by 33 of the 34 patients (97%) with heart failure with reduced ejection fraction not on one of those drugs. Fifty-seven patients (85%) had a do-not-resuscitate (DNR) status.

CONCLUSION:

A majority of heart failure-related mortality was among patients who opted for a DNR status with end-stage heart failure, limiting the appropriateness of administering evidence-based therapies. No care gaps were identified that contributed to mortality at our institution. The CMS 30-day model fails to take important variables into consideration.

• Authors: Robert T Faillace, Gregory W Yost, Yashasvi Chugh, Jeffrey Adams, Beni R Verma, Zaid Said, Ibrahim Ismail Sayed, Ashley Honushefsky, Sanjay Doddamani, Peter B Berger
• Journal: The American journal of medicine (Am J Med) Vol. 131 Issue 2 Pg. 201.e9-201.e15 (02 2018) ISSN: 1555-7162 [Electronic] United States
• PMID: 28941750 (Publication Type: Journal Article)
• Copyright: Copyright © 2018 Elsevier Inc. All rights reserved.

Chemical References

• Cardiovascular Agents

Topics

• Adolescent
• Adult
• Aged
• Cardiac Resynchronization Therapy Devices
• Cardiovascular Agents (therapeutic use)
• Cause of Death
• Contraindications, Drug
• Contraindications, Procedure
• Electric Countershock
• Evidence-Based Medicine
• Female
• Heart Failure (classification, mortality, therapy)
• Hospital Mortality
• Hospitalization
• Humans
• Male
• Middle Aged
• Quality of Health Care
• Resuscitation Orders
• Terminal Care (standards)
• Young Adult