Heart Failure Puts Fewer in Hospital

Heart Failure Puts Fewer in Hospital - WSJ.com online.wsj.com By RON WINSLOW and SHIRLEY S. WANG Hospital admissions for elderly U.S. patients with heart failure fell by nearly 30% over a decade, an analysis of federal Medicare data shows, a surprising finding that offers fresh evidence of progress in the battle against cardiovascular disease. The report, being published Wednesday in the Journal of the American Medical Association, is the first to document a decline in admissions in the U.S. for the condition, an enormously costly problem and the most common reason for hospitalization among Medicare beneficiaries. Hospital admissions for elderly U.S. patients with heart failure fell by nearly 30% in the past decade, a surprising finding that offers fresh evidence of progress in the battle against heart disease. Stefanie Ilgenfritz has details on The News Hub. The finding is based on data from more than 55 million patients in Medicare’s conventional fee-for-service program who were hospitalized for heart failure between 1999 and 2008. Researchers estimated there were 229,000 fewer admissions for heart failure in 2008 than would have been expected had the rate of admissions remained at 1999 levels. The analyses were conducted on data collected from 1998 through 2008. As a result of the improvement, the Medicare program saved an estimated $4.1 billion in hospital costs related to heart failure, according to the report. Heart disease overall is still the leading cause of death in the U.S., and this latest research comes with caveats. For heart-failure patients who were hospitalized, death rates one year after that fell only slightly—to 29.6% in 2008 from 31.7% in 1999. Hospitalization rates also varied significantly by state, and the improvement for black men was smaller than that of other groups. But the gains, coming as the population ages and as obesity and diabetes—both risk factors for heart disease—are enormous public-health concerns, were a welcome surprise to some experts. Many attributed the improvements to better preventive measures and disease management, as well as a reduction in elderly rates of heart attack—a common cause of heart failure. “At a time when we bemoan a lot of things in health care, this is a remarkable success story,” says Harlan Krumholz, a Yale University cardiologist and senior author of the study. Heart failure is a progressive weakening of the heart’s ability to pump blood to the rest of body that in late stages typically results in accumulation of fluid in the lungs and lower extremities. It is often accompanied by poor kidney function and other problems. The American Heart Association estimates that total costs for treating patients with heart failure, including associated indirect costs, were $39.2 billion in 2010. Dr. Krumholz and his colleagues, including first author Jersey Chen, also a Yale cardiologist, said they couldn’t say with certainty what is behind the admissions decline. But Dr. Krumholz’s team in a separate analysis of Medicare data 18 months ago reported a 23% decline in admissions for heart attacks. Because they damage the heart muscle, heart attacks can lead to heart failure. Ralph Brindis, immediate past-president of the American College of Cardiology and a senior adviser for cardiovascular disease at Northern California Kaiser Permanente, said he was “moderately surprised and encouraged” by the finding in light of the aging of the population. The improvements likely reflect better prevention and early treatment of high blood pressure and coronary-artery disease, said Dr. Brindis, who wasn’t involved in the study. These factors include reductions in the smoking rate and lowering cholesterol levels using drugs known as statins, as well as diet. John Harold, a cardiologist at Cedars-Sinai Heart Institute in Los Angeles, said he has seen fewer patients admitted for heart failure and heart attacks. He and other doctors have a greater awareness of the risk factors for heart failure as well as a better arsenal of treatment. When a patient with heart failure comes in to see him—Dr. Harold was scheduled to see five such patients on Tuesday—he addresses their blood pressure and weight, as well as their smoking and control over their diabetes if applicable. He believes patients are generally more educated now about health, such as the consequences of smoking, compared with the 1990s, and are more willing to change their behavior. They are now recruited to participate in their care in a way they weren’t before, he says. He will ask patients to chart their weight daily and alert him if it fluctuates by two or three pounds in a short period, because fluid gain could be a sign that something is wrong. Guidelines for treating heart failure, which were issued for the first time by the American College of Cardiology and American Heart Association in 1998, also have helped doctors, according to Dr. Harold, who serves as vice president of the ACC. Though obesity continues to bedevil Americans, its rate has steadied in recent years. By 2008, nearly 70% of the U.S. adult population was considered overweight or obese, but that number hadn’t changed for women since 1999 and for men since 2003, according to the Centers for Disease Control and Prevention. Smoking rates, on the other hand, dropped to 20.8% in 2007 from 23.3% in 2000 of U.S. adults 18 and older, according to the CDC. “This is occurring in a period without a major game-changing breakthrough in treatment,” Dr. Krumholz said. He also noted that hospital readmissions for heart failure weren’t reduced during the study period. That suggests the benefit was significantly in patients who avoided the hospital to begin with. Drugs that reduce high cholesterol, which are largely statins, were the most popular class of medication in 2008, with 202 million prescriptions dispensed, up from 145 million in 2004, according to IMS Health, which tracks prescription drugs. Other drugs that treat heart failure or heart disease, including beta blockers and ACE inhibitors, were also among the top 10 classes of drug dispensed in 2008 and up from five years earlier. Beyond that, Dr. Krumholz, the study’s senior author, said a focus in the past decade on quality improvement and treating patients according to evidence-based guidelines—including better use of medications in people at risk for heart failure—may be paying dividends. Clyde Yancy, chief of cardiology at Northwestern University and a spokesman for the American Heart Association, noted that for patients who did wind up in the hospital, the death rates one year later didn’t decline dramatically over that same period—a finding that he said wasn’t surprising. Such patients usually have other medical conditions as well, and they may end up dying because of one of those other reasons, he said. Dr. Yancy, who wasn’t involved with the study, signaled some items of concern in the report. Some populations, such as black men and those in certain regions across the country, didn’t fare as well as others, prompting questions about whether differences in access to or quality in care might be responsible for the disparities, he said. Write to Ron Winslow at ron.winslow@wsj.com and Shirley S. Wang at shirley.wang@wsj.com