Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California.
Keio University School of Medicine, Tokyo, Japan.
JAMA Cardiol. 2020 Sep 1;5(9):1042-1047. doi: 10.1001/jamacardio.2020.2028.
The Centers for Medicare & Medicaid Services and the Veterans Affairs Health Care System provide incentives for hospitals to reduce 30-day readmission and mortality rates. In contrast with the large body of evidence describing readmission and mortality in the Medicare system, it is unclear how heart failure readmission and mortality rates have changed during this period in the Veterans Affairs Health Care System.
To evaluate trends in readmission and mortality after heart failure admission in the Veterans Affairs Health Care System, which had no financial penalties, in a decade involving focus on heart failure readmission reduction (2007-2017).
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from all Veterans Affairs-paid heart failure admissions from January 2007 to September 2017. All Veterans Affairs-paid hospital admissions to Veterans Affairs and non-Veterans Affairs facilities for a primary diagnosis of heart failure were included, when the admission was paid for by the Veterans Affairs. Data analyses were conducted from October 2018 to March 2020.
Admission for a primary diagnosis of heart failure at discharge.
Thirty-day all-cause readmission and mortality rates.
A total of 164 566 patients with 304 374 hospital admissions were included. Among the 304 374 hospital admissions between 2007 and 2017, 298 260 (98.0%) were for male patients, and 195 205 (64.4%) were for white patients. The mean (SD) age was 70.8 (11.5) years. The adjusted odds ratio of 30-day readmission declined throughout the study period to 0.85 (95% CI, 0.83-0.88) in 2015 to 2017 compared with 2007 to 2008. The adjusted odds ratio of 30-day mortality remained stable, with an adjusted odds ratio of 1.01 (95% CI, 0.96-1.06) in 2015 to 2017 compared with 2007 to 2008. Stratification by left ventricular ejection fraction showed similar readmission reduction trends and no significant change in mortality, regardless of strata.
In this analysis of an integrated health care system that provided guidance and nonfinancial incentives for reducing readmissions, such as public reporting of readmission rates, risk-adjusted 30-day readmission declined despite inclusion of clinical variables in risk adjustment, but mortality did not decline. Future investigations should focus on evaluating the effectiveness of specific approaches to readmission reduction to inform efficient and effective application in individual health systems, hospitals, and practices.
医疗保险和医疗补助服务中心和退伍军人事务医疗保健系统为医院提供激励措施，以降低 30 天再入院率和死亡率。与描述医疗保险系统中再入院和死亡率的大量证据相反，退伍军人事务医疗保健系统在此期间心力衰竭再入院率和死亡率的变化情况尚不清楚。
评估退伍军人事务医疗保健系统（在十年期间内一直关注心力衰竭再入院率的降低，没有财务处罚）中心力衰竭入院后再入院和死亡率的趋势，该系统从 2007 年到 2017 年。
设计、地点和参与者：这项队列研究使用了 2007 年 1 月至 2017 年 9 月期间所有退伍军人事务支付的心力衰竭入院数据。所有退伍军人事务支付的医院入院治疗心力衰竭的主要诊断，当入院由退伍军人事务支付时，包括退伍军人事务和非退伍军人事务设施的所有主要诊断为心力衰竭的住院治疗。数据分析于 2018 年 10 月至 2020 年 3 月进行。
因心力衰竭出院时的主要诊断。
30 天全因再入院率和死亡率。
共纳入 164566 例患者，共 304374 例住院。在 2007 年至 2017 年期间的 304374 例住院中，298260 例（98.0%）为男性患者，195205 例（64.4%）为白人患者。平均（SD）年龄为 70.8（11.5）岁。与 2007 年至 2008 年相比，2015 年至 2017 年期间，30 天再入院的调整后比值比下降至 0.85（95%CI，0.83-0.88）。30 天死亡率的调整后比值比保持稳定，2015 年至 2017 年与 2007 年至 2008 年相比，调整后比值比为 1.01（95%CI，0.96-1.06）。无论分层如何，分层显示左心室射血分数的再入院减少趋势相似，死亡率无显著变化。
在这项对提供指导和非财务激励措施以降低再入院率的综合医疗保健系统的分析中，尽管在风险调整中纳入了临床变量，但 30 天再入院率下降，尽管包括了临床变量，但死亡率并未下降。未来的研究应侧重于评估降低再入院率的具体方法的有效性，以告知在个别卫生系统、医院和实践中进行有效和有效的应用。
