Epidemiology of Heart Failure in the United States

In 2010, nearly 7 million Americans 18 years of age and older had a diagnosis of HF; by 2030, an additional 3 million Americans will have the condition.^10,11 The incidence of HF increases with age; it affects 1 of every 100 people after 65 years of age.¹² Coronary disease and uncontrolled hypertension are the highest population-attributable risks for HF.¹³ Three-quarters of HF patients have antecedent hypertension.

Survival after HF diagnosis has improved over time, as shown by data from the Framingham Heart Study.^14,15 However, the death rate remains high: 50 percent of people diagnosed with HF die within 5 years after diagnosis.^14,15 Among Medicare beneficiaries, more than 30 percent of patients with HF die within 1 year after hospitalization.¹⁶

HF hospitalizations in the United States have declined by almost 30 percent during the past decade. However, national data show no evidence that readmission rates for HF patients have fallen during the past 2 decades.¹⁷

Heart Failure and Preventable Readmissions

Goldfield and colleagues defined a preventable readmission as one clinically related to the prior admission if there was a reasonable expectation that it could have been prevented by provision of quality care in the initial hospitalization, adequate discharge planning, adequate postdischarge followup, or improved coordination between inpatient and outpatient health care teams.¹⁸ Although hospital readmission within 30 days of discharge is a crude measure, it has long been used as a quality metric.

In 2007, the Medicare Payment Advisory Commission called for hospital-specific public reporting of readmission rates, identifying HF as a priority condition. The Commission stated that readmissions for HF were common, costly, and often preventable.¹⁹ An estimated 12.5 percent of admissions for HF were potentially preventable; this number is based on claims data analysis that identifies “red flags” in readmission diagnoses that are likely to represent conditions associated with a prior admission (and, therefore, likely preventable).²⁰

Readmissions following an index hospitalization for HF appear to be related to various conditions. An analysis of 2007 to 2009 Medicare claims data showed that 24.8 percent of beneficiaries admitted with HF were readmitted within 30 days; 35.2 percent of those readmissions were for HF, and the remainder of readmissions were for diverse indications (e.g., renal disorders, pneumonia, arrhythmias, and septicemia/shock).⁵ The broad range of conditions responsible for readmissions may reflect a “posthospitalization syndrome”—a generalized vulnerability to illness among recently discharged patients.^5,21

The relationship between readmission rates and other important outcomes (e.g., mortality, emergency room visits) is unclear. Some data suggest that hospitals with the lowest mortality rate among patients with HF tend to have higher readmission rates.²² Some predict that interventions aimed at reducing readmissions may increase use of other health care services, such as emergency room observational visits.²³

Transitional Care for People With Heart Failure

Poorly executed care transitions can lead to inappropriate use of hospital, emergency care, and other services. Recently, experts have used the phrase transitional care interventions to describe disease-management interventions targeted toward populations transitioning from one care setting to another.^7,24 Naylor and colleagues defined transitional care as “a broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another” (p.747).^7,24

Transitional care interventions overlap with other forms of care (primary care, care coordination, discharge planning, disease management and case management). However, they aim specifically to avoid poor clinical outcomes arising from uncoordinated care.²⁴

Similarly, the American Geriatrics Society defines transitional care as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location” (p. 30).²⁴ Interventions include logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. In general, the intended mechanism of action of these interventions is to prevent complications that can occur during the transition from one care setting to another (e.g., medication errors or misunderstanding of self-care instructions) and thus avoid unnecessary readmissions that result from those complications.

No clear consensus exists about when the transition period ends. Although evaluating 30-day readmissions is important for certain stakeholders (hospitals, payers, quality improvement organizations, health care providers), outcomes beyond this period are clinically important and may benefit from overall improvements in care. Outcomes far away from the index hospitalization probably reflect the natural history of HF or an unrelated illness, whereas a higher proportion of early readmissions are thought to be preventable. No clear recipe or set of intervention components defines transitional care interventions; interventions occurring at the patient, health care provider, facility, and system levels are emphasized throughout the care transition. Transitional care interventions tend to focus on the following: patient or caregiver education (including education on self-care, e.g., self-titrating diuretics), medication reconciliation, coordination with outpatient providers, arrangements for future care (e.g., home health, outpatient followup), and symptom monitoring or reinforcement of education during the transition (e.g., home visits, telephone support, or additional outpatient visits).

Existing Guidelines

The 2013 American Heart Association/American College of Cardiology (AHA/ACC) Heart Failure guidelines addressed postdischarge HF interventions.²⁵ These guidelines focus on the importance of optimizing HF pharmacotherapy before discharge, providing HF education before discharge (including self-care management), and addressing barriers to care among other factors. Specifically, the following components were noted as reasonable care options: a follow-up visit within 7 to 14 days of disease or a telephone followup within 3 days of discharge (or both).²⁶ The AHA/ACC guidelines also recommend initiating multidisciplinary (MDS)-HF disease management programs for patients at high risk for readmission.

The 2010 Heart Failure Society of America guidelines are similar; their guidance emphasizes particular components of discharge planning.²⁷ The Society does not provide specific guidance on the optimal components of transitional care interventions aimed at preventing readmissions for patients with HF.

Current Practice

Several national performance measures pertain to the standard of care for hospital discharge of HF patients. The Joint Commission performance measures mandate that all patients with HF should receive comprehensive written discharge instructions or other educational materials that address activity level, diet, discharge medications, follow-up appointment, weight monitoring, and planned actions to take should symptoms worsen.²⁸ Hospitals publicly report these measures. In 2011, the ACC/AHA/AMA (American Medical Association) Performance Consortium added a documented postdischarge appointment to the list of recommended HF performance measures.²⁹ Required documentation includes location, date, and time for a follow-up office visit or home health care visit.

Current clinical practice in the care of adults with HF after hospitalization is quite diverse. A recent telephone survey of 100 U.S. hospitals found wide variation in education, discharge processes, care transition, and quality-improvement methods for patients hospitalized with HF.¹⁷ Readmission rates vary by both geographic location and insurance coverage.⁶