Hospital Performance and Long-Term Survival After HF Hospitalization

Study Questions:

What is the association of hospital-specific 30-day risk-standardized mortality rate (RSMR) with long-term survival among patients hospitalized with heart failure (HF) in the American Heart Association Get With The Guidelines–HF registry?


The investigators conducted a longitudinal observational study of 106,304 patients with HF who were admitted to 317 centers participating in the Get With The Guidelines–HF registry from January 1, 2005, to December 31, 2013, and had Medicare-linked follow-up data. Hospital-specific 30-day RSMR was calculated using a hierarchical logistic regression model. In the model, 30-day mortality rate was a binary outcome, patient baseline characteristics were included as covariates, and the hospitals were treated as random effects. The association of 30-day RSMR-based hospital groups (low to high 30-day RSMR: quartile 1 [Q1] to Q4) with long-term (1-year, 3-year, and 5-year) mortality was assessed using adjusted Cox models. Data analysis took place from June 29, 2017, to February 19, 2018. The main outcome measures were 1-year, 3-year, and 5-year mortality rates.


Of the 106,304 patients included in the analysis, 57,552 (54.1%) were women and 84,595 (79.6%) were white, and the median (interquartile range) age was 81 (74-87) years. The 30-day RSMR ranged from 8.6% (Q1) to 10.7% (Q4). Hospitals in the low 30-day RSMR group had greater availability of advanced HF therapies, cardiac surgery, and percutaneous coronary interventions. In the primary landmarked analyses among 30-day survivors, there was a graded inverse association between 30-day RSMR and long-term mortality (Q1 vs. Q4: 5-year mortality, 73.7% vs. 76.8%). In adjusted analysis, patients admitted to hospitals in the high 30-day RSMR group had 14% (95% confidence interval [CI], 10-18) higher relative hazards of 5-year mortality compared with those admitted to hospitals in the low 30-day RSMR group. Similar findings were observed in analyses of survival from admission, with 22% (95% CI, 18-26) higher relative hazards of 5-year mortality for patients admitted to Q4 vs. Q1 hospitals.


The authors concluded that lower hospital-level 30-day risk-standardized mortality rate is associated with greater 1-year, 3-year, and 5-year survival for patients with HF.


This longitudinal observational study reports a long-term survival advantage associated with care at centers with lower 30-day RSMR for patients hospitalized with HF. There were significant differences in adherence to certain process-of-care measures, with higher use of implantable cardioverter-defibrillators and cardiac resynchronization therapies, greater postdischarge follow-up, and greater use of advanced HF therapies at hospitals with low versus high 30-day RSMR, highlighting the potential role of quality of care in contributing to differences in long-term survival across these hospitals. These findings underscore the need to increase the focus on 30-day RSMR as a performance metric to optimize quality care and thereby improve long-term clinical outcomes for patients with HF.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: ACC18, ACC Annual Scientific Session, Cardiac Resynchronization Therapy, Cardiac Surgical Procedures, Defibrillators, Implantable, Geriatrics, Hospital Mortality, Hospitalization, Medicare, Outcome Assessment (Health Care), Percutaneous Coronary Intervention, Quality of Health Care, Risk Assessment, Secondary Prevention, Heart Failure

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