30-Day Episode Payments and Heart Failure Outcomes

Study Questions:

What is the association between 30-day payments for an episode of heart failure (HF) at the hospital level with patient outcomes?

Methods:

The authors utilized Medicare claims data for all fee-for-service beneficiaries hospitalized for HF between July 1, 2011, and June 30, 2014, to examine the association between 30-day Medicare payments at the hospital level (beginning with a hospital admission for HF and across multiple settings following discharge) and patient 30-day mortality using mixed-effect logistic regression models. For patients with >1 HF admission across the 3-year period, they included only one randomly selected episode of care. They classified 30-day HF episode payments at the hospital level into low- (<25th percentile), average- (25th-75th percentile), and high-spending (>75th percentile) for descriptive purposes, similar to previous studies.

Results:

The authors included 1,343,792 patients hospitalized for HF across 2,948 hospitals with ≥25 eligible HF cases and episode payment information. The 30-day episode payments for HF care varied nearly two-fold across hospitals. Mean 30-day episode payments were $15,423 ± $1,523. Median 30-day episode payments per beneficiary were $13,732 in the low-payment group, $15,308 in the average-payment group, and $17,207 in the high-payment group. Overall observed mortality in the cohort was 11.3%. Higher hospital-level 30-day payments were associated with lower patient mortality after adjustment for patient characteristics (odds ratio per $1,000 increase in payments, 0.961; 95% confidence interval [CI], 0.954-0.967; p ≤ 0.001). Overall, patients admitted for HF to hospitals with 30-day payments 1 standard deviation (SD) ($1,523) above the mean, compared with hospitals 1 SD below the mean, had an associated ~1.3% lower mortality. This relationship was slightly attenuated after accounting for hospital characteristics and HF volume, but remained significant (odds ratio per $1,000 increase, 0.968; 95% CI, 0.962-0.975; p ≤ 0.001). Additional adjustment for potential mediating factors, including cardiac service capability and post-acute service use, did not significantly affect the relationship.

Conclusions:

The authors of this study concluded that 30-day episode payments at the hospital level for HF care were associated with lower patient mortality.

Perspective:

Although this is an observational study, the findings are important because it indicates that aligning fiscal incentives improves outcomes in HF patients. Further research is needed to determine the best interventions that improve outcomes in HF patients, so that hospitals can be incentivized to allocate scarce resources in such services.

Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Episode of Care, Fee-for-Service Plans, Geriatrics, Health Expenditures, Heart Failure, Hospital Mortality, Medicare, Outcome Assessment (Health Care), Patient Discharge


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