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Trends in Acute MI and Heart Failure in Ontario
Study Questions:
What are the temporal trends of readmission and mortality after acute myocardial infarction (AMI) and heart failure (HF) in Ontario, Canada, where reducing hospital readmissions has not had a policy incentive?
Methods:
The investigators analyzed a cohort comprised of AMI or HF patients ≥65 years of age who had been hospitalized from 2006 to 2017 in Ontario, Canada. Primary outcomes were 30-day readmission and post-discharge mortality. Secondary outcomes included in-hospital mortality, 30-day mortality from admission, and in-hospital mortality or 30-day mortality post-discharge. Adjusted monthly trends for each outcome were examined over the study period. Temporal changes in the risk-adjusted rates of the outcomes across months or years were examined using linear regression models.
Results:
The cohorts included 152,808 AMI and 223,283 HF patients. Age- and sex-standardized AMI hospitalization rates in Ontario declined 32% from 2006 to 2017, while HF hospitalization rates declined slightly (9.1%). For AMI, risk-adjusted 30-day readmission rates declined from 17.4% in 2006 to 14.7% in 2017. All AMI risk-adjusted mortality rates also declined from 2006 to 2017, with 30-day post-discharge mortality from 5.1% to 4.4%. For HF, overall risk-adjusted 30-day readmission was largely unchanged from 2006 to 2014 at 21.9%, followed by a decline to 20.8% in 2017. Risk-adjusted 30-day post-discharge mortality declined from 7.1% in 2006 to 6.6% in 2017.
Conclusions:
The authors concluded that the patterns of outcomes in Ontario are consistent with the United States for AMI, but diverge for HF, and the reasons for the country-specific patterns for HF need further exploration.
Perspective:
This cohort study reports significant reductions in risk-adjusted readmission and mortality rates for AMI and HF in Ontario, Canada, from 2006 to 2017. However, while there were significant reductions in admission rates, risk-adjusted readmissions, and mortality in patients with AMI similar to the United States, Ontario experienced smaller declines in admission and readmission over time with HF as compared to the United States, which had a large reduction in admission and readmission. The basis for the diverging country-specific patterns for patients with HF are not clear, but is concerning for the United States, which has had a trend of increasing post-discharge HF mortality since 2006. Additional studies are indicated to better understand differences in the country-specific patterns for HF, which should incorporate information such as processes of care of HF management and causes of death.
Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure
Keywords: Acute Coronary Syndrome, Heart Failure, Hospital Mortality, Hospitalization, Myocardial Infarction, Patient Discharge, Patient Readmission, Primary Prevention, Risk Adjustment
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