麻豆传媒

Identical policy pressures to participate in public reporting and value-based payment programs did not have the same effect on mortality rates for hospitals admitting patients with acute MI and heart failure, researchers found.

The worst-performing hospitals for acute MI in 2009, or those in the bottom quartile for 30-day mortality, had a mortality rate of 18.6% that year. They managed to cut death rates down to 14.6% in 2015, however, marking larger strides as a group compared with other hospitals (15.7% down to 14.0%, P<0.001 for interaction).

Meanwhile, poor performers among heart failure hospitals also improved mortality rates over time (13.5% to 13.0%, P<0.001), but average mortality among other heart failure hospitals (10.9% to 12.0%, P<0.001, P<0.001 for interaction), according to Paula Chatterjee, MD, MPH, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, and Karen Joynt Maddox, MD, MPH, of Washington University School of Medicine in St. Louis.

It is unclear why the trends should diverge between acute MI and heart failure performance despite being the focus of the same policy changes, they wrote in JAMA Cardiology. One possibility is that attempts at care improvement have driven gains in acute MI survival more so than in heart failure, they suggested.

"Heart failure outcomes may be less sensitive to such pathway-based care, particularly for patients with preserved ejection fraction for whom mortality-reducing interventions remain elusive," they wrote. "Patients with heart failure also tend to be older and more medically complex, such that their mortality is less often cardiovascular in nature. As such, heart failure mortality may be more sensitive to the quality of outpatient longitudinal, multidisciplinary care rather than changes in inpatient treatment."

Also possible is that the diverging trends in 30-day mortality were driven by a difference in the quality of outpatient care, or that a progressively sicker heart failure population has emerged in the last decade, according to Chatterjee and Joynt Maddox.

The investigators had gathered data from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare, so they cautioned that CMS changed how it calculated 30-day mortality during the study period and this may have affected the analysis.

Included in the study were U.S. acute care hospitals with publicly reported mortality data for acute MI (n=2,751) and heart failure (n=3,796).

It turned out that poor-performers for acute MI in 2009 were more often public and for-profit and less often teaching hospitals. On the other hand, baseline poor-performers for heart failure were less likely to be large hospitals.

Presence of an ICU was the only factor found to be associated with improvement over the years for poor performers in heart failure survival, Chatterjee and Joynt Maddox noted.

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