Ambarish Pandey, MD UT Southwestern Medical Center Dallas,

Transcription

1 Hospital Performance Based on 30-Day Risk Standardized Mortality and Long-Term Survival after Heart Failure Hospitalization An Analysis of the GWTG-HF Registry Ambarish Pandey, MD UT Southwestern Medical Center Dallas,

2 Presenter: None Disclosures Co-authors: Detailed disclosures for co-authors can be found online

3 Burden of Heart Failure is Substantial & Associated with Worse Outcomes Trends in HF Prevalence Median Survival in HF Khera, et al. Circulation HF 2017 Shah, et al. JACC 2017

4 Burden of Heart Failure is Substantial & Associated with Worse Outcomes Trends in HF Prevalence Median Survival in HF Khera, et al. Circulation HF 2017 Shah, et al. JACC 2017

5 Health Policies Are Increasingly Focused on Improving HF Care Acute MI, HF, PNA

6 Health Policies Are Increasingly Focused on Improving HF Care Acute MI, HF, PNA Penalty for higher than expected 30- day readmission rates

7 Health Policies Are Increasingly Focused on Improving HF Care Acute MI, HF, PNA Penalty for higher than expected 30- day readmission rates Penalty for higher than expected 30-day mortality rates

8 CMS Incentives Favor Readmission Prevention Over Mortality Reduction Hospital Performance by 30-day Mortality Hospital Performance by 30-day Readmission 0.2 % of max DRG penalty 3% of max DRG penalty

9 CMS Incentives Favor Readmission Prevention Over Mortality Reduction Lower 30-day Readmission rates Hospital Performance by 30-day Mortality Hospital Performance by 30-day Readmission 0.2 % of max DRG penalty 3% of max DRG penalty

10 CMS Incentives Favor Readmission Prevention Over Mortality Reduction In-hospital care-quality Lower 30-day Readmission rates Hospital Performance by 30-day Mortality Hospital Performance by 30-day Readmission 0.2 % of max DRG penalty 3% of max DRG penalty

11 CMS Incentives Favor Readmission Prevention Over Mortality Reduction Hospital Performance by 30-day Mortality Long term mortality rates In-hospital care-quality Hospital Performance by 30-day Readmission Lower 30-day Readmission rates 0.2 % of max DRG penalty 3% of max DRG penalty

12 30-day HF Mortality Rates May Have Increased in The Readmission Penalty Era Dharamrajan, et al. JAMA 2017 Fonarow, et al. JACC 2017

13 30-day HF Mortality Rates May Have Increased in The Readmission Penalty Era Need Better Hospital Performance Metric for HF Care and Outcomes Dharamrajan, et al. JAMA 2017 Fonarow, et al. JACC 2017

14 30-day Risk Standardized Mortality As a Performance Metric For Acute MI Lower 30-day RSMR for AMI is associated with better longterm survival Bucholz, et al. NEJM 2016

15 Knowledge Gap For Hospital Performance Metrics in Acute HF Hospital Performance by 30-day Mortality???? Long term mortality rates Hospital Performance by 30-day Readmission

16 Study Objective Evaluate the association between hospital performance based on 30-day risk standardized mortality rate & longterm survival patients hospitalized with acute HF at GWTG- HF participating centers

17 Study Hypothesis Better hospital performance based on 30-day RSMR will be associated with greater long-term survival among patients hospitalized with acute HF

18 All GWTG-HF participating centers between Study Population

19 Study Population All GWTG-HF participating centers between Patients above 65 years age with available CMS linked data

20 Study Population All GWTG-HF participating centers between Patients above 65 years age with available CMS linked data 106,304 patients from 317 sites

21 Primary Exposure Variable 30-day Risk Standardized Mortality Rate (RSMR) Multivariable hierarchical logistic models Adjusted for patient-level co-variates Hospitals treated as random effects

22 Primary Exposure Variable 30-day Risk Standardized Mortality Rate (RSMR) Multivariable hierarchical logistic models Adjusted for patient-level co-variates Hospitals treated as random effects 30-day RSMR = Predicted deaths (using hospital-specific intercept) Expected deaths (average hospital intercept) X Average mortality rate

23 Study Outcomes Long-term outcomes 5-year all-cause mortality

24 Study Cohort Stratification Quartile 1 79 hospitals 30,827 Patients 30-day RSMR: 8.64% Quartile 2 79 hospitals 24,062 Patients 30-day RSMR: 9.41% Quartile 3 80 hospitals 23,761 Patients 30-day RSMR: 9.90% Quartile 4 79 hospitals 27,654 Patients 30-day RSMR: 10.75% High Performing Low Performing

25 Adjusted Analysis Cox-proportional hazard models for long-term mortality risk Adjusted for patient-level and hospital-level co-variates Separate analysis for 30-day survivors

26 Characteristics Hospital Characteristics Q1 (N = 79) High Performing Q2 (N = 79) Q3 (N = 80) Q4 (N = 79) Low Performing Teaching Hospital (%) Primary PCI Capabilities (%) Cardiac Surgery inhouse (%) Heart Transplant Center (%) day RSMR, median (IQR) 8.64 ( ) 9.41 ( ) 9.90 ( ) ( )

27 Characteristics Hospital Characteristics Q1 (N = 79) High Performing Q2 (N = 79) Q3 (N = 80) Q4 (N = 79) Low Performing Teaching Hospital (%) Primary PCI Capabilities (%) Cardiac Surgery inhouse (%) Heart Transplant Center (%) day RSMR, median (IQR) 8.64 ( ) 9.41 ( ) 9.90 ( ) ( )

28 Characteristics Hospital Characteristics Q1 (N = 79) High Performing Q2 (N = 79) Q3 (N = 80) Q4 (N = 79) Low Performing Teaching Hospital (%) Primary PCI Capabilities (%) Cardiac Surgery inhouse (%) Heart Transplant Center (%) day RSMR, median (IQR) 8.64 ( ) 9.41 ( ) 9.90 ( ) ( )

29 Characteristics Hospital Characteristics Q1 (N = 79) High Performing Q2 (N = 79) Q3 (N = 80) Q4 (N = 79) Low Performing Teaching Hospital (%) Primary PCI Capabilities (%) Cardiac Surgery inhouse (%) Heart Transplant Center (%) day RSMR, median (IQR) 8.64 ( ) 9.41 ( ) 9.90 ( ) ( )

30 Patient Characteristics Characteristics Q1 (N = 30,827) High Performing Q2 (N = 24,062) Q3 (N = 23,761) Q4 (N = 27,654) Low Performing Age (median, y) Women (%) White(%) Diabetes (%) Atrial Fibrillation (%) Hx of HF Hospitalization (%)

31 Characteristics Presentation Characteristics Q1 (N = 30,827) High Performing Q2 (N = 24,062) Q3 (N = 23,761) Q4 (N = 27,654) Low Performing Systolic BP, mm Hg Heart Rate Sodium, mg/dl BNP, pg/ml Troponin, ng/dl EF (%) Creatinine, mg/dl

32 Adherence to Guideline Directed HF Characteristics Evidence-based Beta- Blocker Use Therapies Across Study Groups Q1 (N = 30,827) High Performing Q2 (N = 24,062) Q3 (N = 23,761) Q4 (N = 27,654) Low Performing ACE-i/ARB Use Post Discharge HF follow-up ICD placement Prior to discharge CRT at discharge

33 Adherence to Guideline Directed HF Characteristics Evidence-based Beta- Blocker Use Therapies Across Study Groups Q1 (N = 30,827) High Performing Q2 (N = 24,062) Q3 (N = 23,761) Q4 (N = 27,654) Low Performing ACE-i/ARB Use Post Discharge HF follow-up ICD placement Prior to discharge CRT at discharge

34 Adherence to Guideline Directed HF Characteristics Evidence-based Beta- Blocker Use Therapies Across Study Groups Q1 (N = 30,827) High Performing Q2 (N = 24,062) Q3 (N = 23,761) Q4 (N = 27,654) Low Performing ACE-i/ARB Use Post Discharge HF follow-up ICD placement Prior to discharge CRT at discharge

35 Hospital Performance by 30-day RSMR and Long-term Survival Long-term Outcomes Q1 Q2 High Performing Overall Population Q3 Q4 Low Performing Median Survival, days (95% CI) 717 ( ) 685 ( ) 654 ( ) 579 ( )

36 Hospital Performance by 30-day RSMR and Long-term Outcomes Median Survival, days (95% CI) Long-term Survival Q1 Q2 High Performing Overall Population 717 ( ) 685 ( ) Q3 654 ( ) Q4 Low Performing 579 ( ) 5-year Mortality (%)

37 Hospital Performance by 30-day RSMR and Long-term Outcomes Median Survival, days (95% CI) Q1 Q2 High Performing Overall Population 717 ( ) 685 ( ) Q3 654 ( ) Q4 Low Performing 579 ( ) 5-year Mortality (%) day Survivors Median Survival, days (95% CI) Long-term Survival 832 ( ) 825 ( ) 814 ( ) 759 ( ) 5-year Mortality (%)

38 Adjusted Association of Hospital Performance by 30-day RSMR with 5-y Mortality Overall Population Q1 (High Performing) Q2 Q3 Q4 (Low Performing) Lower risk Hazard Ratio Higher risk Adjusted for patient- and hospital-level covariates

39 Adjusted Association of Hospital Performance by 30-day RSMR with 5-y Mortality Overall Population Q1 (High Performing) Q2 Q3 22% Risk Q4 (Low Performing) Lower risk Hazard Ratio Higher risk Adjusted for patient- and hospital-level covariates

40 Adjusted Association of Hospital Performance by 30-day RSMR with 5-y Mortality Overall Population 30-day Survivors Q1 (High Performing) Q2 Q3 22% Risk Q4 (Low Performing) Lower risk Hazard Ratio Higher risk Lower risk Hazard Ratio Higher risk Adjusted for patient- and hospital-level covariates

41 Limitations Findings may not be generalizable to non-gwtg-hf centers Potential for residual or unmeasured confounding Cannot establish causation between hospital performance based on 30-day RSMR and long-term survival

42 Conclusions High performing hospitals based on 30-day RSMR have better long-term survival for patients hospitalized with acute HF This survival advantage at centers with low 30-day RSMR continues to accrue beyond 30-days and persists in long-term 30-day RSMR may be a useful metric to incentivize quality care and improve long-term outcomes

43 Acknowledgements Co-authors Kershaw Patel Li Liang Adam DeVore Roland Matsouaka Deepak Bhatt Clyde Yancy Adrian Hernandez Paul Heidenreich James de Lemos Gregg Fonarow Statistical Support Duke Clinical Research Institute Funding The American Heart Association supports the Get With The Guidelines Heart Failure program (GWTG-HF). GWTG-HF has been previously funded through support from Medtronic, GlaxoSmithKline Ortho-McNeil and the AHA Pharmaceutical Roundtable.

44 Ambarish Pandey, Kershaw V. Patel, Li Liang, Adam D. DeVore, Roland Matsouaka, Deepak L. Bhatt, Clyde W. Yancy, Adrian F. Hernandez, Paul A. Heidenreich, James A. de Lemos, and Gregg C. Fonarow Association of Hospital Performance Based on 30-Day Risk- Standardized Mortality Rate With Long-term Survival After Heart Failure Hospitalization: An Analysis of the Get With The Guidelines Heart Failure Registry Published online March 12, 2018 Available at jama.com and on The JAMA Network Reader at mobile.jamanetwork.com