Beta-Blockers Don't Up 30-Day Readmissions in Reduced-EF Heart Failure: Analysis

Marlene Busko

January 09, 2015

BIRMINGHAM, AL — Older Medicare patients with heart failure and reduced ejection fraction (HFrEF) who were hospitalized for acute decompensation and were initiated on beta-blockers when they were discharged did not have worse 30-day readmission rates than others who were not given these drugs, in a new study[1].

Moreover, not only was long-term, 4-year survival better, as expected, but 30-day survival was also better, in this matched-cohort study published online December 29, 2014, in the American Journal of Medicine.

These findings are important, since all-cause 30-day readmission is a hospital and physician performance measure in the Affordable Care Act, lead author Dr Vikas Bhatia (University of Alabama, Birmingham) told heartwire .

Until now, although beta-blockers are known to reduce sudden cardiac death and pump-failure death in the long term in heart failure, it was unknown whether their initial negative inotropic effect would lead to early hospital readmission, he added.

Now this study showed that, in patients with heart failure and reduced ejection fraction, "in 30 days, [beta-blockers are already] decreasing mortality by 50% to 60%, so not giving patients beta-blockers . . . when they . . . might die of sudden cardiac death would be depriving them of good care," Bhatia said.

"There should be no worry about increasing hospital readmissions, and clinicians can feel good that they are giving a drug that will actually decrease mortality."

Harsh Penalties for Not Meeting 30-Day Readmission Targets

Researchers estimate that US hospitals may collectively lose $7 billion in the next 10 years due to penalties for above-average 30-day all-cause hospital readmissions, Bhatia said.

To examine how initiation of beta-blockers on hospital discharge would affect 30-day all-cause readmissions, they identified 3067 Medicare patients who, between 1998 and 2001, were discharged from 106 hospitals in Alabama with a diagnosis of heart failure and an ejection fraction <45%.

Of these 3067 patients, 2202 patients (72%) had not been on beta-blockers when they were admitted to the hospital. A minority, 383 patients (17%), were subsequently discharged with a prescription for a beta-blocker.

Using propensity scores, 380 of the 383 patients receiving beta-blockers were matched with 380 patients not receiving these drugs, according to 36 baseline characteristics.

The matched patients had a mean age of 73 years; 44% were women and 33% were African American.

At 30 days after hospital discharge, beta-blocker use was not associated with increased 30-day all-cause or heart-failure readmission, but it was linked with significantly lower mortality.

Risk of 30-Day Readmission or Mortality, in a Propensity-Matched Cohort of Medicare Beneficiaries Hospitalized with Heart Failure

30-d outcome Events, % of patients (n) HR (95% CI)* P
Discharge prescription for beta-blocker
No (n=380) Yes (n=380)
All-cause hospital readmission 23 (86) 20 (77) 0.87 (0.64–1.18) 0.377
Heart-failure readmission 8 (30) 8 (29) 0.95 (0.57–1.58) 0.837
All-cause mortality 5 (20) 2 (6) 0.29 (0.12–0.73) 0.008
*Hazard ratios for patients receiving a beta-blocker vs those not receiving a beta-blocker

At 4 years after hospital discharge, those in the beta-blocker group had a significantly lower mortality (HR 0.81, 95% CI 0.67–0.98) but not all-cause readmission (HR 0.89, 95% CI 0.76–1.04).

"If we look at more recent data, we should find much more active prescription of beta-blockers," Bhatia speculated. Although the registry data did not specify which beta-blocker patients received, he said that "the benefit with beta-blockers is [likely] across the board, but some beta-blockers are more beneficial than others, like carvedilol and long-acting metoprolol."

Bhatia and others recently showed that in the same patient population, the use of digoxin[2] and ACE inhibitors or angiotensin-receptor blockers[3] was associated with decreased hospital readmission.

"We want to look at all therapies that are approved to decrease mortality and even hospital readmission—for example, digoxin, ACE inhibitors, and spironolactone—and see what can be used to decrease hospital readmission as well as mortality, which would be icing on the cake. On the one hand, you are decreasing mortality, which you want, but on the other hand, there are some core measures you need to meet for a hospital to get paid and not get penalized," according to Bhatia.

The authors have reported no relevant financial relationships.

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