Higher Spending Associated With Better Survival in Hospitalized HF

Debra L. Beck

April 17, 2018

Higher 30-day spending on heart failure (HF) care was associated with lower patient mortality in a Medicare claims study that included data from over 1.3 million HF hospitalizations from 2011 to 2014.

"Every $1000 increase in hospital-level spending was associated with a 4% reduction in the odds of 30-day mortality after adjustment," report Rishi Wadhera, MD, MPhil, from the Brigham and Women's Hospital, Boston, Massachusetts, and colleagues.

"Our findings raise concern that incentives to reduce spending for an episode of care through pay-for-performance programs, like the Hospital Value-Based Purchasing  (HVBP) program, which almost 1300 US hospital participate in, could have unintended consequences that adversely affect patient care," Wadhera told theheart.org | Medscape Cardiology.

This is of concern because a spending efficiency metric was recently added to the HVBP program, in addition to outcome metrics, he said. The Affordable Care Act established the HVBP program through Medicare to financially incentivize hospitals to meet certain quality benchmarks.

"This is a particularly important study for heart failure because it is the most common cause of hospitalization amongst Medicare beneficiaries, and if you look, there was a decade or so of steady improvement in heart failure mortality in the United States and that's really slowed in recent years," Wadhera said. "I think one of the questions this study raises is, should we be prioritizing outcomes like death more so than spending efficiency in pay-for-performance programs?"

Their findings were published online April 11 in JACC Heart Failure.

Wadhera et al analyzed data on 1,343,792 Medicare beneficiaries hospitalized for HF across 2948 US hospitals.

Median 30-day hospital-level expenditure, which was measured across multiple settings following discharge, was $15,423 per patient. Observed 30-day mortality in the cohort was 11.3%.

The investigators included not just costs for the initial HF hospitalization but also subsequent costs across multiple settings after discharge.

The survival benefit associated with greater expenditure persisted in models adjusted for patient case mix, hospital-level differences, and then differences in rates of post-acute care use.

Table. 30-Day Mortality by Increasing 30-Day Hospital-Level Episode Payments

Model Odds Ratio per $1000 Increase (95% CI)a
Unadjusted 0.975 (0.969 - 0.982)
Adjusted for patient characteristics 0.961(0.954 - 0.967)
Adjusted for patients/hospital characteristics 0.972 (0.966 - 0.979)
Adjusted for patient/hospital characteristics, and HF volume 0.968 (0.962 - 0.975)
Fully adjustedb 0.969 (0.962 - 0.976)
a P < .001 for all models.

bAdjusted for patient/hospital characteristics, F volume, cardiac service capability, and discharge disposition (skilled nursing facility and home healthcare).


The investigators used a spending mechanism that was stripped of all adjustments made to Medicare spending.

"Episode payments were assessed on a hospital rather than patient level to examine the impact of a patient population being exposed to varying styles of care rather than the individual patient being exposed to more intense care, and to diminish the likelihood of patient-level confounding," the authors write.

The report was accompanied by an editorial by Marvin A. Konstam, MD, Tufts Medical Center, Boston.

"If you look at a curve of healthcare value on the y-axis vs cost on the x-axis, what you want is to see that as you spend more, you get more value," Konstam said in an interview with theheart.org | Medscape Cardiology.

"I think if you look at this paper in that framework, it's saying that, at least in [the population studied], you could argue that we're still on that upsloping curve because there is a positive correlation between the amount of money spent and the outcomes."

He agreed that the analysis by Wadhera and colleagues generates "a cautionary note" about pursuing cost reduction in populations with HF.

Minority Patients

In the same issue of JACC Heart Failure, a separate Medicare expenditure study showed that minority patients hospitalized with HF with preserved ejection fraction had greater acute care services costs compared with white patients.

This study included Medicare Part A inpatient payments at index hospitalization, 30 days, and 1 year for 53,065 Medicare beneficiaries included in the Get With The Guidelines–Heart Failure registry between 2006 and 2014.

The investigators, led by Boback Ziaeian, MD, PhD, from the University of California Los Angeles, found that minority patients — in particular blacks and Hispanics — had significantly higher hospital costs at index admission and 1 year after an index admission.

Median Medicare costs for the index hospitalization were $7241 for the entire cohort, $7049 for whites, $8269 for blacks, $8808 for Hispanics, $8477 for Asians, and $8963 for other racial/ethnic groups (P < .0001).

After adjustment for patient characteristics, hospital factors, and regional socioeconomic status, cost ratios for the index admission did not differ by race or ethnicity.

However, at 30 days, among patients who were readmitted, blacks had 9% higher adjusted costs compared with whites (95% CI, 1% - 7%; P = .020).  

By 1 year, costs of acute care services were 14% higher for blacks (P < .001), 7% higher for Hispanics (P = .041), and 24% higher for patients of other races (P = .003). No significant differences were seen between expenditures on white and Asian patients at 1 year.

A limitation of the study was that it included only in-hospital payments and not Medicare Part B or Part D costs related to outpatient visits, inpatient physician payments, testing, ambulance services, or outpatient drugs. These other items drive about 40% of total direct healthcare expenditure for HF, noted Ziaeian et al.

Konstam also commented on this latter study in his editorial. "Combining the 2 sets of findings, one can conclude that efforts to reduce service utilization should be undertaken with careful consideration of the value of that service to the population being served," he writes.

"Rather than focusing on service utilization per se, interventions should be directed primarily toward improving health —  as by providing disease management services and by addressing the underlying drivers of disease. If we follow this course, we will secondarily reduce utilization of costly services, while deriving the greatest value for our patients."

Get With The Guidelines–Heart Failure is sponsored, in part, by Amgen Cardiovascular and has been funded in the past through support from Medtronic, GlaxoSmithKline, Ortho-McNeil, and the American Heart Association Pharmaceutical Roundtable. Wadhera and Ziaeian have disclosed no relevant financial relationships.

JACC Heart Failure. Published online April 11, 2018. Wadhera et al abstract, Ziaeian et al abstract, Editorial

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