Heart Failure Patients Fare Worse in Nursing Homes

Nearly one-quarter of Medicare patients hospitalized for heart failure are subsequently discharged to a skilled nursing facility, and those patients are significantly more likely to be rehospitalized or die within 1 year than are similar patients discharged to home, according to the findings of a large observational study of more than 15,400 patients from 149 hospitals.

Absolute rehospitalization rates in those discharged to a skilled nursing facility vs. home were 27% vs. 23.5%, respectively, at 30 days, and 76.1% vs. 72.2%, respectively, at 1 year. All-cause mortality rates were 14.4% vs. 4.1% at 30 days and 53.5% vs. 29.1% at 1 year, Dr. Larry A. Allen and his colleagues reported online March 29 in Circulation: Heart Failure.

After adjustment for numerous demographic and health-related factors, discharge to a skilled nursing facility in these patients remained significantly associated with an increased risk of death (hazard ratio 1.76), said Dr. Allen of the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado Denver, Aurora, Colo. (Circulation: Heart Failure 2011 March 29 [doi:10.1161/CIRCHEARTFAILURE.110.959171]).

Patients included in the analysis were 15,459 adults aged 65 years or older (median age 80 years) who were discharged to a skilled nursing facility (24.1%), to home with home health service (22.3%), or to home with self-care (53.6%). The patients had been hospitalized for heart failure for at least 3 days (median 5 days) during 2005-2006.

The patients were part of the Get With The Guidelines – Heart Failure Program registry, an ongoing, voluntary quality-improvement initiative of the American Heart Association, the investigators said.

Factors found to be significantly associated with discharge to a skilled nursing facility included longer hospital stay (odds ratio 1.12 per day); advanced age (OR 1.98 per 10-year increase); female sex (OR 1.53); systolic blood pressure (OR 0.94 per 10 mm Hg increase); left ventricular ejection fraction less than 40% (OR 0.91); sodium level (OR 1.05 per 10 mEq/L increase); and history of hyperlipidemia (OR 0.74), anemia (OR 1.31), diabetes (OR 1.19), valvular heart disease (OR 0.72), myocardial infarction (OR 0.86), bypass surgery or percutaneous coronary intervention (OR 0.80), implantable defibrillator (OR 0.76), depression (OR 2.11), stroke (OR 1.55), peripheral vascular disease (OR 1.13), or chronic obstructive pulmonary disease or asthma (OR 1.11).

Across the country, the rate of discharges to skilled nursing facilities was highest in the Northeast (30%) and lowest in the West (23.6%). Hospitals that treated more racial minorities and younger patients were among those with the lowest rates of discharge to skilled nursing facilities.

In this study, hospitalized heart failure patients who were discharged to a skilled nursing facility were 79% more likely to die than those discharged to home – even after adjusting for a wide range of patient factors known to be associated with adverse outcomes, the investigators said.

"However, discharge to [a skilled nursing facility] is by its very nature determined by criteria such as poor mobility, cognitive impairment, frailty, and poor in-home support, which are also important determinants of outcome," they wrote, noting that those determinants of outcome were not captured in this analysis. Therefore, the researchers said, conclusions about whether discharge to a skilled nursing facility directly impacts patient outcomes cannot be drawn.

Still, the findings have potential implications for communicating prognoses to patients and families, medical decision-making, and assessing care provided at skilled nursing facilities, they said.

The high absolute rates of death following discharge to skilled nursing facilities, in particular, have potential implications for communication, discharge planning, and goals of care, they said.

"Additionally, we must consider whether a different set of quality measures [is] needed for this unique group of patients," the investigators concluded.

This study was funded by the American Heart Association, GlaxoSmithKline, and Medtronic through their support of the Get With The Guidelines – Heart Failure Program, and the Agency for Healthcare Research and Quality. Dr. Allen had no conflicts of interest to disclose. Other authors on the study reported numerous relationships with various pharmaceutical companies and other organizations.

Nearly one-quarter of Medicare patients hospitalized for heart failure are subsequently discharged to a skilled nursing facility, and those patients are significantly more likely to be rehospitalized or die within 1 year than are similar patients discharged to home, according to the findings of a large observational study of more than 15,400 patients from 149 hospitals.

Absolute rehospitalization rates in those discharged to a skilled nursing facility vs. home were 27% vs. 23.5%, respectively, at 30 days, and 76.1% vs. 72.2%, respectively, at 1 year. All-cause mortality rates were 14.4% vs. 4.1% at 30 days and 53.5% vs. 29.1% at 1 year, Dr. Larry A. Allen and his colleagues reported online March 29 in Circulation: Heart Failure.

After adjustment for numerous demographic and health-related factors, discharge to a skilled nursing facility in these patients remained significantly associated with an increased risk of death (hazard ratio 1.76), said Dr. Allen of the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado Denver, Aurora, Colo. (Circulation: Heart Failure 2011 March 29 [doi:10.1161/CIRCHEARTFAILURE.110.959171]).

Patients included in the analysis were 15,459 adults aged 65 years or older (median age 80 years) who were discharged to a skilled nursing facility (24.1%), to home with home health service (22.3%), or to home with self-care (53.6%). The patients had been hospitalized for heart failure for at least 3 days (median 5 days) during 2005-2006.

The patients were part of the Get With The Guidelines – Heart Failure Program registry, an ongoing, voluntary quality-improvement initiative of the American Heart Association, the investigators said.

Factors found to be significantly associated with discharge to a skilled nursing facility included longer hospital stay (odds ratio 1.12 per day); advanced age (OR 1.98 per 10-year increase); female sex (OR 1.53); systolic blood pressure (OR 0.94 per 10 mm Hg increase); left ventricular ejection fraction less than 40% (OR 0.91); sodium level (OR 1.05 per 10 mEq/L increase); and history of hyperlipidemia (OR 0.74), anemia (OR 1.31), diabetes (OR 1.19), valvular heart disease (OR 0.72), myocardial infarction (OR 0.86), bypass surgery or percutaneous coronary intervention (OR 0.80), implantable defibrillator (OR 0.76), depression (OR 2.11), stroke (OR 1.55), peripheral vascular disease (OR 1.13), or chronic obstructive pulmonary disease or asthma (OR 1.11).

Across the country, the rate of discharges to skilled nursing facilities was highest in the Northeast (30%) and lowest in the West (23.6%). Hospitals that treated more racial minorities and younger patients were among those with the lowest rates of discharge to skilled nursing facilities.

In this study, hospitalized heart failure patients who were discharged to a skilled nursing facility were 79% more likely to die than those discharged to home – even after adjusting for a wide range of patient factors known to be associated with adverse outcomes, the investigators said.

"However, discharge to [a skilled nursing facility] is by its very nature determined by criteria such as poor mobility, cognitive impairment, frailty, and poor in-home support, which are also important determinants of outcome," they wrote, noting that those determinants of outcome were not captured in this analysis. Therefore, the researchers said, conclusions about whether discharge to a skilled nursing facility directly impacts patient outcomes cannot be drawn.

Still, the findings have potential implications for communicating prognoses to patients and families, medical decision-making, and assessing care provided at skilled nursing facilities, they said.

The high absolute rates of death following discharge to skilled nursing facilities, in particular, have potential implications for communication, discharge planning, and goals of care, they said.

"Additionally, we must consider whether a different set of quality measures [is] needed for this unique group of patients," the investigators concluded.

This study was funded by the American Heart Association, GlaxoSmithKline, and Medtronic through their support of the Get With The Guidelines – Heart Failure Program, and the Agency for Healthcare Research and Quality. Dr. Allen had no conflicts of interest to disclose. Other authors on the study reported numerous relationships with various pharmaceutical companies and other organizations.

Nearly one-quarter of Medicare patients hospitalized for heart failure are subsequently discharged to a skilled nursing facility, and those patients are significantly more likely to be rehospitalized or die within 1 year than are similar patients discharged to home, according to the findings of a large observational study of more than 15,400 patients from 149 hospitals.

Absolute rehospitalization rates in those discharged to a skilled nursing facility vs. home were 27% vs. 23.5%, respectively, at 30 days, and 76.1% vs. 72.2%, respectively, at 1 year. All-cause mortality rates were 14.4% vs. 4.1% at 30 days and 53.5% vs. 29.1% at 1 year, Dr. Larry A. Allen and his colleagues reported online March 29 in Circulation: Heart Failure.

After adjustment for numerous demographic and health-related factors, discharge to a skilled nursing facility in these patients remained significantly associated with an increased risk of death (hazard ratio 1.76), said Dr. Allen of the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado Denver, Aurora, Colo. (Circulation: Heart Failure 2011 March 29 [doi:10.1161/CIRCHEARTFAILURE.110.959171]).

Patients included in the analysis were 15,459 adults aged 65 years or older (median age 80 years) who were discharged to a skilled nursing facility (24.1%), to home with home health service (22.3%), or to home with self-care (53.6%). The patients had been hospitalized for heart failure for at least 3 days (median 5 days) during 2005-2006.

The patients were part of the Get With The Guidelines – Heart Failure Program registry, an ongoing, voluntary quality-improvement initiative of the American Heart Association, the investigators said.

Factors found to be significantly associated with discharge to a skilled nursing facility included longer hospital stay (odds ratio 1.12 per day); advanced age (OR 1.98 per 10-year increase); female sex (OR 1.53); systolic blood pressure (OR 0.94 per 10 mm Hg increase); left ventricular ejection fraction less than 40% (OR 0.91); sodium level (OR 1.05 per 10 mEq/L increase); and history of hyperlipidemia (OR 0.74), anemia (OR 1.31), diabetes (OR 1.19), valvular heart disease (OR 0.72), myocardial infarction (OR 0.86), bypass surgery or percutaneous coronary intervention (OR 0.80), implantable defibrillator (OR 0.76), depression (OR 2.11), stroke (OR 1.55), peripheral vascular disease (OR 1.13), or chronic obstructive pulmonary disease or asthma (OR 1.11).

Across the country, the rate of discharges to skilled nursing facilities was highest in the Northeast (30%) and lowest in the West (23.6%). Hospitals that treated more racial minorities and younger patients were among those with the lowest rates of discharge to skilled nursing facilities.

In this study, hospitalized heart failure patients who were discharged to a skilled nursing facility were 79% more likely to die than those discharged to home – even after adjusting for a wide range of patient factors known to be associated with adverse outcomes, the investigators said.

"However, discharge to [a skilled nursing facility] is by its very nature determined by criteria such as poor mobility, cognitive impairment, frailty, and poor in-home support, which are also important determinants of outcome," they wrote, noting that those determinants of outcome were not captured in this analysis. Therefore, the researchers said, conclusions about whether discharge to a skilled nursing facility directly impacts patient outcomes cannot be drawn.

Still, the findings have potential implications for communicating prognoses to patients and families, medical decision-making, and assessing care provided at skilled nursing facilities, they said.

The high absolute rates of death following discharge to skilled nursing facilities, in particular, have potential implications for communication, discharge planning, and goals of care, they said.

"Additionally, we must consider whether a different set of quality measures [is] needed for this unique group of patients," the investigators concluded.

This study was funded by the American Heart Association, GlaxoSmithKline, and Medtronic through their support of the Get With The Guidelines – Heart Failure Program, and the Agency for Healthcare Research and Quality. Dr. Allen had no conflicts of interest to disclose. Other authors on the study reported numerous relationships with various pharmaceutical companies and other organizations.