Key result
Excluding patients with left ventricular assist devices or heart transplants from acute myocardial infarction and heart failure cohorts changed hospital 30-day risk-standardized mortality and readmission rates by less than 0.1%.
Why the study?
Concern has been raised about the consequences of including patients with an LVAD or heart transplantation in hospital readmission and mortality measures.
Does excluding LVAD and heart transplant patients change hospital 30-day mortality and readmission measures for AMI and HF?
Observational (n=1,521,878)
Yes
Does excluding LVAD and heart transplant patients change hospital 30-day mortality and readmission measures for AMI and HF?
Effect estimate: <0.1% change
Excluding LVAD and heart transplant patients from hospital 30-day mortality and readmission measures for AMI and HF does not significantly alter hospital performance rates, despite these patients having distinct clinical trajectories.
Excluding LVAD or transplant patients leaves AMI and HF hospital metrics unchanged; supports current inclusion but leaves risk-adjustment refinements open.
Background Concern has been raised about consequences of including patients with left ventricular assist device (LVAD) or heart transplantation (HT) in readmission and mortality measures. Methods We calculated unadjusted and hospital-specific 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates for all Medicare fee-for-service beneficiaries with a primary diagnosis of AMI or HF discharged between July 2010 and June 2013. Hospitals were compared before and after excluding LVAD and HT patients. LVAD indication was measured. Results For the AMI and HF cohorts, ≤0.2% of patients received an LVAD and ≤0.1% received HT in either cohort. Less than 2% of hospitals had either ≥6 patients who received an LVAD or, independently, had ≥1 HT. The AMI mortality and readmission cohorts used 1.8% and 2.8% of LVADs for semi-permanent/permanent indications, versus 73.8% and 78.0% for HF patients, respectively. The rest were for temporary/external indications. In the AMI cohort, RSMR for hospitals without LVAD patients versus hospitals with ≥6 LVADs was 14.8% and 14.3%, and RSRR was 17.8% and 18.3%, respectively; the HF cohort RSMR was 11.9% and 9.7% and RSRR was 22.6% and 23.4%, respectively. In the AMI cohort, RSMR for hospitals without versus with HT patients was 14.7% and 13.9% and RSRR was 17.8% and 17.7%, respectively; in the HF cohort, RSMR was 11.9% and 11.0%, and RSRR was 22.6% and 22.6%, respectively. Estimations changed ≤0.1% after excluding LVAD or HT patients. Conclusion Hospitals caring for ≥6 patients with LVAD or ≥1 HT had lower RSMRs but higher RSRRs on average. Rates were insignificantly changed when these patients were excluded. LVADs were primarily for acute-care in the AMI cohort and chronic support in the HF cohort. LVAD and HT patients are a distinct group with differential care requirements and outcomes, thus should be considered separately from the rest of the HF cohort.
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Brandt et al. (2019) conducted an observational in Acute myocardial infarction (AMI) or heart failure (HF) (n=1,521,878). Exclusion of LVAD and heart transplant patients vs. Inclusion of LVAD and heart transplant patients was evaluated on Hospital 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates (<0.1% change). Excluding patients with left ventricular assist devices or heart transplants from acute myocardial infarction and heart failure cohorts changed hospital 30-day risk-standardized mortality and readmission rates by less than 0.1%.
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