Early Versus Late Readmission During the Vulnerable Phase Following Hospitalization for Heart Failure: Reply

We thank Kimura and colleagues for extending the discussion of our findings with complementary registry data from Japan exploring the post-discharge period following heart failure (HF) hospitalization. Our analysis of the ASCEND-HF trial found that approximately 10% of patients were readmitted within 30 days following discharge from an index hospitalization with worsening HF.1 One third of readmissions occurred within 7 days and two thirds within 15 days, indicating a skewed relationship in timing of readmission. The readmission rate was higher in North America than in Asia or Europe. Interestingly, timing of readmission within the first 30 days (early vs. later) was not associated with a differential relationship with clinical outcomes. An equally important finding was the high proportion of non-HF-related (54%) or even non-cardiovascular (36%) causes of readmission. We are in agreement with Kimura and colleagues regarding the importance of the ‘vulnerable phase’ for recurrent events, which patients with HF enter as they transition into the outpatient setting following acute stabilization. HF patients are at an increased risk for readmission and death as has been shown in several analyses.2, 3 The time window associated with a particularly high risk clearly extends beyond the first 30 days. As the Japanese data suggest, approximately the same percentage of patients are admitted in the time from day 0–30 as from day 31–180. A holistic management strategy may not unnecessarily focus on the 30-day metric when individual patients may benefit to a greater extent from longer term, sustained interventions. As many are well aware, the use of 30 days as cut-off is based on the health care metric set forward by the Centers for Medicaid and Medicare Services (CMS). While this is an arbitrary cut-off that does not follow a particular pathophysiologic rationale, countries around the world commonly use the same policy-driven 30-day benchmark.4 A recent review of the impact of the Hospital Readmission Reduction Program in the US has yielded some alarming results. Despite a US wide reduction in 30-day readmissions, there is evidence of simultaneously increased 30-day and 1-year mortality.5-7 While these findings have been contested,8 it does raise the question whether HF readmission to hospital during the vulnerable phase is an adverse event that is detrimental to the patient's clinical course. It is well possible that over-aggressive attempts to prevent hospital readmissions do more harm than good. Thus, a critical review of the US but also worldwide readmission reduction programmes is urgently needed. Conflict of interest: M.F.: AxonTherapies, Coridea, Cibiem. GE Healthcare, supported by AHA grant 17MCPRP33460225 and the NHLBI T32 postdoctoral training grant 5T32HL007101-42. R.J.M.: Amgen, AstraZeneca, Bristol Myers Squibb, Gilead, GlaxoSmithKline, Novartis, Otsuka, ResMed, Thoratec.