Conference Coverage

Observational hospital stays for HF linked to worse outcomes



– The Centers for Medicare & Medicaid Services policy providing financial incentives for hospitals to readmit patients for heart failure for an observational stay rather than as an inpatient is antithetical to the patients’ best interests, according to data presented at the American Heart Association scientific sessions.

“We showed that if you get admitted under observation, the risk of you coming back is much higher than if you’re under an inpatient stay,” said Ahmad Masri, MBBS, of the University of Pittsburgh.

Dr. Ahmad Masri Bruce Jancin/Frontline Medical News

Dr. Ahmad Masri

CMS doesn’t impose financial penalties on hospitals for readmission of heart failure patients under observational status, and such stays don’t count as inpatient readmissions. Savvy administrators therefore encourage gaming the system through liberal use of the observational stay.

“Since CMS instituted this rule in 2013, there has been a surge in utilization of observational status versus inpatient status,” Dr. Masri noted.

That might make sense if the patients selected for in-hospital observation were less ill at the time than the heart failure patients admitted as inpatients, but that wasn’t the case in his large, retrospective study.

Dr. Masri reported on 21,339 patients with a total of 52,493 admissions for a primary diagnosis of heart failure during 2008-2015 in an 18-hospital health care system. After excluding admissions which involved cardiac surgery or in-hospital mortality, the total was 50,654 admissions.

Of these admissions, 5% were for in-hospital observation; 17% were inpatient admissions with discharge in less than 2 days. The two groups were similar in terms of age, comorbid conditions, and use of guideline-directed medications, although 36% of patients admitted under observation had a left ventricular ejection fraction below 40%, compared with 30% of those with an inpatient admission for less than 2 days.

The majority of patients in both groups were readmitted for heart failure within 1 year; however, the readmission rate was 23% lower in the group with an inpatient stay of less than 2 days, in an analysis adjusted for age, sex, ejection fraction, hypertension, diabetes, pneumonia, chronic obstructive pulmonary disease, liver disease, and renal failure.

Similarly, the group with an inpatient stay of less than 2 days’ duration was 24% less likely to have a cardiac readmission within 1 year than the group admitted for a penalty-free observational stay. The short inpatient stay group’s 1-year all-cause readmission rate was also 24% lower. All of these differences were statistically significant and clinically meaningful.

Yet 1-year all-cause mortality in the two groups was no different.

“This suggests that the difference between these two groups is more of an administrative distinction than a reflection of patient status at time of admission. It looks like it’s just random,” according to Dr. Masri. “There is a real need for a patient-centered, streamlined approach in evaluating and treating patients with heart failure, with a revised treatment-based algorithm and admission rules that guide physicians and shape health care policy.”

He reported having no financial conflicts of interest regarding this study.

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