ACC 2018: 30-day Risk-Standardized Mortality Rate may be useful hospital performance metric

March 12, 2018 – DCRI researchers call for increasing the focus on 30-day RSMR to improve long-term clinical outcomes for heart failure patients.

Adrian HernandezA late-breaking clinical trial presented today by DCRI researchers at this year’s annual American College of Cardiology conference in Orlando, Florida, evaluated the association of hospital-specific 30-day Risk-Standardized Mortality Rate (RSMR) with long-term mortality among patients hospitalized with heart failure (HF) in the American Heart Association Get With The Guidelines–HF registry.

The results were published simultaneously in JAMA Cardiology.

Get With The Guidelines (GWTG) is a hospital-based quality improvement initiative designed to close the treatment gap in cardiovascular disease, stroke, and resuscitation and includes modules in coronary artery disease, heart failure, atrial fibrillation, stroke and resuscitation. Created by the American Heart Association and American Stroke Association, GWTG collects millions of patient records from U.S. hospitals, creating vast databases for advancing scientific research.

GWTG-HF was created for improving care of patients with HF by promoting consistent adherence to the latest scientific treatment guidelines. HF is the leading cause of hospitalization among Medicare beneficiaries in the United States and is associated with considerable risk of morbidity and mortality.

According to researchers, among patients hospitalized with HF, the long-term clinical implications of hospitalization at hospitals based on 30-day RSMRs was not previously known. Hospital 30-day all-cause RSMR following HF hospitalization, is a measure that estimates a hospital-level, 30-day mortality rate for patients discharged from the hospital with a principal diagnosis of HF. Mortality is defined as death from any cause within 30 days from the start of admission.

“While the focus nationally has been on how to reduce hospital readmissions after heart failure, the greater gain may be towards improving survival,” said DCRI’s Adrian Hernandez, MD, director of Health Services and Outcomes Research. “With this study, our overall goal was looking at long-term survival after a hospital admission for heart failure, and if patients discharged from hospitals that have 30-day lower risk of mortality, also have better long-term outcomes,” he said.

Recent years have seen heightened focus on readmission of HF patients to the hospital, and hospitals with high 30-day readmission rates face financial penalties. However, readmissions are a complex metric, with many readmissions being avoidable, and their association with long-term patient outcomes questionable.

“There’s been a lot of efforts to reduce the variation in HF readmissions as a quality of care indicator,” said Hernandez, “The key question is whether there is any relationship to what hospitals do for the health of patients with heart failure 30 days after discharge has any impact on long-term outcomes.” According to Hernandez, this study reinforces that, “as opposed to only paying attention to readmissions, we should pay much more attention to early mortality as a performance metric.”

The longitudinal study included 106,304 HF patients 65 years and older, admitted to 317 centers participating in the GWTG-HF registry between January 2005 and December 2013 and had Medicare-linked follow-up data. The researchers calculated hospital-specific 30-day RSMR and assessed the association of 30-day RSMR-based hospital groups with long-term mortality using adjusted Cox models, which provide an estimate of the treatment effect on survival, after adjustment for other explanatory variables.

The study found that hospitals in the low 30-day RSMR group had greater availability of advanced HF therapies, cardiac surgery, and percutaneous coronary interventions. Compared with patients admitted to hospitals with low 30-day RSMRs, patients at hospitals with high 30-day RSMRs had 14 percent higher risk-adjusted relative risk of 5-year mortality, meaning that lower hospital-level 30-day RSMR was found to be associated with greater 1-year, 3-year, and 5-year survival for patients with HF.

According to researchers, these differences in 30-day survival continued to accumulate beyond 30 days and persisted long term, suggesting that 30-day RSMR may be a useful performance metric to incentivize quality care and improve long-term outcomes in patients hospitalized with HF.

The study found the survival advantage associated with treatment at hospitals with lower 30-day RSMR to be durable over time, independent of mortality differences within the first 30 days. The sum of these findings, according to researchers, highlight the need to increase the focus on 30-day RSMR as a performance metric to motivate quality care and to improve long-term clinical outcomes for patients with HF.

In addition to Hernandez, other researchers included Ambarish Pandey, Kershaw V. Patel, Li Liang, Adam D. DeVore, Roland Matsouaka, Deepak L. Bhatt, Clyde W. Yancy, Paul A. Heidenreich, James A. de Lemos and Gregg C. Fonarow.