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Is 30-day mortality after admission for heart failure an appropriate metric for quality?
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BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) model for publicly reporting national 30-day-risk-adjusted mortality rates for patients admitted with heart failure fails to include clinical variables known to impact total mortality or take into consideration the culture of end-of-life care. We sought to determine if those variables were related to the 30-day mortality of heart failure patients at Geisinger Medical Center.
METHODS: Electronic records were searched for patients with a diagnosis of heart failure who died from any cause during hospitalization or within 30-days of admission.
RESULTS: There were 646 heart-failure related admissions amongst 530 patients (1.2 admissions/patient). Sixty-seven of the 530 (13%) patients died: 35 (52%) died during their hospitalization and 32 (48%) died after discharge but within 30-days of admission; of these 27 (40%) had been transferred in for higher acuity care. Fifty-one (76%) died from heart failure, and 16 (24%) from other causes. Fifty-five (82%) patients were classified as AHA Stage-D, 58(87%) as NYHA Class-IV and 30 (45%) had right-ventricular systolic dysfunction. None of the 32 patients who died after discharge met recommendations for beta blockers. Criteria for prescribing ACE-I, ARB, and MRA were not met by 33 (97%) of the 34 patients with heart-failure-with-reduced-ejection-fraction not on one of those drugs. Fifty-seven patients (85%) had a DNR status.
CONCLUSION: A majority of heart failure related mortality was amongst patients who opted for a DNR status with end-stage heart failure, limiting the appropriateness of administering evidence based therapies. No care gaps were identified that contributed to mortality at our institution. The CMS 30-day model fails to take important variables into consideration.
http://www.amjmed.com/article/S0002-9343(17)30936-1/pdf
Voir la revue «The American journal of medicine, 131»
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