National and regional trends in heart failure hospitalization and mortality rates for Medicare beneficiaries, 1998-2008

Abstract

Context: It is not known whether recent declines in ischemic heart disease and its risk factors have been accompanied by declines in heart failure (HF) hospitalization and mortality.

Objective: To examine changes in HF hospitalization rate and 1-year mortality rate in the United States, nationally and by state or territory.

Design, setting, and participants: From acute care hospitals in the United States and Puerto Rico, 55,097,390 fee-for-service Medicare beneficiaries hospitalized between 1998 and 2008 with a principal discharge diagnosis code for HF.

Main outcome measures: Changes in patient demographics and comorbidities, HF hospitalization rates, and 1-year mortality rates.

Results: The HF hospitalization rate adjusted for age, sex, and race declined from 2845 per 100,000 person-years in 1998 to 2007 per 100,000 person-years in 2008 (P < .001), a relative decline of 29.5%. Age-adjusted HF hospitalization rates declined over the study period for all race-sex categories. Black men had the lowest rate of decline (4142 to 3201 per 100,000 person-years) among all race-sex categories, which persisted after adjusting for age (incidence rate ratio, 0.81; 95% CI, 0.79-0.84). Heart failure hospitalization rates declined significantly faster than the national mean in 16 states and significantly slower in 3 states. Risk-adjusted 1-year mortality decreased from 31.7% in 1999 to 29.6% in 2008 (P < .001), a relative decline of 6.6%. One-year mortality rates declined significantly in 4 states but increased in 5 states.

Conclusions: The overall HF hospitalization rate declined substantially from 1998 to 2008 but at a lower rate for black men. The overall 1-year mortality rate declined slightly over the past decade but remains high. Changes in HF hospitalization and 1-year mortality rates were uneven across states.

Figure 1

Risk-standardized HF hospitalization rate by state, (A) 1998 and (B) 2008 State-specific HF hospitalizations rates per 100,000 for 1998 and 2008. States categorized as having HF hospitalization rate significantly higher or lower than the national mean (2-sided p<0.05) based on bootstrapped 95% confidence intervals.

Figure 2

Change in risk-standardized (A) HF hospitalization rate and (B) 1-year mortality rate from 1998 to 2008, by state. Point estimates represented by diamonds with 95% confidence intervals. The vertical line represents the overall national decline (for HF hospitalization rate or no change (for 1-year mortality). Probability represents the likelihood that the change in a state’s HF hospitalization rate exceeds that of the overall national rate (−838 per 100,000), or that the change in a state’s mortality rate exceeded zero, based on bootstrap analysis.

Figure 3

Risk-standardized 1-year mortality rate by region, (A) 1999 and (B) 2008 State-specific 1-year mortality rate after HF hospitalizations for 1999 and 2008. States categorized as having 1-year mortality rate significantly higher or lower than the national mean (2-sided p<0.05) based on bootstrapped 95% confidence intervals