Approximately 25% of patients hospitalized
for decompensated heart failure (HF) are
readmitted within 30 days of discharge,
making HF the leading cause for
30-day all-cause readmissions in the U.S.
However, those HF patients enrolled in
hospice at discharge are significantly less
likely to be readmitted to hospital for any
reason, according to a report published in
Circulation: Heart Failure.
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“To the best of our knowledge, this is the
first study to report a robust independent
association of discharge hospice referral
and lower 30-day hospital readmission in
Medicare beneficiaries with HF regardless of
EF (ejection fraction),” write the authors.
“Furthermore, this beneficial association
of hospice referral with readmission was
observed throughout the entire six months
post-discharge period and was unaffected by
all-cause mortality,” they add.
Investigators analyzed data from patient
medical records linked to Medicare
utilization files for 8,032 beneficiaries
hospitalized for decompensated HF from
1998 to 2001 (mean age, 79 years; female,
58%; non-white, 18%) in one of 106
Alabama facilities. Propensity scores were
used to assemble a matched cohort of 179
patients referred to hospice at discharge
(“hospice-referral patients”) and 179
patients who died within six months but
had not been referred to hospice (“hospiceeligible”
- 22% of all patients died within six
months; 8% of these patients were
discharged to hospice.
- 2% overall were discharged to hospice.
- 21% of patients were readmitted for all
causes within 30 days of discharge.
Outcomes: Hospice versus
- 30-day all-cause readmission occurred
in 41% of the patients not referred to
hospice who died within six months
(“hospice-eligible patients”) and 5% of
hospice-referral patients (hazard ratio
[HR] associated with hospice referral,
0.12; 95% confidence interval [CI], 0.06
- Among patients who survived for the first
30 days, 30-day all-cause readmission
occurred in 39% and 8% of hospiceeligible-
patients and hospice-referral
patients, respectively (HR, 0.17; 95% CI,
0.08 to 0.36).
- Among those patients who died in the
first 30 post-discharge days, 30-day all-cause readmission occurred in 47%
of hospice-eligible patients and 1% of
hospice-referral patients (HR, 0.03;
95% CI, 0.04 to 0.21).
- 30-day readmission for HF occurred in
17% of hospice-eligible patients and
2% of hospice-referral patients (HR,
0.14; 95% CI, 0.05 to 0.40).
- 90-day all-cause readmission occurred
in 59% of hospice-eligible patients and
13% of hospice-referral patients (HR,
0.18; 95% CI, 0.12 to 0.29).
- Among patients who died within 90
days of discharge, 3-month all-cause
readmission occurred in 56% of
hospice-eligible patients and 7% of
hospice-referral patients (HR, 0.15;
95% CI, 0.07 to 0.31).
- 6-month all-cause readmission occurred
in 64% of hospice-eligible and 18%
of hospice-referral patients (HR, 0.18;
95% CI, 0.12 to 0.28).
- Although mortality at 30 days was
higher among the hospice-referral
group compared with the hospiceeligible
group (43% vs 27%), mortality
was similar for both groups at 90 days
(64% vs 67%).
“By 90 days post-discharge, mortality
rates were similar between the groups
and as a result, hospice referral was also
associated with a significantly lower risk
of the combined end point of 90-day
all-cause readmission or 90-day all-cause
mortality,” note the authors.
As HF progresses, patients commonly
experience steadily worsening
symptoms, as opposed to the periods
of relative stability interrupted by acute
exacerbations they experienced earlier in
the disease course. Patients and families
often lack prognostic awareness, point
out the authors, and symptoms such as
worsening dyspnea may prompt them to
seek help from acute care facilities.
Among the many benefits of hospice
is that the enrollment process includes
explicit discussion of prognosis and goals
of care, so that patients know what to
expect and can choose how they want
to be treated. Hospice care also aims to
address dyspnea and other symptoms
common in end-stage HF, such as pain,
anxiety, and depression, the authors note.
“The substantially lower readmission rate
in the hospice-referral group in our study
suggests that the palliative care approach
used by hospice teams may have been
effective in alleviating HF symptoms,
thus obviating needs for readmission,”
Yet many patients with HF are not
referred to hospice, or are referred too
late to benefit from the comprehensive
palliative approach. “National estimates
suggest that hospice median length of
stay is only 19 days overall and 17 days
for patients with HF, and that 35% of
patients die or are discharged within
seven days of hospice admission,” write
the authors. They point out that most HF
patients in their study who died within
six months of hospital discharge did not
even receive hospice referral.
“These findings suggest that a more
accurate identification of hospice eligible
patients and a more appropriate
hospice-referral approach may potentially
lower 30-day all-cause readmission
for hospitalized patients with HF,” the
Source: “Discharge Hospice Referral and Lower
30-Day All-Cause Readmission in Medicare
Beneficiaries Hospitalized for Heart Failure,”
Circulation: Heart Failure; July 2015; 8(4):733-
740. Kheirbek RE, et al; Veterans Affairs
Medical Center, Washington, DC; Department
of Medicine, George Washington University,
Washington, DC; Department of Medicine,
Georgetown University, Washington, DC.