Elsevier

International Journal of Cardiology

Volume 320, 1 December 2020, Pages 70-76
International Journal of Cardiology

Risk of readmission after heart failure hospitalization in older adults with congenital heart disease

https://doi.org/10.1016/j.ijcard.2020.06.025Get rights and content

Highlights

  • Half congenital heart disease patients with heart failure are readmitted in 1-year.

  • Readmission risk varies over time with the first 8 weeks having the highest risk.

  • After 27 weeks from discharge, the risk of readmission stabilizes.

  • The role of systemic diseases on readmissions increases during the 1-year period.

  • Very short length of stay is associated with increased early readmission risk.

Abstract

Background

Hospital readmissions are common in adults with congenital heart disease (CHD) with heart failure (HF). We sought to examine the temporal risk of readmissions, the prompting diagnoses and their determinants within one-year after a first HF hospitalization in older CHD patients.

Method

We assembled a cohort from the Quebec CHD database of patients whose first-ever HF hospitalization occurred after age 40. Subjects were followed from the first HF discharge to the earliest of all-cause readmission, death, or one-year post-discharge. The Fine and Gray model was used to measure the weekly readmission risks. The one-year period was categorized into different stages based on readmission risks. A multinomial logistic regression model was adopted to identify the determinants of patients falling in different readmission stages.

Results

The one-year death-adjusted cumulative readmission risk was 48.8%. The absolute weekly risk of readmission was the highest at week 2, declined by 50% at week 8, and reached a plateau at week 27. Three phases—vigilance (1-8 weeks), transition (9-27 weeks), and plateau (28-52 weeks)—were identified, corresponding to high-risk, decreasing-risk, and stable-risk periods. Cardiovascular diseases accounted for 61.7%, 50.3%, and 43.2% of all readmissions during the three phases; systemic diseases accounted for 15.2%, 19.9%, and 31.2%. A history of past-12-month interventional procedures saw significantly decreased readmission risks. Longer hospital stays were associated with lower readmission risks at the vigilance phase only.

Conclusion

Policy makers and caregivers should account for the change in risk over time, and phase-tailored strategies should be planned to effectively reduce readmissions.

Introduction

Thanks to improvements in medical and surgical care, the majority of patients with congenital heart disease (CHD) are now adults, and many are entering into middle or older age [1]. A recent scientific statement from the American Heart Association emphasized the need for research on disease progression and complications in older CHD patients [2]. Patients over the age of 40 were identified as a particularly high-need group, with a paucity of evidence to support their care.

As the most common comorbid condition in adult CHD (ACHD) patients, heart failure (HF) has been documented to be associated with an increased hospitalization rate [[3], [4], [5]], significant morbidity [3,6] and decreased survival [[7], [8], [9]]. Our group has previously constructed a risk score to predict the risk of 1-year HF hospitalization (HFH) in ACHD patients [10]. We subsequently documented the predictors of 1-year mortality for patients after HFH [11] and found that multiple hospital admissions were the predominant predictor of mortality for older CHD patients with HF. As such, in this study, we turned our attention to readmissions for ACHD-HF patients.

Most readmissions are avoidable through an understanding of risk-change trends and risk factors and the adoption of appropriate strategies. In the general population, patients have an elevated risk of readmission for at least one year after a first HFH [[12], [13], [14]]. During this one-year period, the daily risk of readmission decreased by 50% at 38 days [12]. The pathophysiology and clinical manifestation of HF in ACHD patients may differ, and research from the general population may not be generalizable to this growing population. Little consideration has been given to readmission after a HFH in the ACHD population. With this study, we sought to characterize and identify, for 1-year post-discharge after a first HFH: (1) how the risk of readmission evolved over time; (2) the diagnoses prompting readmissions; and (3) risk factors for hospital readmission.

Section snippets

Data source and study population

This study was based on the Quebec CHD database, which merged the Quebec administrative medical claims database, the hospital discharge summary and Death Registry [1,15]. We used ICD-9 and 10 as well as surgery/procedure codes throughout the subject’s lifetime to identify CHD patients as we have previously published for the first time in 2007 [16]. All patients were assigned a CHD diagnosis by using a hierarchical algorithm which cross checked all CHD diagnoses among inpatient diagnoses,

Measurements

The study endpoint was the first readmission to hospital within one year after the first HFH. We excluded readmissions with an ICD-9 V code and an ICD-10 Z code because these codes represent planned admissions for a specific treatment [17,18].

To explore how the risk of readmission varied over time in the first-year post-discharge from the first HFH, we identified the occurrence of readmissions on a weekly basis (1-52 weeks). Death was identified as a competing risk of readmission. To explore

Results

From January 1, 2000, to March 31, 2010, a total of 1,828 patients met the inclusion criteria and were discharged after being newly hospitalized for HF (Figure A.1). Thirty-eight patients were excluded due to lack of adequate follow-up. Thus, 1,790 patients were included, among whom, 342 (19.11%) were readmitted by 30 days and 1000 (55.9%) were readmitted by one year after the index hospitalization. The most frequent CHD lesions in older adults were valvular lesions (48%), followed by shunt

Discussion

We found that hospital readmission within one year after the first HFH was common, occurring in 55% of ACHD patients over 40 years old. The weekly risk of first readmission takes 8 weeks to decline by 50% after the first HFH, and after 27 weeks the risks of readmission plateau at a significantly lower level. We have identified a three-phase terrain as the vigilance (1-8 weeks), transition (9-27 weeks) and plateau (28-52 weeks) phases for the full year after the first HFH. Cardiovascular

Conclusion

Readmission to hospital is common in ACHD-HF patients, with over half being readmitted within one year after the first HFH. We found a variably declining readmission risk over time and proposed a three-phase model for recovery in the first year after HF discharge, comprised of vigilance, transition and plateau phases. A decreasing attributable proportion of cardiovascular readmissions and an increasing proportion of systemic diseases were noted over time during this one-year period. An

Author Statement

Wang Fei: Conceptualization, Methodology, Software, Formal analysis, Data curation, Visualization, Writing-Original draft. Harel-Sterling Lee: Visualization, Writing-Original draft. Liu Aihua: Conceptualization, Methodology, Visualization, Supervision, Writing - Review & Editing. Brophy James: Methodology, Writing - Review & Editing. Paradis Gilles: Supervision, Writing - Review & Editing. Marelli Ariane: Conceptualization, Methodology, Writing- Reviewing and Editing, Supervision, Funding

Funding

This work was supported by the Canadian Institute of Health Research Foundation Grant (PI: Dr. Ariane Marelli, ID: 148462). Dr. Marelli is a Clinical Research Scholar of the Fonds de Recherche en Santé Québec in Canada.

Disclosures

None

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