Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort studyBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h411 (Published 06 February 2015) Cite this as: BMJ 2015;350:h411
- Kumar Dharmarajan, cardiology fellow1,
- Angela F Hsieh, statistician2,
- Vivek T Kulkarni, medical student2,
- Zhenqiu Lin, statistician2,
- Joseph S Ross, assistant professor of medicine3,
- Leora I Horwitz, assistant professor of medicine3,
- Nancy Kim, assistant professor of medicine3,
- Lisa G Suter, assistant professor of medicine4,
- Haiqun Lin, associate professor of public health5,
- Sharon-Lise T Normand, professor of biostatistics6,
- Harlan M Krumholz, professor of medicine2
- 1Department of Internal Medicine, Columbia University Medical Center, NY, USA
- 2Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
- 3Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- 4Section of Rheumatology, Yale University School of Medicine, New Haven, CT, USA
- 5Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
- 6Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
- Correspondence to: K Dharmarajan, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
- Accepted 17 December 2014
Objective To characterize the absolute risks for older patients of readmission to hospital and death in the year after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
Design Retrospective cohort study.
Setting 4767 hospitals caring for Medicare fee for service beneficiaries in the United States, 2008-10.
Participants More than 3 million Medicare fee for service beneficiaries, aged 65 years or more, surviving hospitalization for heart failure, acute myocardial infarction, or pneumonia.
Main outcome measures Daily absolute risks of first readmission to hospital and death for one year after discharge. To illustrate risk trajectories, we identified the time required for risks of readmission to hospital and death to decline 50% from maximum values after discharge; the time required for risks to approach plateau periods of minimal day to day change, defined as 95% reductions in daily changes in risk from maximum daily declines after discharge; and the extent to which risks are higher among patients recently discharged from hospital compared with the general elderly population.
Results Within one year of hospital discharge, readmission to hospital and death, respectively, occurred following 67.4% and 35.8% of hospitalizations for heart failure, 49.9% and 25.1% for acute myocardial infarction, and 55.6% and 31.1% for pneumonia. Risk of first readmission had declined 50% by day 38 after hospitalization for heart failure, day 13 after hospitalization for acute myocardial infarction, and day 25 after hospitalization for pneumonia; risk of death declined 50% by day 11, 6, and 10, respectively. Daily change in risk of first readmission to hospital declined 95% by day 45, 38, and 45; daily change in risk of death declined 95% by day 21, 19, and 21. After hospitalization for heart failure, acute myocardial infarction, or pneumonia, the magnitude of the relative risk for hospital admission over the first 90 days was 8, 6, and 6 times greater than that of the general older population; the relative risk of death was 11, 8, and 10 times greater.
Conclusions Risk declines slowly for older patients after hospitalization for heart failure, acute myocardial infarction, or pneumonia and is increased for months. Specific risk trajectories vary by discharge diagnosis and outcome. Patients should remain vigilant for deterioration in health for an extended time after discharge. Health providers can use knowledge of absolute risks and their changes over time to better align interventions designed to reduce adverse outcomes after discharge with the highest risk periods for patients.
Contributors: KD and HMK devised the study concept and design, analyzed and interpreted the data, and drafted the paper; they are the guarantors. AFH performed all statistical analyses. AFH, VTK, ZL, JSR, LIH, NK, LGS, HL, and S-LTN analyzed and interpreted the data and critically revised the manuscript for important intellectual content. HMK obtained funding, acquired the data, and supervised the study. KD and HMK had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analyses.
Funding: KD, JSR, and LIH are supported by grants K23AG048331, K08AG032886, and K08AG038336, respectively, from the National Institute on Aging and American Federation for Aging Research through the Paul B Beeson career development award program. HMK is supported by grant 1U01HL105270-04 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the American Federation for Aging Research.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: support from the National Heart, Lung, and Blood Institute for the submitted work; VTK and HL have no financial relationships in the previous three years with any organizations that might have an interest in the submitted work; KD, AFH, ZL, JSR, LIH, NK, LGS, S-LTN, and HMK work under contract with the Centers for Medicare & Medicaid Services in the United States to develop and maintain performance measures; JSR is a member of a scientific advisory board for FAIR Health; HMK is chair of a cardiac scientific advisory board for UnitedHealth; JSR and HMK are the recipients of research grants from Medtronic and Johnson & Johnson through Yale University;.
Ethical approval: This study was approved by the Human Investigation Committee (institutional review board) at Yale University.
Data sharing: No additional data available owing to data use agreement with the Centers for Medicare & Medicaid Policy.
Transparency: The lead authors (KD and HMK) affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.