Low household income may predict higher risk for 30-day HF readmission
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CHICAGO — Adults with an index HF hospitalization were 20% more likely to be readmitted within 30 days for a HF-specific cause if they lived in a low-income area as opposed to a high-income one, researchers reported.
The data were presented at the American Heart Association Scientific Sessions.
Despite the implementation of the Hospital Readmission Reductions Program (HRRP), 30-day readmission rates for adults with HF have increased, Stephen J. Greene, MD, assistant professor of medicine at Duke Clinical Research Institute and Duke University School of Medicine, and colleagues wrote in a simultaneous publication in JACC Heart Failure. Social determinants of health like household income may impact readmissions, and financial penalties associated with HRRP could be of greatest consequence for hospitals and patients in low-income areas, the researchers wrote.
“Multiple prior studies have found the implementation of the HRRP to be associated with increases in mortality and/or readmission among patients hospitalized for HF,” Greene told Healio. “Our current work suggests this apparent negative association of the HRRP with higher readmissions seems to disproportionately impact patients who live in neighborhoods with lower household income. Following HRRP, there were greater increases in 30-day readmissions among patients in lower household income quartiles, and this contributed to growing disparities in 30-day readmissions over time across the levels of household income.”
Assessing readmissions by ZIP code
Greene and colleagues analyzed data from 9,020,742 U.S. adults admitted with a primary diagnosis of HF as the first admission from the start of a given year between 2010 and 2019, using the National Readmission Database. Researchers assessed readmissions at the patient level within 30 days of the index hospitalization; household income was aggregated by ZIP code and divided into quartiles: low income, middle income, upper-middle income and high income. The pre-HRRP period was 2010 to 2012 and the post-HRRP period was 2013 through 2019.
Within the cohort, 19.7% of patients had all-cause readmissions and 8.1% had a HF-specific readmission within 30 days. The mean age was 72 years; women accounted for 48.9% of hospitalizations.
Researchers found that patients in the low-income quartile were 14% more likely to be readmitted within 30 days for any cause (adjusted OR = 1.14, 95% CI, 1.12-1.15; P < .001) and 20% more likely to be readmitted within 30 days for a HF-specific cause (aOR = 1.2; 95% CI, 1.18-1.22; P < .001) compared with patients in the high-income quartile.
During the study period, adjusted all-cause readmission rates increased for patients in the low-income quartile (18.8% to 19%; P for trend < .001) and middle-income quartile (17.5% to 17.9%; P for trend < .001); however, readmission rates remained steady for patients in the upper-middle income quartile (17.7% to 17.3%; P for trend = .24) and decreased for patients in the high-income quartile (16.8% to 16.4%; P for trend = .039; P for interaction < .001).
Adjusted HF-specific readmission rates similarly increased for patients in the low-income quartile (8.8% to 9.1%; P for trend < .001) and middle-income quartile (7.7% to 8.1%; P for trend < .001), whereas readmission rates decreased for patients in the upper-middle income quartile (7.7% to 7.5%; P for trend = .014) and decreased for patients in the high-income quartile (6.9% to 6.7%; P for trend = .003; P for interaction < .001).
Associations between HRRP and mean all-cause and HF readmissions varied by income quartile, with greater increases in readmissions observed for patients in lower quartiles (P for interaction < .001).
‘Unintended consequences’ of HRRP
“Previously observed associations between the HRRP and increased readmission may be predominantly driven by the impact on patients of lower household income,” Greene told Healio. “This suggests that this already vulnerable group, a group already with incremental challenges to their health potentially relating to socioeconomic status and social determinants of health, appears to disproportionately face the apparent adverse consequences of this health care policy.”
The researchers noted that additional studies are needed to identify best strategies to equitably improve patient-centered outcomes in HF, including hospitals serving lower-income patients.
“Multiple prior studies have suggested that the HRRP is in urgent need of reassessment, and this study adds one more very unfortunate layer to the scope of this critical problem,” Greene told Healio. “There continues to be major concerns over the unintended consequences of the HRRP.”
Reference:
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Aliyev N, et al. Abstract SA2124. Presented at: American Heart Association Scientific Sessions; Nov. 5-7, 2022; Chicago (hybrid meeting).
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