Clinical research study
Digoxin Use and Lower 30-day All-cause Readmission for Medicare Beneficiaries Hospitalized for Heart Failure

https://doi.org/10.1016/j.amjmed.2013.08.027Get rights and content

Abstract

Background

Heart failure is the leading cause for hospital readmission, the reduction of which is a priority under the Affordable Care Act. Digoxin reduces 30-day all-cause hospital admission in chronic systolic heart failure. Whether digoxin is effective in reducing readmission after hospitalization for acute decompensation remains unknown.

Methods

Of the 5153 Medicare beneficiaries hospitalized for acute heart failure and not receiving digoxin, 1054 (20%) received new discharge prescriptions for digoxin. Propensity scores for digoxin use, estimated for each of the 5153 patients, were used to assemble a matched cohort of 1842 (921 pairs) patients (mean age, 76 years; 56% women; 25% African American) receiving and not receiving digoxin, who were balanced on 55 baseline characteristics.

Results

Thirty-day all-cause readmission occurred in 17% and 22% of matched patients receiving and not receiving digoxin, respectively (hazard ratio [HR] for digoxin, 0.77; 95% confidence interval [CI], 0.63-0.95). This beneficial association was observed only in those with ejection fraction <45% (HR 0.63; 95% CI, 0.47-0.83), but not in those with ejection fraction ≥45% (HR 0.91; 95% CI, 0.60-1.37; P for interaction, .145), a difference that persisted throughout the first 12 months postdischarge (P for interaction, .019). HRs (95% CIs) for 12-month heart failure readmission and all-cause mortality were 0.72 (0.61-0.86) and 0.83 (0.70-0.98), respectively.

Conclusions

In Medicare beneficiaries with systolic heart failure, a discharge prescription of digoxin was associated with lower 30-day all-cause hospital readmission, which was maintained at 12 months, and was not at the expense of higher mortality. Future randomized controlled trials are needed to confirm these findings.

Section snippets

Data Source and Study Patients

The current study is based on the Alabama Heart Failure Project, the details of which have been described previously.21, 22 Briefly, 9649 medical records of 8555 unique fee-for-service Medicare beneficiaries discharged with a primary discharge diagnosis of heart failure from 106 Alabama hospitals between 1998 and 2001 were abstracted by trained technicians at the Clinical Data Abstraction Center. For patients with multiple hospitalizations, charts from the first hospitalization were used.23 A

Baseline Characteristics

Matched patients had a mean age (± SD) of 76 (± 11) years; 56% were women, and 25% were African American. Those receiving digoxin were more likely to be white men, have low ejection fraction and pulmonary edema, and receive diuretics and angiotensin-converting enzyme inhibitors on discharge (Table 1, Figure 1). These and other imbalances in baseline characteristics were attenuated to inconsequential levels after matching.

Digoxin and 30-Day All-Cause Hospital Readmission

During the 30 days after index hospitalization, all-cause hospital

Discussion

Findings from the current study demonstrate that among a well-balanced cohort of Medicare beneficiaries hospitalized for acute decompensation of heart failure, a new discharge prescription for digoxin was associated with a significant lower risk of 30-day all-cause hospital readmission. Digoxin use also was associated with a lower risk for all-cause readmission, heart failure readmission, all-cause mortality, and the combined end points at all times throughout the 12 months postdischarge,

Conclusions

Medicare beneficiaries with heart failure and reduced ejection fraction hospitalized for acute decompensation who received discharge prescriptions for digoxin had lower risk of 30-day all-cause hospital readmission. This benefit of digoxin extended throughout 12 months of follow-up and was not at the cost of higher mortality. Findings of efficacy of digoxin in reducing 30-day all-cause hospital admission in the DIG trial and clinical effectiveness to lower 30-day all-cause hospital readmission

References (51)

  • A. Ahmed et al.

    Renin-angiotensin inhibition in systolic heart failure and chronic kidney disease

    Am J Med

    (2012)
  • A. Ahmed et al.

    Renin-angiotensin inhibition in diastolic heart failure and chronic kidney disease

    Am J Med

    (2013)
  • M.A. Feller et al.

    Baseline characteristics, quality of care, and outcomes of younger and older Medicare beneficiaries hospitalized with heart failure: findings from the Alabama Heart Failure Project

    Int J Cardiol

    (2012)
  • M. Mujib et al.

    Angiotensin-converting enzyme inhibitors and outcomes in heart failure and preserved ejection fraction

    Am J Med

    (2013)
  • C. Wahle et al.

    A propensity-matched study of outcomes of chronic heart failure (HF) in younger and older adults

    Arch Gerontol Geriatr

    (2009)
  • K.F. Adams et al.

    Relationship of serum digoxin concentration to mortality and morbidity in women in the digitalis investigation group trial: a retrospective analysis

    J Am Coll Cardiol

    (2005)
  • A. Ahmed

    Chronic heart failure in older adults

    Med Clin North Am

    (2011)
  • A. Ahmed et al.

    Effectiveness of digoxin in reducing one-year mortality in chronic heart failure in the Digitalis Investigation Group trial

    Am J Cardiol

    (2009)
  • G.C. Fonarow et al.

    Characteristics, treatments, and outcomes of patients with preserved systolic function hospitalized for heart failure: a report from the OPTIMIZE-HF Registry

    J Am Coll Cardiol

    (2007)
  • J. Butler et al.

    Outpatient utilization of angiotensin-converting enzyme inhibitors among heart failure patients after hospital discharge

    J Am Coll Cardiol

    (2004)
  • S.F. Jencks et al.

    Rehospitalizations among patients in the Medicare fee-for-service program

    N Engl J Med

    (2009)
  • J. Rau

    Hospitals face pressure to avert readmissions

    The New York Times

    (November 26, 2012)
  • J. Stone et al.

    Medicare Hospital Readmissions: Issues, Policy Options and PPACA

    (2010)
  • Sommers C, Cunningham PJ. Physician visits after hospital discharge: implications for reducing readmissions. The...
  • L.O. Hansen et al.

    Interventions to reduce 30-day rehospitalization: a systematic review

    Ann Intern Med

    (2011)
  • Cited by (0)

    Funding: AA was in part supported by the National Institutes of Health (NIH) through grants (R01-HL085561, R01-HL085561-S, and R01-HL097047) from the National Heart, Lung, and Blood Institute and a generous gift from Ms. Jean B. Morris of Birmingham, AL. RMA is supported in part by grant number UL1 TR000165 from NIH.

    Conflict of Interest: None.

    Authorship: AA conceived the study hypothesis and design in collaboration with the coauthors. AA and KP wrote the first draft. AA and KP performed statistical analyses in collaboration with IBA, TEL, and CJM. All authors interpreted the data, participated in critical revision of the paper for important intellectual content, and approved the final version of the article. IBA, AA, CJM, and KP had full access to data.

    View full text