Another Reason Why There Was A Decline In U S Hospitalizations for Heart Failure

By now, many Disease Management Care Blog readers have become aware of this JAMA research study that used Medicare fee-for-service claims data to examine the nationwide rate of hospitalizations for chronic heart failure.  From 1998 to 2008, there was a counterintuitive 30% decline in the U.S. from a baseline rate of 2845 to a new rate of 2007 admissions per 100,000 person-years. 

The authors credit better care of heart attacks (damage from a heart attack to can lead to a flabby dilated heart), better prevention (such as more aggressive treatment of high blood pressure, which also causes heart damage) and a more "effective" medical system (such as better outpatient follow-up, use of alternate levels of care, flu shots prescriptions of ACE inhibitors and beta blocker medications).  The authors of the study think the numbers are remarkable because the U.S. population is getting older and healthier persons (without heart failure) seem to be signing up for managed care Medicare Advantage.

The DMCB is wondering about another possibility that has nothing to do with epidemiology or quality.  Rather, it could be the impact of Medicare payment rates on billing patterns.  After all, if heart failure is the leading Medicare inpatient diagnosis, shouldnt a decrease there have an impact on the overall hospitalization rate?

The DMCB explains:

When beneficiaries are discharged from a hospital, the bill (or the claim) submitted to Medicare is based on a "Diagnosis Related Group."  While the invention and logic of DRGs complicated, theyre important because the principal diagnosis determines the amount of the global payment for that hospitalization. While this may be overly simplistic, a discharge with a diagnosis of "heart failure" prompts Medicare to pay a hospital "X" dollars, while a diagnosis of pneumonia or kidney failure will render payments of "Y" and "Z" dollars, respectively.  In general, the more complicated the diagnosis, the greater the payment.

All well and good, but suppose the hospital has a patient with several concurrent problems and has a choice on which DRG to use?  As anyone who has taken care of hospitalized patients knows, there are usually multiple diagnoses present in any patient at one time.  Pneumonia may or may not have provoked the heart attack that led to the kidney failure that led to the leg swelling and the shortness of breath.  Given three simultaneous diagnoses, Medicare billing guidelines state that the hospital should use their best judgement to determine which DRG to bill. All things being equal, smart hospitals will probably use the DRG that renders the greatest payment.

The DMCB isnt saying that fraudulent billing (for example) accounts for the decrease in heart failure hospitalizations for Medicare. However, it knows some diagnosis related groups can be less remunerative than others and that in the last ten years, DRG payment rates have evolved and that hospitals have learned how to "code" more accurately and aggressively.  Based on the example at the bottom of this page, the DMCB wonders if some patients that were diagnosed with heart failure in 1988 would have been diagnosed with something more remunerative in 2007. 

In other words, there may have been the same number of hospitalizations involving the same patients with the same disease burden.  It was the case mix that changed?

The authors of the study to their credit cant discount the possibility:  They argue that if coding had changed there would have been a shift in the mortality rate of patients with heart failure:

"We were unable to determine whether the observed changes were due to changes by hospitals in medical coding; however, substantial up-coding or down-coding would likely result in changes to the coefficients of the CMS HF mortality model, and these coefficients remained stable from 2005 to 2008."

The authors may have a point, but that assumes the modeling - also based on claims - is trustworthy.

Of course, there is no way, based on Medicare billing claims alone, to determine whether measurement also played a role in the decline in heart failure admissions.  That would take an audit of the medical records themselves.

CoQ10 Can Lower High Blood Pressure to Prevent Congestive Heart Failure

Reporting in the journal Biofactors, researchers found that patients with congestive heart failure that were supplemented with the active form of coenzyme Q10 (ubiquinol) improved ejection fraction by 39%. Ejection fraction is a critical marker of heart function used to determine the volume of blood pumped by the heart through the vascular system.

CoQ10 is essential to convert nutrients to energy and power the cellular engine, and natural production in the body declines with age. Extensive research explains how you can benefit from daily supplementation with this powerful co-enzyme to restore healthy energy balance and prevent age-related heart disease.

CoQ10 Improves Quality of Life for Heart Failure Patients

The study conducted at the East Texas Medical Center and Trinity Mother Francis Hospital focused on patients with advanced congestive heart failure that were classified as Stage IV, the most severe form of the disease. Patients were supplemented with 580 mg of the ubiquinol form of coenzyme Q10 daily to increase plasma blood levels by a factor of four.

The researchers found “the improvement in plasma CoQ10 levels is correlated with both clinical improvement and improvement in measurement of left ventricular function.” Prior to CoQ10 supplementation, most of the participants were considered critically ill and confined to bed or a wheel chair. After a regimen of ubiquinol, patients typically improved two classification levels (Stage IV to II or III to I) and were able to carry on a productive lifestyle.

CoQ10 Improves Blood Vessel Elasticity to Lower Blood Pressure

Hypertension is a serious problem that affects as many as one in three adults in the US today. High blood pressure is closely associated with coronary artery closure due to plaque formation and arterial stiffening as the normally elastic vessels require more pressure to fully circulate blood to the body. The result of a study published in the journal Nutrition and Metabolism found that coenzyme Q10 supplemented along with other potent antioxidant nutrients (vitamin C, vitamin E, and selenium) significantly increased small and large arterial elasticity that led to lower blood pressure and risk of a heart attack.

Subjects in this study received 60 mg of CoQ10 for a period of six months along with moderate amounts of the other nutrients. In addition to improved arterial elasticity, researchers found a significant decline in HbA1C blood sugar control and an increase in protective HDL cholesterol levels. The authors of the research concluded that the CoQ10 nutrient antioxidant cocktail “has beneficial effect on glucose and lipid metabolism, blood pressure and arterial compliance in patients with multiple cardiovascular risk factors.”

It comes as no surprise to most alternative health-minded individuals that nutrients obtained from natural sources exert a powerful influence on human health. Adults will want to supplement with 50 to 100 mg per day (higher amounts may be necessary for existing cardiovascular disease) of the ubiquinol form of co-enzyme Q10 to maintain optimal health, energy and protection from age-related diseases of the heart.

Grapes reduce heart failure associated with hypertension

A study appearing in the Journal of Nutritional Biochemistry¹ demonstrates that grapes are able to reduce heart failure associated with chronic high blood pressure (hypertension) by increasing the activity of several genes responsible for antioxidant defense in the heart tissue. Grapes are a known natural source of antioxidants and other polyphenols, which researchers believe to be responsible for the beneficial effects observed with grape consumption. This study, funded by a grant from the National Institutes of Health (NIH), and conducted at the University of Michigan Health System, uncovered a novel way that grapes exert beneficial effects in the heart: influencing gene activities and metabolic pathways that improve the levels of glutathione, the most abundant cellular antioxidant in the heart.

An estimated 1 billion people worldwide have hypertension, which increases the risk of heart failure by 2 to 3-fold. Heart failure resulting from chronic hypertension can result in an enlarged heart muscle that becomes thick and rigid (fibrosis), and unable to fill with blood properly (diastolic dysfunction) or pump blood effectively. Oxidative stress is strongly correlated with heart failure, and deficiency of glutathione is regularly observed in both human and animal models of heart failure. Antioxidant-rich diets, containing lots of fruits and vegetables, consistently correlate with reduced hypertension.

In this study, conducted at the University of Michigan Health System, hypertensive, heart failure-prone rats were fed a grape-enriched diet for 18 weeks. The results reproduced earlier findings that grape consumption reduced the occurrence of heart muscle enlargement and fibrosis, and improved the diastolic function of the heart. Furthermore, the mechanism of action was uncovered: grape intake "turned on" antioxidant defense pathways, increasing the activity of related genes that boost production of glutathione.

"Our earlier studies showed that grapes could protect against the downward spiral of hypertensive heart failure, but just how that was accomplished – the mechanism – was not yet known," said lead investigator E. Mitchell Seymour, Ph.D. "The insights gained from our NIH study, including the ability of grapes to influence several genetic pathways related to antioxidant defense, provide further evidence that grapes work on multiple levels to deliver their beneficial effects."

Seymour noted that the next phase of the NIH study, which will continue into 2014, will allow his team to further define the mechanisms of grape action, and also look at the impact of whole grape intake compared to individual grape phytonutrients on hypertension-associated heart failure.

"Our hypothesis is that whole grapes will be superior to any individual grape component, in each of the areas being investigated," said Dr. Seymour. "The whole fruit contains hundreds of individual components, which we suspect likely work together to provide a synergistic beneficial effect."

The insights gained from this research will further the knowledge on grapes and heart health, but will also provide translational information on the value of dietary (whole foods) and dietary supplement approaches for prevention of heart disease stemming from chronic hypertension.

"The NIH grant is allowing the team at the University of Michigan Medical System to expand its work in this important area and further highlight the multi-faceted role of grapes in supporting heart health," said Kathleen Nave, president of the California Table Grape Commission. "This work will also provide key insights into the role of whole fruit versus individual components of a fruit, using grapes as the benchmark."