Predicted Mortality and Cardiology Follow-Up Following Heart Failure Hospitalizations Among Veterans Health Administration Patients

Background: Guidelines recommend timely follow-up with a cardiology specialist for patients hospitalized with heart failure (HF), but it is unknown whether the timeliness of specialty cardiovascular care post-discharge correlates with clinical risk.

Objective: Assess the association between estimated mortality risk and post-HF hospitalization cardiology follow-up.

Methods: In a cohort of Veterans hospitalized with HF in acute care VA hospitals between 1/1/2018 and 9/15/2022, we estimated the association of mortality risk at discharge with post-discharge cardiology encounters via logistic regression. We also evaluated the association between cardiology visits and sociodemographic and clinical characteristics, and described variability in post-discharge follow-up rates across VA facilities.

Results: We identified a cohort of 84,348 Veterans hospitalized with HF with 120,619 hospital admissions. Of a sub-cohort of 57,554 Veterans with 79,866 hospitalizations surviving at least one year after discharge, 32.1% of hospitalizations were followed by a cardiology visit within two weeks, and 49.3% within one month. Marginal probabilities of two-week and one-month follow-up were higher for hospitalizations in the highest-risk quintile than those in the lowest-risk quintile (34% vs. 30% and 51% vs. 47%, respectively; p<0.001 for both intervals). In a time-to-event model in the full cohort, there was a slightly negative association between risk and likelihood of one-month follow-up (coefficient for MAGGIC score = -0.004, 95% confidence interval [CI] -0.005 - -0.003). Black Veterans were less likely to have either two-week or one-month follow-up (adjusted odds ratios 0.93 [95% confidence interval [CI] 0.90-0.97] for two weeks and 0.93 [95% CI 0.89-0.96] for one month). Female Veterans were also less likely to have follow-up within one month of hospital discharge (adjusted odds ratio 0.90 [95% CI 0.90-0.98]). Conversely, patients with a primary versus secondary hospital diagnosis of HF and those with reduced versus preserved ejection fraction were more likely to have two-week follow-up (adjusted odds ratios 1.67 [95% CI 1.62-1.73] and 1.72 [95% CI 1.67-1.78], respectively) and one-month follow-up (adjusted odds ratios 1.83 [95% CI 1.78-1.88] and 1.85 [95% CI 1.80-1.90], respectively). One-month follow-up rates varied from 5% to 69% across VA facilities.

Conclusions: The rate of visits with a cardiologist within two weeks or one month following HF hospitalization was low overall, was at most modestly associated with estimated mortality risk at discharge, and varied by sex, race/ethnicity, and across VA facilities. Increasing visit rate after HF hospitalization should be evaluated as a mechanism to improve outcomes after HF hospitalizations, particularly for higher-risk individuals.