Heart failure (HF) disproportionately affects older adults, and the COVID-19 public health emergency coincided with substantial changes in health care utilization in the United States. Using Centers for Medicare & Medicaid Services Medicare Fee-For-Service data, we examined national trends in HF hospitalizations, risk-adjusted 30-day mortality, and 30-day readmissions from January 2017 through December 2021 among beneficiaries aged ≥65 years. Prepandemic data from 2017–2019 were used to train Auto-Regressive Integrated Moving Average models to project expected outcomes during the pandemic period, enabling estimation of excesses or deficits relative to observed values. Among 2,209,153 HF hospitalizations, the median age-adjusted hospitalization rate declined from 134.5 per 100,000 person-years before March 2020 to 101.0 per 100,000 person-years during March 2020–December 2021, corresponding to an average monthly deficit of 33.5 per 100,000 person-years. The median risk-adjusted 30-day mortality rate declined from 12.9% to 12.5%, and the median risk-adjusted 30-day readmission rate declined from 21.5% to 21.4%. These differences were observed nationally and extended beyond the early pandemic period. In conclusion , HF hospitalizations, 30-day mortality, and 30-day readmissions among Medicare beneficiaries declined during the COVID-19 pandemic relative to expected pre-pandemic trends.
Heart failure (HF) affects approximately 6.7 million American adults, with a disproportionate impact on older age groups. The COVID-19 pandemic further heightened risks in this population, particularly among those with multiple comorbidities. Although HF hospitalizations decreased early in the pandemic, it remains unclear whether this trend persisted and how it impacted mortality and readmissions in subsequent years. Understanding these effects is crucial for pandemic preparedness. Using the Centers for Medicare & Medicaid Services (CMS) Medicare Fee-For-Service (FFS) dataset, we analyzed trends in HF hospitalizations, mortality, and readmissions, quantifying excesses and deficits during the public health emergency (PHE) compared with pre-pandemic years.
The Yale University Institutional Review Board approved the study and waived informed consent for use of deidentified data. This study followed STROBE reporting guidelines.
We analyzed data for CMS Medicare FFS Part A beneficiaries aged ≥65 years from January 2017 through December 2021. Hospitalizations for HF were identified using International Classification of Diseases Tenth Revision code I50.xx. Inclusion required continuous Medicare Part A enrollment for at least 12 months before admission, with exclusions for in-hospital deaths, facility transfers, single-day hospitalizations, and cases involving ventricular assist devices or heart transplants.
Covariates included age, sex, race, ethnicity, region, and preexisting medical conditions. Outcomes were age-adjusted hospitalization rates and risk-adjusted 30-day mortality and readmission rates. Duplicate records were removed when representing the same patient and sex. Age was defined at the time of hospitalization.
To assess the trends over time, we graphically assessed the relationship between monthly age-adjusted HF hospitalization rates, risk-adjusted 30-day all-cause mortality rates, and post-discharge 30-day all-cause readmission rates. Further, risk-adjusted Auto-Regressive Integrated Moving Average (ARIMA) models were projected for the 2 pandemic years (2020–2021) using the 3 pre-pandemic years (2017–2019) as the training dataset. Finally, we calculated the excess or deficit based on the differences between predicted and observed for the 3 risk-adjusted metrics during the pandemic years.
Overall, 2,209,153 HF hospitalizations were included, with a mean age of 80.2 years, of whom 50.6% were female ( Table 1 ). The cohort consisted of 82.0% White and 12.2% Black individuals. The most common medical conditions associated with HF were renal failure (68.4%), coronary artery disease (67.6%), hypertension (64.3%), and diabetes (52.7%). The crude all-cause mortality rate was slightly higher in the 2020–2021 group (13.1%) compared with the pre-pandemic 2017–2019 group (12.8%).
Table 1
Characteristics of heart failure hospitalizations from January 2017 to December 2021.
| Total (N = 2,209,153) | 2017–2019 (N = 1,467,497) | 2020–2021 (N = 741,656) | |
|---|---|---|---|
| Mean age (SD), y | 80.2 (8.6) | 80.2 (8.6) | 80.0 (8.5) |
| Age ≥85 y, % | 743,707 (33.7%) | 501,902 (34.2%) | 241,805 (32.6%) |
| Sex at birth, Women, % | 1,117,585 (50.6%) | 744,895 (50.8%) | 372,690 (50.3%) |
| Racial group | |||
| White, % | 2,067,845 (82.0%) | 1,198,563 (81.7%) | 869,282 (82.4%) |
| Black, % | 307,446 (12.2%) | 185,739 (12.7%) | 121,707 (11.5%) |
| Other, % | 146,511 (5.8%) | 83,195 (5.7%) | 63,316 (6.0%) |
| Geographic region | |||
| Northeast, % | 438,670 (19.9%) | 292,704 (19.9%) | 145,966 (19.7%) |
| Midwest, % | 539,832 (24.4%) | 358,033 (24.4%) | 181,799 (24.5%) |
| South, % | 884,683 (40.0%) | 589,962 (40.2%) | 294,721 (39.7%) |
| West, % | 332,579 (15.1%) | 217,693 (14.8%) | 114,886 (15.5%) |
| Territories, % | 13,389 (0.6%) | 9,105 (0.6%) | 4,284 (0.6%) |
| Comorbid conditions | |||
| Hypertension | 1,431,378 (64.8%) | 977,822 (66.6%) | 453,556 (61.2%) |
| Diabetes mellitus | 1,169,817 (53.0%) | 771,433 (52.6%) | 398,384 (53.7%) |
| History of MI | 260,131 (11.8%) | 169,288 (11.5%) | 90,843 (12.2%) |
| Unstable angina | 198,691 (9.0%) | 131,213 (8.9%) | 67,478 (9.1%) |
| Coronary artery disease | 1,505,623 (68.2%) | 1,011,765 (68.9%) | 493,858 (66.6%) |
| Stroke | 107,274 (4.9%) | 72,533 (4.9%) | 34,741 (4.7%) |
| Peripheral vascular disease | 642,870 (29.1%) | 438,312 (29.9%) | 204,558 (27.6%) |
| Valvular disease | 1,042,486 (47.2%) | 691,514 (47.1%) | 350,972 (47.3%) |
| Renal failure | 1,521,115 (68.9%) | 1,010,721 (68.9%) | 510,394 (68.8%) |
| Respiratory failure | 773,669 (35.0%) | 511,723 (34.9%) | 261,946 (35.3%) |
| COPD | 1,016,813 (46.0%) | 695,126 (47.4%) | 321,687 (43.4%) |
| Pneumonia | 738,009 (33.4%) | 502,564 (34.2%) | 235,445 (31.7%) |
| Liver disease | 112,974 (5.1%) | 71,396 (4.9%) | 41,578 (5.6%) |
| Psychiatric disease | 150,761 (6.8%) | 93,615 (6.4%) | 57,146 (7.7%) |
| Functional disability | 166,148 (7.5%) | 111,920 (7.6%) | 54,228 (7.3%) |
| Dementia | 454,566 (20.6%) | 306,650 (20.9%) | 147,916 (19.9%) |
| Malnutrition | 280,243 (12.7%) | 186,329 (12.7%) | 93,914 (12.7%) |
| Metastatic cancer | 119,876 (5.4%) | 77,134 (5.3%) | 42,742 (5.8%) |
| Musculoskeletal injuries | 666,602 (30.2%) | 439,482 (29.9%) | 227,120 (30.6%) |
| All-cause mortality | 208,224 (11.8%) | 131,561 (11.4%) | 76,663 (12.3%) |
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