Shifting From Event Rates to Time at Home After Hospitalization for Heart Failure With Reduced Ejection Fraction: Trends and Equity in Days Alive and Out of Hospital in Singapore

BACKGROUND: Conventional postdischarge monitoring for heart failure (HF) with reduced ejection fraction focuses on readmission and mortality, but these end points may not summarize cumulative patient-centered health. We examined whether secular trends in conventional end points translated into improved days alive and out of hospital (DAOH), and whether trends differed by age, sex, and ethnicity. METHODS: Using the Singapore Cardiovascular Longitudinal Outcomes Database, we conducted a population-based cohort study of patients discharged alive after first HF with reduced ejection fraction hospitalization during 2011 to 2019. We estimated risk-adjusted annual trends in 30-day and 1-year DAOH, all-cause and HF-specific readmission, and all-cause and cardiovascular mortality, and tested trend heterogeneity by age, sex, and ethnicity with multiplicity adjustment. RESULTS: Among 10 147 patients (median age, 68.9 years; 31.5% women; 65.4% Chinese; 20.0% Malay), risk-adjusted 30-day DAOH did not change materially (annual change, 0.01 [95% CI, −0.03 to 0.05] d/y; P -trend=0.554), whereas 30-day HF-specific readmission declined, with no change in 30-day all-cause readmission, all-cause mortality, or cardiovascular mortality. In contrast, 1-year DAOH improved from 291.7 to 301.0 days (1.16 [95% CI, 0.57–1.75] d/y; P -trend <0.001). In parallel, 1-year HF-specific readmission, all-cause mortality, and cardiovascular mortality declined, while 1-year all-cause readmission remained stable. Improvements were not uniform across population subgroups. Declines in HF-specific readmission were steeper in men than women at 30 days and 1 year, and 1-year DAOH gains were greater among Malay than Chinese patients after multiplicity adjustment. CONCLUSIONS: Improvement was seen in 1-year but not 30-day DAOH after first HF with reduced ejection fraction hospitalization, alongside reductions in 1-year HF-specific readmission, all-cause mortality, and cardiovascular mortality. Dissimilar slopes highlight potentially inequitable benefits. DAOH may provide a patient-centered complement to conventional end points for monitoring burden and equity.