3.3 Ten-year trends for heart failure outcomes 171 DISCUSSION We present here contemporary crude and age-standardised estimates for mortality and readmission rates among hospitalised HF patients in a middle-income Asian country. Using linked population data, this study has revealed improving trends in short-term mortality following an incident hospitalisation for HF in Malaysia. However, mortality at one year has remained constant while readmissions within thirty days rose steadily during the observation period. We have noted distinct differences in patient outcomes by sex and ethnicity. First, readmission rates were consistently higher in men compared to women and in Chinese and Indians compared to Malay patients. Second, overall short-term mortality outcomes were poorest in Others compared to all other ethnicities while men had slightly worse outcomes than women for 30-day mortality. Third, improvements in survival after HF hospitalisation varied by ethnic groups with Others showing the steepest decline in one-year mortality. In-hospital mortality after incident HF hospitalisation in Malaysia was higher compared to the 4.1% reported from a HF registry in China.17 Nevertheless, it is necessary to take into consideration that being enrolled in a registry is associated with better outcomes.18 Next, we observed a seven percent decline for in-hospital mortality for both men and women. This is in contrast to a rise in Brazil, from 8.3% to 10.8% between 2008 and 2017.19 Similar to inpatient mortality, the rates of mortality within 30 days was also decreasing, albeit to a smaller extent. No direct comparisons were available for middle-income countries. However, the decline observed here were consistent to those observed in several high-income settings including Western Australia, the Netherlands, and Sweden20–23. Several explanations are possible. The observed decline in short-term mortality is partly a reflection of improving population health, as seen with life expectancy increases from 73.7 years in 2008 to 75 years in 2018.24 Other explanations include earlier identification of cases as a result of rising population health awareness, improved pre-hospital emergency services 25,26 and an increase in the number of medical specialists in the past two decades. MOH hospitals have experienced almost doubling of the number of emergency medicine specialists from 93 to 167 from 2010 to 2013 and a modest increase in the number of cardiologists from 47 to 53 within the same period.27 There are no known changes in reimbursement practices or implementation of nationwide
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