Effectiveness of public report cards for improving the quality of cardiac care: the EFFECT study: a randomized trial

CONTEXT

Publicly released report cards on hospital performance are increasingly common, but whether they are an effective method for improving quality of care remains uncertain.

OBJECTIVE

To evaluate whether the public release of data on cardiac quality indicators effectively stimulates hospitals to undertake quality improvement activities that improve health care processes and patient outcomes.

DESIGN, SETTING, AND PATIENTS

Population-based cluster randomized trial (Enhanced Feedback for Effective Cardiac Treatment [EFFECT]) of 86 hospital corporations in Ontario, Canada, with patients admitted for acute myocardial infarction (AMI) or congestive heart failure (CHF).

INTERVENTION

Participating hospital corporations were randomized to early (January 2004) or delayed (September 2005) feedback of a public report card on their baseline performance (between April 1999 and March 2001) on a set of 12 process-of-care indicators for AMI and 6 for CHF. Follow-up performance data (between April 2004 and March 2005) also were collected.

MAIN OUTCOME MEASURES

The coprimary outcomes were composite AMI and CHF indicators based on 12 AMI and 6 CHF process-of-care indicators. Secondary outcomes were the individual process-of-care indicators, a hospital report card impact survey, and all-cause AMI and CHF mortality.

RESULTS

The publication of the early feedback hospital report card did not result in a significant systemwide improvement in the early feedback group in either the composite AMI process-of-care indicator (absolute change, 1.5%; 95% confidence interval [CI], -2.2% to 5.1%; P = .43) or the composite CHF process-of-care indicator (absolute change, 0.6%; 95% CI, -4.5% to 5.7%; P = .81). During the follow-up period, the mean 30-day AMI mortality rates were 2.5% lower (95% CI, 0.1% to 4.9%; P = .045) in the early feedback group compared with the delayed feedback group. The hospital mortality rates for CHF were not significantly different.

CONCLUSION

Public release of hospital-specific quality indicators did not significantly improve composite process-of-care indicators for AMI or CHF.

TRIAL REGISTRATION

http://clinicaltrials.gov Identifier: NCT00187460.

"Dose-dependent" impact of recurrent cardiac events on mortality in patients with heart failure

BACKGROUND

The mortality impact of recurrent cardiac hospitalizations has not been delineated in community-based heart failure patients. We determined if a "dose-dependent" relationship exists between heart failure events and death, accounting for temporal changes in age, comorbidities, and disease severity.

METHODS

Among heart failure patients in the Enhanced Feedback For Effective Cardiac Treatment Study with onset between April 1999 and March 2001, we compared long-term survival (until March 2006) in those with recurrent heart failure or cardiovascular events, relative to those free of such events.

RESULTS

In 9138 patients, 28,442 person-years of follow-up were examined (mean age: 75.3 years, 49.6% male). Recurrent heart failure events occurred 1, 2, 3, and >or=4 times in 2352 (25.7%), 1020 (11.2%), 505 (5.5%), and 596 (6.5%) patients, respectively. Cardiovascular readmissions occurred 1, 2, 3, and >or=4 times in 2522 (27.6%), 1509 (16.5%), 975 (10.7%), and 1672 (18.3%) patients, respectively. Compared with those without recurrent heart failure events, the adjusted relative mortality rates for 1, 2, 3, and >or=4 heart failure events were 2.41 (95% confidence interval [CI], 2.24-2.60), 3.00 (95% CI 2.72-3.32), 4.00 (95% CI, 3.51-4.56), and 5.16 (95% CI, 4.55-5.85), respectively. Compared with those without cardiovascular events, the adjusted relative mortality rates for 1, 2, 3, and >or=4 cardiovascular events were 3.33 (95% CI, 3.05-3.63), 4.61 (95% CI, 4.16-5.10), 6.29 (95% CI, 5.59-7.07), and 8.95 (95% CI, 8.05-9.95), respectively.

CONCLUSIONS

The risk of death increases progressively and independently with each heart failure or cardiovascular event. The number of prior events predicts mortality and should be ascertained in patients with heart failure.

Influence of socioeconomic status on lifestyle behavior modifications among survivors of acute myocardial infarction

The impact of secondary prevention initiatives on survival in higher-risk socioeconomically disadvantaged patients after acute myocardial infarction (AMI) may depend on behavioral adaptive responsiveness, uptake, and adherence to healthier lifestyles. From December 1999 to February 2003, 1,801 patients in Ontario, Canada were interviewed regarding their lifestyle behaviors at 30 days after their index AMI hospitalization. Data were obtained using self-reported surveys, medical chart abstraction, and administrative data linkage. Multivariate analyses were adjusted for baseline sociodemographic, cardiac risk severity, and co-morbid conditions. Socioeconomically disadvantaged patients had greater cardiac risk severity at baseline than did their wealthier better-educated counterparts. Compared with lower-income patients, patients with higher incomes were less likely to smoke (adjusted odds ratio [OR] for highest vs lowest income tertiles 0.36, 95% confidence interval [CI] 0.21 to 0.63, p <0.001), more likely to participate in exercise (adjusted OR 1.40, 95% CI 1.07 to 1.85, p = 0.02), and more likely to decrease or discontinue alcohol use (adjusted OR 1.64, 95% CI 1.16 to 2.34, p = 0.06). The relation between education and lifestyle behaviors was less pronounced for education than for income. After adjustment for baseline factors, patients who acknowledged participation in regular physical exercise at 1 month had a significantly lower long-term mortality than those who did not. In conclusion, socioeconomically disadvantaged patients were sicker at baseline and less behaviorally responsive to embarking on healthy lifestyle changes after AMI than were those of higher socioeconomic status.

Factors associated with the use of evidence-based therapies after discharge among elderly patients with myocardial infarction

BACKGROUND

In an accompanying article, we report moderate between-hospital variation in the postdischarge use of beta-blockers, angiotensin-modifying drugs and statins by elderly patients who had been admitted to hospital with acute myocardial infarction. Our objective was to identify the characteristics of patients, physicians, hospitals and communities associated with differences in the use of these medications after discharge.

METHODS

For this retrospective, population-based cohort study, we used linked administrative databases. We examined data for all patients aged 65 years or older who were discharged from hospital in 2005/06 with a diagnosis of myocardial infarction. We determined the effect of patient, physician, hospital and community characteristics on the rate of postdischarge medication use.

RESULTS

Increasing patient age was associated with lower postdischarge use of medications. The odds ratios (ORs) for a 1-year increase in age were 0.98 (95% confidence interval [CI] 0.97-0.99) for beta-blockers, 0.97 (95% CI 0.97-0.98) for angiotensin-converting-enzyme inhibitors and angiotensin-receptor blockers and 0.94 (95% CI 0.93-0.95) for statins. Having a general or family practitioner, a general internist or a physician of another specialty as the attending physician, relative to having a cardiologist, was associated with lower postdischarge use of beta-blockers, angiotensin-modifying agents and statins (ORs ranging from 0.46 to 0.82). Having an attending physician with 29 or more years experience, relative to having a physician who had graduated within the past 15 years, was associated with lower use of beta-blockers (OR 0.71, 95% CI 0.60-0.84) and statins (OR 0.81, 95% CI 0.67-0.97).

INTERPRETATION

Patients who received care from noncardiologists and physicians with at least 29 years of experience had substantially lower use of evidence-based drug therapies after discharge. Dissemination strategies should be devised to improve the prescribing of evidence-based medications by these physicians.

Use of evidence-based therapies after discharge among elderly patients with acute myocardial infarction

BACKGROUND

Postdischarge use of evidence-based drug therapies has been proposed as a measure of quality of care for myocardial infarction patients. We examined trends in the use of evidence-based drug therapies after discharge among elderly patients with myocardial infarction.

METHODS

We performed a cross-sectional study in a retrospective population-based cohort that was created using linked administrative databases. We included patients aged 65 years and older who were discharged from hospital with a diagnosis of myocardial infarction between Apr. 1, 1992, and Mar. 31, 2005. We determined the annual percentage of patients who filled a prescription for statins, beta-blockers and angiotensin-modifying drugs within 90 days after discharge.

RESULTS

The percentage of patients who filled a prescription for a beta-blocker increased from 42.6% in 1992 to 78.1% in 2005. The percentage of patients who filled a prescription for an angiotensin-modifying drug increased from 42.0% in 1992 to 78.4% in 2005. The percentage of patients who filled a prescription for a statin increased from 4.2% in 1992 to 79.2% in 2005. In 2005, about half of the hospitals had rates of use for each of these therapies that were less than 80%. The temporal rate of increase in statin use after discharge was slower among noncardiologists than among cardiologists (3.5%-2.8% slower). The rate of increase was 4.8% slower for among physicians with low volumes of myocardial infarction patients than among those with high volumes of such patients and was 5.7% greater at teaching hospitals compared with nonteaching hospitals.

INTERPRETATION

Use of statins, beta-blockers and angiotensin-modifying drugs increased from 1992 to 2005. The rate of increase in the use of these medications after discharge varied across physician and hospital characteristics.

The relationship between unprovoked venous thromboembolism, age, and acute myocardial infarction

BACKGROUND

Patients with unprovoked venous thromboembolism (VTE) may be at increased risk of acute myocardial infarction (AMI). However, the nature and clinical significance of this association remain unclear, particularly as it relates to age of presentation.

METHODS

We performed a longitudinal matched cohort study utilizing multiple administrative databases. Ontario residents aged 20-64 years diagnosed with unprovoked VTE from 1 April 1991 to 31 March 1995 (n = 6065) were matched to a population cohort (n = 12 040) in 1 : 2 fashion on the basis of age, gender, socioeconomic class, cardiovascular risk factors and other comorbidities. The primary outcome was a comparison of relative risk of AMI over 10-year follow-up in subjects with unprovoked VTE (overall and stratified by age) vs. controls. Secondary outcomes included risk of death or the composite endpoint of AMI and/or death.

RESULTS

Patients 20-39 years of age presenting with unprovoked VTE had an increased risk of AMI [adjusted hazard ratio (HR) 3.92, 95% confidence interval (CI) 1.65-9.35] as compared to controls; the association was applicable to those without atherosclerotic risk factors at baseline. There was no significant relationship between unprovoked VTE and AMI among patients 40-64 years old, with or without atherosclerotic risk factors. Irrespective of age, patients with unprovoked VTE had an increased risk of all-cause death or our composite endpoint of AMI and/or death as compared to patients without VTE.

CONCLUSIONS

Unprovoked VTE is associated with a nearly 4-fold higher risk of subsequent AMI among younger patient populations. Future studies must explore the risk-benefit tradeoffs of long-term surveillance and management options among such patient populations.

The relationship between physician supply, cardiovascular health service use and cardiac disease burden in Ontario: supply-need mismatch

BACKGROUND

While health service use appears to be positively correlated with resource availability, no study has explored the interactions among health service supply, cardiovascular disease burden and health service use. The objective of the present study was to examine the relationship among cardiovascular evaluation and management intensity, physician supply and cardiovascular disease burden in the Canadian population.

METHODS

The present cross-sectional, population-based study consisted of adult residents in Ontario in 2001. Cardiac evaluation and management intensity, the main outcome measure, was measured at the individual level, and consisted of receiving one or more of the following services: noninvasive cardiac testing, coronary angiography and statin use (the latter among individuals 65 years of age and older). Mortality was the secondary outcome measure. Cardiovascular disease burden, and cardiologist and primary care physician supply were measured at the regional (ie, county) level. Analyses were adjusted for age and sex using Poisson regression, accounting for regional clustering.

RESULTS

Regional per capita cardiologist supply varied more than twofold across regions, but was inversely related to the regional cardiovascular disease burden (r=-0.34, P=0.01). Primary care physician supply was relatively evenly distributed across regions. Residents in areas with more cardiologists were more likely to receive some form of cardiac intervention (RR=1.074, 95% CI 1.066 to 1.082 per additional cardiologist per 100,000). Those in areas with more primary care physicians were also more likely to receive noninvasive cardiac testing (RR=1.056, 95% CI 1.051 to 1.061 per six additional primary care physicians per 100,000). However, the intensity of provision of cardiac health services was unrelated to regional cardiovascular disease burden and was not associated with improved survival.

CONCLUSIONS

The mismatch between physician supply and cardiac disease burden may explain why cardiovascular health service use is neither concordant with the cardiovascular disease burden nor associated with mortality in the population. These results underscore the importance of physician service maldistribution and supply-sensitive care on the appropriateness of cardiac health service use.

Cardiologists' charting varied by risk factor, and was often discordant with patient report

OBJECTIVE

To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report.

STUDY DESIGN AND SETTING

A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance.

RESULTS

With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's k, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history.

CONCLUSION

Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.

Life expectancy after an index hospitalization for patients with heart failure: a population-based study

BACKGROUND

An understanding of the life expectancy of patients with heart failure (HF) may assist in difficult treatment decisions such as placement of an implantable cardioverter-defibrillator or initiation of end-of-life care. However, previous studies have focused on predicting shorter-term mortality and limited data currently exist to predict expected survival among hospitalized patients with HF.

METHODS

We studied 9943 patients who were newly hospitalized with HF between 1999 and 2001 in Ontario, Canada. Median survival was calculated using survival analysis and stratified by baseline characteristics and the EFFECT HF risk score. These analyses were repeated for the 1467 patients who had left ventricular ejection fraction of < or = 30%.

RESULTS

The average age of our HF cohort was 75.8 years and 50.4% of the patients were female. After a median follow-up of 6 years, hospitalized patients with HF had a 5-year mortality rate of 68.7% and a median survival of 2.4 years. Mortality varied substantially across risk groups such that median survival was only 8 months for patients in the high-risk group and only 3 months in the very high risk group. Similarly, among patients with depressed left ventricular ejection fraction, median survival was only 6 and 3 months in the high- and very high risk groups, respectively.

CONCLUSIONS

Prognostic estimations using median survival may improve the ability of physicians to identify subgroups of patients with HF who have limited life expectancy. This information may assist in communicating prognostic information and guiding difficult treatment decisions among hospitalized patients with HF.

Thiazolidinediones and cardiovascular outcomes in older patients with diabetes

CONTEXT

Thiazolidinediones (TZDs), used to treat type 2 diabetes, are associated with an excess risk of congestive heart failure and possibly acute myocardial infarction. However, the association between TZD use and cardiovascular events has not been adequately evaluated on a population level.

OBJECTIVE

To explore the association between TZD therapy and congestive heart failure, acute myocardial infarction, and mortality compared with treatment with other oral hypoglycemic agents.

DESIGN, SETTING, AND PATIENTS

Nested case-control analysis of a retrospective cohort study using health care databases in Ontario. We included diabetes patients aged 66 years or older treated with at least 1 oral hypoglycemic agent between 2002 and 2005 (N = 159 026) and followed them up until March 31, 2006.

MAIN OUTCOME MEASURES

The primary outcome consisted of an emergency department visit or hospitalization for congestive heart failure; secondary outcomes were an emergency department visit or hospitalization for acute myocardial infarction and all-cause mortality. The risks of these events were compared between persons treated with TZDs (rosiglitazone and pioglitazone) and other oral hypoglycemic agent combinations, after matching and adjusting for prognostic factors.

RESULTS

During a median follow-up of 3.8 years, 12 491 patients (7.9%) had a hospital visit for congestive heart failure, 12,578 (7.9%) had a visit for acute myocardial infarction, and 30 265 (19%) died. Current treatment with TZD monotherapy was associated with a significantly increased risk of congestive heart failure (78 cases; adjusted rate ratio [RR], 1.60; 95% confidence interval [CI], 1.21-2.10; P < .001), acute myocardial infarction (65 cases; RR, 1.40; 95% CI, 1.05-1.86; P = .02), and death (102 cases; RR, 1.29; 95% CI, 1.02-1.62; P = .03) compared with other oral hypoglycemic agent combination therapies (3478 congestive heart failure cases, 3695 acute myocardial infarction cases, and 5529 deaths). The increased risk of congestive heart failure, acute myocardial infarction, and mortality associated with TZD use appeared limited to rosiglitazone.

CONCLUSION

In this population-based study of older patients with diabetes, TZD treatment, primarily with rosiglitazone, was associated with an increased risk of congestive heart failure, acute myocardial infarction, and mortality when compared with other combination oral hypoglycemic agent treatments.

Effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome

BACKGROUND

Restrictions on the nonurgent use of hospital services were imposed in March 2003 to control an outbreak of severe acute respiratory syndrome (SARS) in Toronto, Ont. We describe the impact of these restrictions on health care utilization and suggest lessons for future epidemics.

METHODS

We performed a retrospective population-based study of the Greater Toronto Area (hereafter referred to as Toronto) and unaffected comparison regions (Ottawa and London, Ont.) before, during and after the SARS outbreak (April 2001-March 2004). We determined the adjusted rates of hospital admissions, emergency department and outpatient visits, diagnostic testing and drug prescribing.

RESULTS

During the early and late SARS restriction periods, the rate of overall and medical admissions decreased by 10%-12% in Toronto; there was no change in the comparison regions. The rate of elective surgery in Toronto fell by 22% and 15% during the early and late restriction periods respectively and by 8% in the comparison regions. The admission rates for urgent surgery remained unchanged in all regions; those for some acute serious medical conditions decreased by 15%-21%. The rates of elective cardiac procedures declined by up to 66% in Toronto and by 71% in the comparison regions; the rates of urgent and semi-urgent procedures declined little or increased. High-acuity visits to emergency departments fell by 37% in Toronto, and inter-hospital patient transfers fell by 44% in the circum-Toronto area. Drug prescribing and primary care visits were unchanged in all regions.

INTERPRETATION

The restrictions achieved modest reductions in overall hospital admissions and substantial reductions in the use of elective services. Brief reductions occurred in admissions for some acute serious conditions, high-acuity visits to emergency departments and inter-hospital patient transfers suggesting that access to care for some potentially seriously ill patients was affected.

Effect of Cardiac and Noncardiac Conditions on Survival After Defibrillator Implantation

OBJECTIVES

We sought to examine outcomes in recipients of implantable cardioverter-defibrillators (ICDs) and the effect of age, gender, and comorbidities on survival.

BACKGROUND

Age, gender, and comorbidities may significantly affect outcomes in ICD recipients.

METHODS

We examined factors associated with mortality in 2,467 ICD recipients in Ontario, Canada, using a province-wide database. Comorbidities were identified retrospectively by examining all diagnosis codes within the 3 years before implant.

RESULTS

Mean ages at ICD implant were 63.2 +/- 12.5 years (1,944 men) and 59.8 +/- 15.9 years (523 women). Mortality rates at one and 2 years were 7.8% and 14.0%. Older age at implant increased the risk of death with hazard ratios (HR) of 2.05 (95% confidence interval [CI] 1.70 to 2.47) and 3.00 (95% CI 2.43 to 3.71) for those 65 to 74 years and >/=75 years, respectively (both p < 0.001), but gender was not a predictor of death. Common noncardiac conditions associated with death included peripheral vascular disease (adjusted HR 1.50, 95% CI 1.18 to 1.91), pulmonary disease (adjusted HR 1.35, 95% CI 1.10 to 1.66), and renal disease (adjusted HR 1.57, 95% CI 1.25 to 1.99). Many ICD recipients had prior heart failure (46.2%) with an increased HR of 2.33 for death (95% CI 1.96 to 2.76; p < 0.001). Greater comorbidity burden conferred increased risk, with HRs adjusted for age, gender, and heart failure of 1.72 (95% CI 1.44 to 2.05), 2.79 (95% CI 2.15 to 3.62), and 2.98 (95% CI 1.74 to 5.10) for those with 1, 2, and 3 or more noncardiac comorbidities, respectively (all p < 0.001).

CONCLUSIONS

Age, noncardiac comorbidities, and prior heart failure influence survival outcomes in ICD recipients. These factors should be considered in the care of ICD recipients.

Age-social stratification designs had a negligible impact on income-mortality associations

OBJECTIVES

Age-social stratification has been used to offset socioeconomic status (SES) misclassification due to cohort effects. This study was to evaluate whether age-income stratification designs generate comparable income-mortality associations as those whose income rankings are based on absolute thresholds.

STUDY DESIGN AND SETTING

Using self-reported income as our SES variable, and mortality as our outcome measure, the impact of age-social stratification was examined in two distinct cohorts: one with acute myocardial infarction (AMI) (n=3,138), and the second free of cardiovascular disease (n=15,115). Age-adjusted income-mortality associations were compared between age-social stratification techniques, which used "age-relative" income thresholds and "absolute" income thresholds whose ranks were independent of patient age.

RESULTS

In both cohorts, crude mortality inversely correlated with age and income. Techniques using "age-relative" income thresholds yielded similar adjusted odds ratio for mortality as did those that used "absolute" income threshold methods (differences in adjusted odds ratios [+/-95% confidence interval (CI)] between "absolute" and "age-relative" classifications for highest vs. lowest income tertiles: -0.05 [-0.24, 0.12] among patients with AMI and 0.05 [-0.03, 0.13] among patients without cardiovascular disease).

CONCLUSION

More complex designs incorporating age-social stratification techniques generate similar income-mortality associations as more simplified approaches, which classified SES using absolute income thresholds.

Coronary Angiography Following Acute Myocardial Infarction in Ontario, Canada

BACKGROUND

The role of scientific evidence in shaping recommendations on capacity targets and cardiovascular technology utilization is unclear.

METHODS

The temporal growth in the use of coronary angiography services and the use of statins after an acute myocardial infarction (AMI) was determined for all patients older than 65 years admitted to any hospital in Ontario, Canada, between 1992 and 2004. A Bayesian change-point regression model was used to determine the rate of maximum uptake (inflection point) for use of cardiac catheterization service and statins after AMI. The inflection points were compared with the corresponding publication dates of the first positive evidence for outcome efficacy of use of cardiac catheterization service and statins after AMI as obtained from randomized control trials.

RESULTS

The use of post-AMI coronary angiography closely mirrored overall temporal increases in cardiac catheterization capacity between 1992 and 2004 (r = 0.95, P<.001). The inflection point for post-AMI angiography service use was September 1998, 11 months before the publication of the first positive randomized controlled trial demonstrating benefit of routine post-AMI angiography. Conversely, the inflection point for statin therapy occurred in October 1998, 47 months after the publication of the first positive randomized controlled trial demonstrating the benefits of statin therapy for the secondary prevention of coronary artery disease. These findings were consistent regardless of the presence of on-site cardiac catheterization facilities at the admitting AMI institution and patient illness severity levels.

CONCLUSION

The proliferation of cardiac catheterization in Ontario is attributable to factors other than the emergence of published scientific evidence.

Relation between cardiac troponin I and mortality in acute decompensated heart failure

BACKGROUND

Troponin level elevations are common in patients with acute decompensated heart failure (ADHF), yet their prognostic value above and beyond traditional predictors of outcomes in heart failure is uncertain.

METHODS

In the EFFECT study, we determined the association between cardiac troponin I and all-cause mortality in 2025 patients hospitalized for heart failure in Ontario, Canada, between April 1, 1999, and March 31, 2001.

RESULTS

Cardiac troponin I levels >0.5 microg/L (median 1.7 microg/L, interquartile range 0.9-4.8 microg/L) occurred in 699 (34.5%) patients and was an independent predictor of mortality (adjusted hazard ratio 1.49, 95% CI 1.25-1.77, P < .001). Furthermore, we observed a dose-response relationship between cardiac troponin I and mortality that persisted after adjustment for potential confounding factors (adjusted hazard ratio 1.10 per 1 microg/L increase, 95% CI 1.05-1.15, P < .001). The association between cardiac troponin I and mortality was similar for patients with and without other features of acute ischemia on presentation (P > .05 for interaction).

CONCLUSIONS

In patients hospitalized for ADHF who had cardiac troponin levels measured during the course of clinical practice, cardiac troponin I was an independent predictor of all-cause mortality. Cardiac troponin testing is easily accessible, has predictive value above and beyond traditional clinical predictors of mortality, and may help guide medical decision making in patients with ADHF.