Emergency department visits for heart failure and subsequent hospitalization or observation unit admission

BACKGROUND

Treatment of acute heart failure in the emergency department (ED) or observation unit is an alternative to hospitalization. Both ED management and observation unit management have been associated with reduced costs and may be used to avoid penalties related to rehospitalizations. The purpose of this study was to examine trends in ED visits for heart failure and disposition following such visits.

METHODS

We used the National Hospital Ambulatory Medical Care Survey, a representative sample of ED visits in the United States, to estimate rates and characteristics of ED visits for heart failure between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit.

RESULTS

The number of ED visits for heart failure remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%, 95% CI -3.7% to +2.5%). Of these visits, 74.2% led to hospitalization, wheras 3.1% led to observation unit admission. The likelihood of hospitalization did not change during the period (adjusted prevalence ratio 1.00, 95% CI 0.99-1.01 for each additional year), whereas admission to the observation unit increased annually (adjusted prevalence ratio 1.12, 95% CI 1.01-1.25). We observed significant regional differences in likelihood of hospitalization and observation admission.

CONCLUSIONS

The number of ED visits for heart failure and the high proportion of ED visits with subsequent inpatient hospitalization have not changed in the last decade. Opportunities may exist to reduce hospitalizations by increasing short-term management of heart failure in the ED or observation unit.

Building skill in heart failure self-care among community dwelling older adults: results of a pilot study

OBJECTIVE

Most of the day-to-day care for heart failure (HF) is done by the patient at home and requires skill in self-care. In this randomized controlled trial (RCT) we tested the efficacy of a community-based skill-building intervention on HF self-care, knowledge and health-related quality of life (HRQL) at 1- and 3-months.

METHODS

An ethnically diverse sample (n=75) of patients with HF (53% female; 32% Hispanic, 27% Black; mean age 69.9±10 years) was randomized to the intervention group (IG) or a wait-list control group (CG). The protocol intervention focused on tactical and situational HF self-care skill development delivered by lay health educators in community senior centers. Data were analyzed using mixed (between-within subjects) ANOVA.

RESULTS

There was a significant improvement in self-care maintenance [F(2,47)=3.42, p=.04, (Cohen's f=.38)], self-care management [F(2,41)=4.10, p=.02, (Cohen's f=.45) and HF knowledge [F(2,53)=8.00, p=.001 (Cohen's f=.54)] in the IG compared to the CG.

CONCLUSIONS

The skill-building intervention improved self-care and knowledge but not HRQL in this community-dwelling sample.

PRACTICE IMPLICATIONS

Delivering an intervention in a community setting using lay health educators provides an alternative to clinic- or home-based teaching that may be useful across diverse populations and geographically varied settings.

Abstract 204: Emergency Department Visits for Heart Failure and Subsequent Hospitalization or Observation Unit Admission

Background: Although the majority of hospitalizations for heart failure (HF) originate in the emergency department (ED), many of these patients might be adequately treated and released in the ED or managed for a short period in an observation unit. Both ED and observation management have been shown to reduce costs and avoid the penalties related to rehospitalization. The purpose of this study was to examine trends in ED visits for HF and disposition following these visits. Because of increasing policy pressure to reduce rehospitalization for HF, we hypothesized that the number of HF patients hospitalized by ED providers decreased over time with a concurrent increase in admissions to the observation unit. We further hypothesized that the overall number of ED visits for HF decreased as a result of improved therapy for HF the last two decades.

Methods: We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) to estimate rates and characteristics of ED visits for HF between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit.

Results: The number of ED visits for HF remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%; 95% CI -3.7% - +2.5%). Of these visits, 74.2% led to hospitalization while 3.1% led to observation unit admission (Figure). The likelihood of hospitalization did not change during the period (adjusted prevalence ratio (aPR) 1.00; 95% CI 0.99-1.01 for each additional year) while admission to observation increased annually (aPR 1.11; 95% CI 1.00-1.23). We observed significant regional differences: as compared to other regions, patients in the Northeast were more likely to be hospitalized (aPR 1.15; 95% CI 1.07-1.22) but less likely to be admitted to an observation unit (aPR 0.43; 95% CI 0.19-1.02).

Conclusions: The number of ED visits for HF has remained stable in the last decade. Although observation unit admissions increased during this period, they constituted a relatively small number of dispositions and did not appear to attenuate the substantial number of ED visits that resulted in hospitalization. Opportunities may exist to reduce hospitalizations by increasing short term management of HF in the observation unit.

Quality of care for heart failure patients hospitalized for any cause

OBJECTIVES

The study sought to assess the quality of care for heart failure patients who are hospitalized for all causes.

BACKGROUND

Performance measures for heart failure target patients with a principal diagnosis of heart failure. However, patients with heart failure are commonly hospitalized for other causes and may benefit from treatments such as angiotensin-converting enzyme (ACE) inhibitors for left ventricular (LV) systolic dysfunction.

METHODS

We assessed rates of compliance with care measures for patients hospitalized with acute or chronic heart failure in the ARIC (Atherosclerosis Risk In Communities) study surveillance catchment area from 2005 to 2009. Rates of compliance were compared between patients with a principal discharge diagnosis of heart failure and those with another principal discharge diagnosis.

RESULTS

Of 4,345 hospitalizations of heart failure patients, 39.6% carried a principal diagnosis of heart failure. Patients with a principal heart failure diagnosis had higher rates of LV function assessment (89.1% vs. 82.5%; adjusted prevalence ratio [aPR]: 1.07; 95% confidence interval [CI]: 1.04 to 1.10) and discharge ACE inhibitor/angiotensin receptor blocker (ARB) in LV dysfunction (64.1% vs. 56.3%; aPR: 1.11; 95% CI: 1.03 to 1.20) as compared to patients hospitalized for another cause. LV assessment and ACE inhibitor/ARB use were associated with reductions in 1-year post-discharge mortality (adjusted odds ratio: 0.66, 95% CI: 0.51 to 0.85; adjusted odds ratio: 0.72, 95% CI: 0.54 to 0.96, respectively) that did not differ for patients with versus without a principal heart failure diagnosis.

CONCLUSIONS

Compared with individuals hospitalized with a principal diagnosis of heart failure, heart failure patients hospitalized for other causes were less likely to receive guideline recommended care. Quality initiatives may improve care by targeting hospitalizations with either principal or secondary heart failure diagnoses.

Heart failure–associated hospitalizations in the United States

OBJECTIVES

This study sought to characterize temporal trends in hospitalizations with heart failure as a primary or secondary diagnosis.

BACKGROUND

Heart failure patients are frequently admitted for both heart failure and other causes.

METHODS

Using the Nationwide Inpatient Sample (NIS), we evaluated trends in heart failure hospitalizations between 2001 and 2009. Hospitalizations were categorized as either primary or secondary heart failure hospitalizations based on the location of heart failure in the discharge diagnosis. National estimates were calculated using the sampling weights of the NIS. Age- and sex-standardized hospitalization rates were determined by dividing the number of hospitalizations by the U.S. population in a given year and using direct standardization.

RESULTS

The number of primary heart failure hospitalizations in the United States decreased from 1,137,944 in 2001 to 1,086,685 in 2009, whereas secondary heart failure hospitalizations increased from 2,753,793 to 3,158,179 over the same period. Age- and sex-adjusted rates of primary heart failure hospitalizations decreased steadily from 2001 to 2009, from 566 to 468 per 100,000 people. Rates of secondary heart failure hospitalizations initially increased from 1,370 to 1,476 per 100,000 people from 2001 to 2006, then decreased to 1,359 per 100,000 people in 2009. Common primary diagnoses for secondary heart failure hospitalizations included pulmonary disease, renal failure, and infections.

CONCLUSIONS

Although primary heart failure hospitalizations declined, rates of hospitalizations with a secondary diagnosis of heart failure were stable in the past decade. Strategies to reduce the high burden of hospitalizations of heart failure patients should include consideration of both cardiac disease and noncardiac conditions.

Abstract 107: Quality Of Care In Heart Failure Patients Hospitalized For Any Cause

Background: Hospital quality performance measures for heart failure (HF) target patients with a principal discharge diagnosis of HF. However, patients with chronic HF are commonly admitted for other causes and are recommended treatments such as angiotensin converting enzyme (ACE) inhibitors for left ventricular (LV) systolic dysfunction. The purpose of this study was to assess the quality of care for HF patients who are hospitalized for all causes.

Methods: We conducted a community-wide surveillance of hospitalized patients with acute or chronic HF as part of the Atherosclerosis Risk in Communities (ARIC) Study from 2005-2009. HF diagnosis was validated by chart abstraction and adjudication by physician committee. We assessed rates of compliance for two available Centers for Medicare & Medicaid Services (CMS) inpatient quality measures: LV function assessment and discharge prescription for an ACE inhibitor or angiotensin receptor blocker (ARB) for patient with LV systolic dysfunction; rates were compared for HF patients with a principal ICD-9 discharge diagnosis of HF and those with another principal discharge diagnosis. Cox proportional hazard models were used to assess the association of quality measures with post-discharge mortality.

Results: Of 4,345 hospitalizations of HF patients, 39.6% carried a principal discharge diagnosis of HF. Individuals with a principal discharge diagnosis of HF had higher rates of LV function assessment (89.1% versus 82.5%, p<0.0001; adjusted prevalence ratio (aPR) 1.07, 95% CI 1.04-1.10) and ACE inhibitor/ARB use in LV dysfunction (64.1% versus 56.3%, p<0.01; aPR 1.11, 95% CI 1.03-1.20) as compared to individuals hospitalized for another cause. LV assessment and ACE inhibitor/ARB use were associated with significant or near significant reductions in post-discharge mortality (adjusted hazard ratios 0.69, 95% CI 0.50-0.90 and 0.73, 95% CI 0.52-1.03, respectively). The associations between quality measures and post-discharge mortality did not differ for patients with versus without a primary discharge diagnosis of HF (p-interaction=0.8 for LV assessment; p-interaction=0.6 for ACE inhibitor/ARB use).

Conclusions: Compared to individuals hospitalized with a principal diagnosis of heart failure, heart failure patients hospitalized for other causes are less likely to receive aspects of guideline recommended care. Quality initiatives may improve care and outcomes by targeting hospitalizations with both a principal and secondary HF diagnosis.

Oral octreotide absorption in human subjects: comparable pharmacokinetics to parenteral octreotide and effective growth hormone suppression

CONTEXT

Oral administration of a novel octreotide formulation enabled its absorption to the systemic circulation, exhibiting blood concentrations comparable to those observed with injected octreotide and maintaining its biological activity.

OBJECTIVES

The aim of the study was to determine oral octreotide absorption and effects on pituitary GH secretion compared to sc octreotide injection.

DESIGN

Four single-dose studies were conducted in 75 healthy volunteers.

INTERVENTION

Oral doses of 3, 10, or 20 mg octreotide and a single sc injection of 100 μg octreotide were administered.

MAIN OUTCOME MEASURE

We measured the pharmacokinetic profile of orally administrated octreotide and the effect of octreotide on basal and stimulated GH secretion.

RESULTS

Both oral and sc treatments were well tolerated. Oral octreotide absorption to the circulation was apparent within 1 h after dose administration. Escalating oral octreotide doses resulted in dose-dependent increased plasma octreotide concentrations, with an observed rate of plasma decay similar to parenteral administration. Both 20 mg oral octreotide and injection of 0.1 mg sc octreotide resulted in equivalent pharmacokinetic parameters [mean peak plasma concentration, 3.77 ± 0.25 vs. 3.97 ± 0.19 ng/ml; mean area under the curve, 16.2 ± 1.25 vs. 12.1 ± 0.45 h × ng/ml); and median time ≥ 0.5 ng/ml, 7.67 vs. 5.88 h, respectively). A single dose of 20 mg oral octreotide resulted in basal (P < 0.05) and GHRH-stimulated (P < 0.001) mean GH levels suppressed by 49 and 80%, respectively.

CONCLUSIONS

The results support an oral octreotide alternative to parenteral octreotide treatment for patients with acromegaly.

17β-Estradiol inhibits iron hormone hepcidin through an estrogen responsive element half-site

Interaction of estrogen with iron at the systemic level is long suspected, but direct evidence linking the two is limited. In the present study, we examined the effects of 17β-estradiol (E2) on hepcidin, a key negative regulator of iron absorption from the liver. We found that transcription of hepcidin was suppressed by E2 treatment in human liver HuH7 and HepG2 cells, and this down-regulation was blocked by E2 antagonist ICI 182780. Chromatin immunoprecipitation, deletion, and EMSA detected a functional estrogen responsive element half-site that is located between -2474 and -2462 upstream from the start of transcription of the hepcidin gene. After cloning the human hepcidin promoter into the pGL3Luc-Reporter vector, luciferase activity was also down-regulated by E2 treatment in HepG2 cells. E2 reduced hepcidin mRNA in wild-type mice as well as in hemochromatosis Fe gene knockout mice. In summary, our data suggest that hepcidin inhibition by E2 is to increase iron uptake, a mechanism to compensate iron loss during menstruation. This mechanism may also contribute to increased iron stores in oral contraceptive users.