Health literacy and outcomes among patients with heart failure

CONTEXT

Little is known about the effects of low health literacy among patients with heart failure, a condition that requires self-management and frequent interactions with the health care system.

OBJECTIVE

To evaluate the association between low health literacy and all-cause mortality and hospitalization among outpatients with heart failure.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study conducted at Kaiser Permanente Colorado, an integrated managed care organization. Outpatients with heart failure were identified between January 2001 and May 2008, were surveyed by mail, and underwent follow-up for a median of 1.2 years. Health literacy was assessed using 3 established screening questions and categorized as adequate or low. Responders were excluded if they did not complete at least 1 health literacy question or if they did not have at least 1 year of enrollment prior to the survey date.

MAIN OUTCOME MEASURES

All-cause mortality and all-cause hospitalization.

RESULTS

Of the 2156 patients surveyed, 1547 responded (72% response rate). Of 1494 included responders, 262 (17.5%) had low health literacy. Patients with low health literacy were older, of lower socioeconomic status, less likely to have at least a high school education, and had higher rates of coexisting illnesses. In multivariable Cox regression, low health literacy was independently associated with higher mortality (unadjusted rate, 17.6% vs 6.3%; adjusted hazard ratio, 1.97 [95% confidence interval, 1.3-2.97]; P = .001) but not hospitalization (unadjusted rate, 30.5% vs 23.2%; adjusted hazard ratio, 1.05 [95% confidence interval, 0.8-1.37]; P = .73).

CONCLUSION

Among patients with heart failure in an integrated managed care organization, low health literacy was significantly associated with higher all-cause mortality.

Regional variation in the use of implantable cardioverter-defibrillators for primary prevention: results from the National Cardiovascular Data Registry

BACKGROUND

Although the use of implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden cardiac death varies by sex, race, and hospital, geographic variation in ICD use remains unexplored. Our objective was to quantify regional variations in the utilization of primary prevention ICDs in the United States, and to evaluate if an association exists between utilization and physician supply or the proportion of patients meeting the trial inclusion criteria.

METHODS AND RESULTS

This is a cross-sectional analysis among the Medicare, fee-for-service population from the National Cardiovascular Data Registry. Using hospital referral regions, we calculated the age-, sex-, and race-adjusted rates of ICD placement for each region and assessed the correlation between these rates and (1) physician supply and (2) the proportion of patients meeting trial inclusion criteria. Substantial variation was found across quintiles of rate ratios of ICD implantation, ranging from 0.39 to 1.77 (compared with a national mean rate of 1.0). This ratio was not correlated with the supply of cardiologists (R(2)=0.01), electrophysiologists (R(2)=0.01), or with the proportion of patients meeting trial inclusion criteria (R(2)<0.01). Over all, 13% of all patients receiving ICDs did not meet trial criteria.

CONCLUSIONS

Marked geographic variation in the use of primary prevention ICDs exists across the United States that is not correlated with physician supply. Although >1 in 10 patients received ICDs outside of trial criteria, this potential overuse did not explain the variation. Future studies should consider underuse or misuse of primary prevention ICDs as causes of geographic variation.

Regional variations in palliative care: do cardiologists follow guidelines?

OBJECTIVES

Regional variation in health care use in the last 6 months of life is well documented. Our objective was to examine whether an association exists between cardiologists' tendencies to discuss palliative care for patients with advanced heart failure and the regional use of health care in the last 6 months of life.

METHODS

We performed a national mail survey of a random sample of 994 eligible Cardiologists from the American Medical Association Masterfile. Hypothetical patient scenarios were used to explore physician management of patient scenarios.

RESULTS

We received 614 responses (response rate: 62%). In a 75-year-old with symptomatic chronic heart failure and asymptomatic nonsustained ventricular tachycardia, cardiologists in regions with high use in the last 6 months of life were less likely to have discussions about palliative care (23% versus 32% for comparisons between the highest and lowest quintiles, p = 0.04). Similarly, in an 85 year-old with symptomatic chronic heart failure and an acute exacerbation, cardiologists in high use regions were less likely to have discussions about palliative care (35% versus 47%, p = 0.0008).

CONCLUSIONS

Despite professional guidelines suggesting that cardiologists discuss palliative care with patients with late stage heart failure, less than half of cardiologists would discuss palliative care in two elderly patients with late-stage heart failure and this guideline discordance was worse in the regions with more health care use in the last 6 months of life.

Quality of care for acute myocardial infarction in 58 U.S. emergency departments

OBJECTIVES

The objectives of this study were to determine concordance of emergency department (ED) management of acute myocardial infarction (AMI) with guideline recommendations and to identify ED and patient characteristics predictive of higher guideline concordance.

METHODS

The authors conducted a chart review study of ED AMI care as part of the National Emergency Department Safety Study (NEDSS). Using a primary hospital discharge diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes 410.XX), a random sample of ED visits for AMI in 58 urban EDs across 20 U.S. states between 2003 and 2006 were identified. Concordance with American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations was evaluated using five individual quality measures and a composite concordance score. Concordance scores were calculated as the percentage of eligible patients who received guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance.

RESULTS

The cohort consisted of 3,819 subjects; their median age was 65 years, and 62% were men. The mean (± standard deviation [SD]) ED composite concordance score was 61 ± 8), with a broad range of values (42 to 84). Except for aspirin use (mean concordance, 82), ED concordance scores were low (beta-blocker use, 56; timely electrocardiogram [ECG], 41; timely fibrinolytic therapy, 26; timely ED disposition for primary percutaneous coronary intervention [PCI] candidates, 43). In multivariable analyses, older age (beta-coefficient per 10-year increase, -1.5; 95% confidence interval [CI] = -2.4 to -0.5) and southern EDs (beta-coefficient, -5.2; 95% CI = -9.6 to -0.9) were associated with lower guideline concordance, whereas ST-segment elevation on initial ED ECG was associated with higher guideline concordance (beta-coefficient, 3.6; 95% CI = 1.5 to 5.7).

CONCLUSIONS

Overall ED concordance with guideline-recommended processes of care was low to moderate. Emergency physicians should continue to work with other stakeholders in AMI care, such as emergency medical services (EMS) and cardiologists, to develop strategies to improve care processes.

Treatment and Risk in Heart Failure

Background— Although the absolute benefits of an intervention are proportional to patients’ underlying risk, studies in heart failure have noted a paradoxical inverse relationship between treatment and risk. The extent to which this reflects higher rates of contraindications in patients with higher risk or larger gaps in care quality has not been explored.

Methods and Results— We studied 18 307 patients with left ventricular systolic dysfunction surviving hospitalization between January 2005 and June 2007 from 194 hospitals participating in Get With The Guidelines (GWTG)–Heart Failure. Patients were categorized according to their estimated risk for in-hospital mortality using a validated risk score. The proportions of patients with documented contraindications to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and β-blockers as well as the use of these medications among patients without contraindications at hospital discharge was determined across levels of risk. For each therapy, the proportion of patients with contraindications was significantly higher with increasing patient risk ( P <0.001 for each). Even after excluding those with contraindications, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and β-blockers was significantly lower with increasing risk ( P <0.001 for each).

Conclusions— The use of evidence-based therapies is lower in patients with heart failure at higher risk of mortality both because of higher rates of contraindications to therapy and lower rates of use among eligible patients. Optimizing heart failure outcomes will require both the expansion of the evidence base for treating the highest-risk patients as well as the development of effective strategies to assure that eligible high-risk patients receive all appropriate therapies.

Importance of measuring glycosylated hemoglobin in patients with myocardial infarction and known diabetes mellitus

Although medical co-morbidities commonly affect clinical outcomes after acute myocardial infarction (AMI), current performance measures of AMI quality focus exclusively on the management of the AMI itself. However, patients with AMIs frequently present with other co-morbidities, such as diabetes mellitus (DM), that also warrant assessment and management. To date, the quality of DM evaluation in patients presenting with AMIs has not been described. From January 2003 to June 2004, the Prospective Registry Evaluating Myocardial Infarction Patients: Events and Recovery-Quality Improvement (PREMIER-QI) enrolled 3,953 patients with AMIs at 19 centers in the United States. The frequency of glycosylated hemoglobin (HbA(1c)) assessment, either during the hospitalization or documented in the chart from the preceding 3 months, was prospectively evaluated. Among 1,168 patients with AMIs with preexisting DM, only 47% had recent HbA(1c) levels available, with marked variability in HbA(1c) assessment among hospitals (range 7% to 81%). Among those with available HbA(1c) levels, 39% had good control (HbA(1c) <7%), 36% had suboptimal control (HbA(1c) 7% to 9%), and 25% had poor control (HbA(1c) >9%). Patients with suboptimal and poor control were more likely to have their DM treatment intensified than those without HbA(1c) assessment (for HbA(1c) 7% to 9%, rate ratio 1.38, 95% confidence interval 1.03 to 1.85; for HbA(1c) >9%, rate ratio 2.20, 95% confidence interval 1.68 to 2.88). Similarly, patients with DM who had HbA(1c) measured were more likely to receive instructions on DM disease management before discharge. In conclusion, the assessment of chronic glycemic control is highly variable among patients with AMIs and DM. Because much of this variability occurs at the hospital level, the evaluation of DM control could represent an additional quality indicator and an opportunity to advance patient-centered AMI care.

The role of social support in health status and depressive symptoms after acute myocardial infarction: evidence for a stronger relationship among women

BACKGROUND

Prior studies have associated low social support (SS) with increased rehospitalization and mortality after acute myocardial infarction. However, relatively little is known about whether similar patterns exist for other outcomes, such as health status and depressive symptoms, and whether these patterns vary by sex.

METHODS AND RESULTS

Using data from 2411 English- or Spanish-speaking patients with acute myocardial infarction enrolled in a 19-center prospective study, we examined the association of SS (low, moderate, high) with health status (angina, disease-specific quality of life, general physical and mental functioning) and depressive symptoms over the first year of recovery. Overall and sex-stratified associations were evaluated using mixed-effects Poisson and linear regression, adjusting for site, baseline health status, baseline depressive symptoms, and demographic and clinical factors. Patients with the lowest SS (relative to those with the highest) had increased risk of angina (relative risk, 1.27; 95% confidence interval [CI], 1.10, 1.48); lower disease-specific quality of life (mean difference [beta]=-3.33; 95% CI, -5.25, -1.41), lower mental functioning (beta=-1.72; 95% CI, -2.65, -0.79), and more depressive symptoms (beta=0.94; 95% CI, 0.51, 1.38). A nonsignificant trend toward lower physical functioning (beta=-0.87; 95% CI, -1.95, 0.20) was observed. In sex-stratified analyses, the relationship between SS and outcomes was stronger for women than for men, with a significant SS-by-sex interaction for disease-specific quality of life, physical functioning, and depressive symptoms (all P<0.02).

CONCLUSIONS

Lower SS is associated with worse health status and more depressive symptoms over the first year of acute myocardial infarction recovery, particularly for women.

Association of longitudinal measures of hemoglobin and outcomes after hospitalization for heart failure

BACKGROUND

Cross-sectional assessments of hemoglobin (Hb) are associated with mortality in patients with heart failure (HF). Our objectives were to characterize patterns of change in Hb over time in patients with HF and to evaluate the relationship between longitudinal measures of Hb and adverse outcomes.

METHODS

The study included 2,478 patients with a primary discharge diagnosis of HF from January 2001 to December 2006. Outcomes included time to death and time to death or HF hospitalization. The association between baseline Hb and outcomes was evaluated using multivariable Cox regression. The longitudinal association was evaluated using a time-dependent Hb predictor variable and using anemia trajectory groups.

RESULTS

For a median of 475 days, baseline Hb was associated with a trend toward increased mortality (hazard ratio [HR] 1.02, 95% CI 0.99-1.06 per g/dL decline). With a time-dependent approach, the magnitude of the association was greater (HR 1.35, 95% CI 1.30-1.39 per g/dL decline). In trajectory analysis, 35% of the cohort had variable patterns of anemia. Persistently low Hb (HR 1.65, 95% CI 1.27-2.14) and a progressive decline in Hb (HR 1.54, 95% CI 1.16-2.05) were associated with increased mortality risk. Patients with recovery of anemia had similar outcomes as those patients who are persistently nonanemic. Results were similar for the composite of death or HF hospitalization.

CONCLUSIONS

Variability in Hb over time is common in patients with HF, and declining Hb is associated with a poor prognosis. Longitudinal characterization of Hb levels has greater prognostic significance than a single measurement. Systematic surveillance of Hb levels may help identify high-risk patients with heart failure.

A validated risk score for in-hospital mortality in patients with heart failure from the American Heart Association get with the guidelines program

BACKGROUND

Effective risk stratification can inform clinical decision-making. Our objective was to derive and validate a risk score for in-hospital mortality in patients hospitalized with heart failure using American Heart Association Get With the Guidelines-Heart Failure (GWTG-HF) program data.

METHODS AND RESULTS

A cohort of 39 783 patients admitted January 1, 2005, to June 26, 2007, to 198 hospitals participating in GWTG-HF was divided into derivation (70%, n=27 850) and validation (30%, n=11 933) samples. Multivariable logistic regression identified predictors of in-hospital mortality in the derivation sample from candidate demographic, medical history, and laboratory variables collected at admission. In-hospital mortality rate was 2.86% (n=1139). Age, systolic blood pressure, blood urea nitrogen, heart rate, sodium, chronic obstructive pulmonary disease, and nonblack race were predictive of in-hospital mortality. The model had good discrimination in the derivation and validation datasets (c-index, 0.75 in each). Effect estimates from the entire sample were used to generate a mortality risk score. The predicted probability of in-hospital mortality varied more than 24-fold across deciles (range, 0.4% to 9.7%) and corresponded with observed mortality rates. The model had the same operating characteristics among those with preserved and impaired left ventricular systolic function. The morality risk score can be calculated on the Web-based calculator available with the GWTG-HF data entry tool.

CONCLUSIONS

The GWTG-HF risk score uses commonly available clinical variables to predict in-hospital mortality and provides clinicians with a validated tool for risk stratification that is applicable to a broad spectrum of patients with heart failure, including those with preserved left ventricular systolic function.

Use of implantable cardioverter defibrillators for primary prevention in the community: do women and men equally meet trial enrollment criteria?

BACKGROUND

Fewer women than men undergo implantable cardioverter defibrillator (ICD) implantation for the primary prevention of sudden cardiac death. The criteria used to select patients for ICD implantation may be more permissive among men than for women. We hypothesized that women who undergo primary prevention ICD implantation more often meet strict trial enrollment criteria for this therapy.

METHODS

We studied 59,812 patients in the National Cardiovascular Data Registry ICD registry undergoing initial primary prevention ICD placement between January 2005 and April 2007. Patients were classified as meeting or not meeting enrollment criteria of either the MADIT-II or SCD-HeFT trials. Multivariable analyses assessed the association between gender and concordance with trial criteria adjusting for demographic, clinical, and system characteristics.

RESULTS

Among the cohort, 27% (n = 16,072) were women. Overall, 85.2% of women and 84.5% of men met enrollment criteria of either trial (P = .05). In multivariable analyses, women were equally likely to meet trial criteria (OR 1.04, 95% CI 0.99-1.10) than men. Significantly more women than men met the trial enrollment criteria among patients older than age 65 (86.6% of women vs 85.3% of men, OR 1.11, 95% CI 1.03-1.19), but this difference was not found among younger patients (82.5% of women vs 83.0% of men, OR 0.97, 95% CI 0.89-1.07).

CONCLUSIONS

In a national cohort undergoing primary prevention ICD implantation, older women were only slightly more likely then men to meet the enrollment criteria for MADIT II or SCD-HeFT. Relative overutilization in men is not an important explanation for gender differences in ICD implantation.

Gender differences in procedure-related adverse events in patients receiving implantable cardioverter-defibrillator therapy

BACKGROUND

Women are at higher risk than men for adverse events with certain invasive cardiac procedures. Our objective was to compare rates of in-hospital adverse events in men and women receiving implantable cardioverter- defibrillator (ICD) therapy in community practice.

METHODS AND RESULTS

Using the National Cardiovascular Data Registry ICD Registry, we identified patients undergoing first-time ICD implantation between January 2006 and December 2007. Outcomes included in-hospital adverse events after ICD implantation. Multivariable analysis assessed the association between gender and in-hospital adverse events, with adjustment for demographic, clinical, procedural, physician, and hospital characteristics. Of 161,470 patients, 73% were male, and 27% were female. Women were more likely to have a history of heart failure (81% versus 77%, P<0.01), worse New York Heart Association functional status (57% versus 50% in class III and IV, P<0.01), and nonischemic cardiomyopathy (44% versus 27%, P<0.01) and were more likely to receive biventricular ICDs (39% versus 34%, P<0.01). In unadjusted analyses, women were more likely to experience any adverse event (4.4% versus 3.3%, P<0.001) and major adverse events (2.0% versus 1.1%, P<0.001). In multivariable models, women had a significantly higher risk of any adverse event (OR 1.32, 95% CI 1.24 to 1.39) and major adverse events (OR 1.71, 95% CI 1.57 to 1.86).

CONCLUSIONS

Women are more likely than men to have in-hospital adverse events related to ICD implantation. Efforts are needed to understand the reasons for higher ICD implantation-related adverse event rates in women and to develop strategies to reduce the risk of these events.

The relationship between gender and clinical management after exercise stress testing

BACKGROUND

Controversy remains regarding whether gender differences exist in clinical management after exercise treadmill testing (ETT).

METHODS

We studied 7,506 patients (49.8% women) without documented coronary heart disease referred for ETT from July 2001 to June 2004 in a community-based setting. We assessed the relationship between gender and subsequent diagnostic testing (secondary stress testing or coronary angiography) within 6 months after ETT. Secondary outcomes included subsequent stress testing, coronary angiography, and new cardiology visits in the 6-month interval. Multivariable analyses assessed the relationship between gender and these outcomes adjusting for demographic, clinical, and stress test characteristics. In subsequent analyses, patients were stratified by Duke Treadmill Scores (Duke University, Durham, NC).

RESULTS

Compared with men, women referred for ETT were older, had a higher prevalence of some cardiac risk factors, achieved lower peak workloads, and, more often, experienced chest pain or ST-segment changes. After accounting for differences in clinical and ETT parameters, gender was not associated with any subsequent diagnostic testing in the 6 months after ETT (OR 1.0, 95% CI 0.85-1.18). In secondary analyses, women were less likely to undergo angiography (OR 0.63, 95% CI 0.47-0.83) with a trend toward more subsequent stress testing. Stratified analyses revealed less subsequent testing in high-to-intermediate Duke Treadmill Score women compared with men (OR 0.61, 95% CI 0.48-0.79). Women and men were equally likely to die (hazards ratio 0.93, 95% CI 0.61-1.44) in the adjusted survival analysis.

CONCLUSIONS

Overall, women and men equally underwent subsequent diagnostic testing after ETT. Although women were less likely to undergo angiography and higher-risk women were less likely to undergo subsequent testing, adverse events were not higher in women. Given these findings, assumptions regarding gender disparities in clinical management after ETT should be reevaluated in other settings.

Medication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease

BACKGROUND

Little is known about the effect of nonadherence among patients with coronary artery disease (CAD) on a broad spectrum of outcomes including cardiovascular mortality, cardiovascular hospitalizations, and revascularization procedures.

METHODS

This was a retrospective cohort study of 15,767 patients with CAD. Medication adherence was calculated as proportion of days covered for filled prescriptions of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and statin medications. Multivariable Cox regression assessed the association between medication nonadherence as a time-varying covariate and a broad range of outcomes, adjusting for demographics and clinical characteristics. Median follow-up was 4.1 years.

RESULTS

Rates of medication nonadherence were 28.8% for beta-blockers, 21.6% for ACE inhibitors, and 26.0% for statins. In unadjusted analysis, nonadherence to each class of medication was associated with higher all-cause and cardiovascular mortality. In multivariable analysis, nonadherence remained significantly associated with increased all-cause mortality risk for beta-blockers (hazard ratio [HR] 1.50, 95% CI 1.33-1.71), ACE inhibitors (HR 1.74, 95% CI 1.52-1.98), and statins (HR 1.85, 95% CI 1.63-2.09). In addition, nonadherence remained significantly associated with higher risk of cardiovascular mortality for beta-blockers (HR 1.53, 95% CI 1.16-2.01), ACE inhibitors (HR 1.66, 95% CI 1.26-2.20), and statins (HR 1.62, 95% CI 1.124-2.13). The findings of increased risk associated with nonadherence were consistent for cardiovascular hospitalization and revascularization procedures.

CONCLUSIONS

Nonadherence to cardioprotective medications is common in clinical practice and associated with a broad range of adverse outcomes. These findings suggest that medication nonadherence should be a target for quality improvement interventions to maximize the outcomes of patients with CAD.