Impact of comorbidity on mortality among older persons with advanced heart failure

Effect of depression on diagnosis, treatment, and mortality of men with clinically localized prostate cancer

PURPOSE

Although demographic, clinicopathologic, and socioeconomic differences may affect treatment and outcomes of prostate cancer, the effect of mental health disorders remains unclear. We assessed the effect of previously diagnosed depression on outcomes of men with newly diagnosed prostate cancer.

PATIENTS AND METHODS

We performed a population-based observational cohort study using Surveillance, Epidemiology, and End Results-Medicare linked data of 41,275 men diagnosed with clinically localized prostate cancer from 2004 to 2007. We identified 1,894 men with a depressive disorder in the 2 years before the prostate cancer diagnosis and determined its effect on treatment and survival.

RESULTS

Men with depressive disorder were older, white or Hispanic, unmarried, resided in nonmetropolitan areas and areas of lower median income, and had more comorbidities (P < .05 for all), but there was no variation in clinicopathologic characteristics. In adjusted analyses, men with depressive disorder were more likely to undergo expectant management for low-, intermediate-, and high-risk disease (P ≤ .05, respectively). Conversely, depressed men were less likely to undergo definitive therapy (surgery or radiation) across all risk strata (P < .01, respectively). Depressed men experienced worse overall mortality across risk strata (low: relative risk [RR], 1.86; 95% CI, 1.48 to 2.33; P < .001; intermediate: RR, 1.25; 95% CI, 1.06 to 1.49; P = .01; high: RR, 1.16; 95% CI, 1.03 to 1.32; P = .02).

CONCLUSION

Men with intermediate- or high-risk prostate cancer and a recent diagnosis of depression are less likely to undergo definitive treatment and experience worse overall survival. The effect of depression disorders on prostate cancer treatment and survivorship warrants further study, because both conditions are relatively common in men in the United States.

Comorbidity profiles and inpatient outcomes during hospitalization for heart failure: an analysis of the U.S. Nationwide inpatient sample

BACKGROUND

Treatment of heart failure (HF) is particularly complex in the presence of comorbidities. We sought to identify and associate comorbidity profiles with inpatient outcomes during HF hospitalizations.

METHODS

Latent mixture modeling was used to identify common profiles of comorbidities during adult hospitalizations for HF from the 2009 Nationwide Inpatient Sample (n = 192,327).

RESULTS

Most discharges were characterized by "common" comorbidities. A "lifestyle" profile was characterized by a high prevalence of uncomplicated diabetes, hypertension, chronic pulmonary disorders and obesity. A "renal" profile had the highest prevalence of renal disease, complicated diabetes, and fluid and electrolyte imbalances. A "neurovascular" profile represented the highest prevalence of cerebrovascular disease, paralysis, myocardial infarction and peripheral vascular disease. Relative to the common profile, the lifestyle profile was associated with a 15% longer length of stay (LOS) and 12% greater cost, the renal profile was associated with a 30% higher risk of death, 27% longer LOS and 24% greater cost, and the neurovascular profile was associated with a 45% higher risk of death, 34% longer LOS and 37% greater cost (all p < 0.001).

CONCLUSIONS

Comorbidity profiles are helpful in identifying adults at higher risk of death, longer length of stay, and accumulating greater costs during hospitalizations for HF.

Contributors to frequent telehealth alerts including false alerts for patients with heart failure: a mixed methods exploration

BACKGROUND

Telehealth data overload through high alert generation is a significant barrier to sustained adoption of telehealth for managing HF patients.

OBJECTIVE

To explore the factors contributing to frequent telehealth alerts including false alerts for Medicare heart failure (HF) patients admitted to a home health agency.

MATERIALS AND METHODS

A mixed methods design that combined quantitative correlation analysis of patient characteristic data with number of telehealth alerts and qualitative analysis of telehealth and visiting nurses' notes on follow-up actions to patients' telehealth alerts was employed. All the quantitative and qualitative data was collected through retrospective review of electronic records of the home heath agency.

RESULTS

Subjects in the study had a mean age of 83 (SD = 7.6); 56% were female. Patient co-morbidities (p<0.05) of renal disorders, anxiety, and cardiac arrhythmias emerged as predictors of telehealth alerts through quantitative analysis (n = 168) using multiple regression. Inappropriate telehealth measurement technique by patients (54%) and home healthcare system inefficiencies (37%) contributed to most telehealth false alerts in the purposive qualitative sub-sample (n = 35) of patients with high telehealth alerts.

CONCLUSION

Encouraging patient engagement with the telehealth process, fostering a collaborative approach among all the clinicians involved with the telehealth intervention, tailoring telehealth alert thresholds to patient characteristics along with establishing patient-centered telehealth outcome goals may allow meaningful generation of telehealth alerts. Reducing avoidable telehealth alerts could vastly improve the efficiency and sustainability of telehealth programs for HF management.

Health services use of older veterans treated and released from veterans affairs medical center emergency departments

OBJECTIVES

To determine predictors of repeat health service use in older veterans treated and released from the emergency department (ED).

DESIGN

Retrospective cohort study.

SETTING

Veterans Affairs Medical Center (VAMC) EDs.

PARTICIPANTS

Nationally representative sample of veterans aged 65 and older treated and released from one of 102 VAMC EDs between October 1, 2007, and June 30, 2008.

MEASUREMENTS

Logistic regression models were used to examine the association between independent variables and primary outcomes (30-day repeat ED visits and hospital admissions).

RESULTS

In 31,206 older veterans, ED diagnoses were commonly related to chronic conditions (22.5%), injuries and acute musculoskeletal conditions (19%), and infections (13.5%). Within 30 days, 22% of older veterans had returned to the ED (n = 4,779) or been hospitalized (n = 2,005). In adjusted models, factors associated with greater odds of repeat ED visits than injury were homelessness (odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3-2.1), previous ED visits (OR = 1.7, 95% CI = 1.6-1.8), previous hospitalization (OR = 1.3, 95% CI = 1.2-1.4), and index ED visit related to infection (1.2, 95% CI = 1.1-1.3). Odds of subsequent hospital admission were higher in veterans with previous hospitalization (OR = 2.5, 95% CI = 2.2-2.8), who were homeless (OR = 1.5, 95% CI = 1.1-2.0), who had aid and attendance benefits (OR = 1.5, 95% CI = 1.2-1.8), who were unmarried (OR = 1.2, 95% CI = 1.1-1.3), and who had an ED visit related to a chronic condition (OR = 1.4, 95% CI = 1.2-1.6) than in those with injury.

CONCLUSION

A substantial proportion of older veterans treated and released from a VAMC ED returned to the ED or were hospitalized within 30 days. Intervening with high-risk older veterans after an ED visit may reduce unscheduled healthcare use.

Contemporary prevalence and correlates of incident heart failure with preserved ejection fraction

BACKGROUND

We assessed the prevalence of preserved left ventricular ejection fraction in patients with incident heart failure and differences in the demographic and clinical characteristics that may differentiate patients presenting with heart failure with preserved versus reduced left ventricular ejection fraction.

METHODS

We identified all patients with newly diagnosed heart failure between 2005 and 2008 from 4 sites in the Cardiovascular Research Network on the basis of hospital discharge and ambulatory visit diagnoses, and assigned a category of preserved, borderline, or reduced left ventricular ejection fraction using data from electronic databases and chart review.

RESULTS

We identified 11,994 patients with incident heart failure; of these, 6210 (51.8%) had preserved left ventricular ejection fraction, 1870 (15.6%) had borderline systolic dysfunction, and 3914 (32.6%) had reduced left ventricular ejection fraction. For those with heart failure with preserved left ventricular ejection fraction, the mean age was 74.7 years and 57.1% were women; for those with borderline systolic dysfunction, the mean age was 71.6 years and 38.4% were women; and for those with reduced left ventricular ejection fraction, the mean age was 69.1 years and 32.6% were women. Compared with white patients, black patients were less likely to have heart failure with preserved systolic function. Those with a history of coronary artery bypass surgery, mitral or aortic valvular disease, atrial fibrillation or flutter, or a diagnosis of hypertension were more likely to have heart failure with preserved systolic function, as were those with a diverse range of noncardiac comorbid conditions, including chronic lung disease, chronic liver disease, a history of a hospitalized bleed, a history of a mechanical fall, a diagnosis of depression, and a diagnosis of dementia. Patients with a history of acute myocardial infarction and a history of ventricular fibrillation or ventricular tachycardia were less likely to have heart failure with preserved left ventricular ejection fraction. Patients with higher systolic blood pressures at baseline and lower low-density lipoprotein levels were more likely to have heart failure with preserved left ventricular ejection fraction, as were those with lower hemoglobin levels and the lowest glomerular filtration rates.

CONCLUSIONS

Heart failure with preserved left ventricular ejection fraction is the most common form of the heart failure syndrome among patients newly presenting with this condition, and women and older adults are especially affected. Evidence-based treatment strategies apply to less than one third of patients with newly diagnosed heart failure.

Co-occurrence of leading lifestyle-related chronic conditions among adults in the United States, 2002-2009

INTRODUCTION

Public health and clinical strategies for meeting the emerging challenges of multiple chronic conditions must address the high prevalence of lifestyle-related causes. Our objective was to assess prevalence and trends in the chronic conditions that are leading causes of disease and death among adults in the United States that are amenable to preventive lifestyle interventions.

METHODS

We used self-reported data from 196,240 adults aged 25 years or older who participated in the National Health Interview Surveys from 2002 to 2009. We included data on cardiovascular disease (coronary heart disease, angina pectoris, heart attack, and stroke), cancer, chronic obstructive pulmonary disease (emphysema and chronic bronchitis), diabetes, and arthritis.

RESULTS

In 2002, an unadjusted 63.6% of participants did not have any of the 5 chronic conditions we assessed; 23.9% had 1, 9.0% had 2, 2.9% had 3, and 0.7% had 4 or 5. By 2009, the distribution of co-occurrence of the 5 chronic conditions had shifted subtly but significantly. From 2002 to 2009, the age-adjusted percentage with 2 or more chronic conditions increased from 12.7% to 14.7% (P < .001), and the number of adults with 2 or more conditions increased from approximately 23.4 million to 30.9 million.

CONCLUSION

The prevalence of having 1 or more or 2 or more of the leading lifestyle-related chronic conditions increased steadily from 2002 to 2009. If these increases continue, particularly among younger adults, managing patients with multiple chronic conditions in the aging population will continue to challenge public health and clinical practice.

Use of a homecare electronic health record to find associations between patient characteristics and re-hospitalizations in patients with heart failure using telehealth

Data from homecare electronic health records were used to explore the association of patient characteristics with re-hospitalizations of patients with heart failure (HF) during a 60-day period of telemonitoring following hospital discharge. Data from 403 Medicare patients with HF who had used telehealth from 2008 to 2010 were analysed. There were 112 all-cause (29%) and 73 cardiac-related (19%) re-hospitalizations within 60 days of the start of telemonitoring. In adjusted analyses, the patients' number of medications and type of cardiac medications were significantly (P < 0.05) associated with an increased risk of re-hospitalization. After stratifying the sample by illness severity, age and gender, other significant (P < 0.05) predictors associated with an increased risk of all-cause and cardiac re-hospitalization were psychiatric co-morbidity, pulmonary and obesity co-morbidities within gender, beta blocker prescription in females and primary HF diagnosis in the oldest age stratum. The study's findings may assist homecare agencies seeking to allocate resources without compromising patient care.

Patterns of comorbidity in older adults with heart failure: the Cardiovascular Research Network PRESERVE study

OBJECTIVES

To examine whether the total burden of comorbidity and pattern of co-occurring conditions varies in individuals with heart failure (HF) with preserved left ventricular ejection fraction (LVEF) (HF-P) or HF with reduced LVEF (HF-R).

DESIGN

Cross-sectional cohort study.

SETTING

Four participating health plans within the National Heart, Lung, and Blood Institute-sponsored Cardiovascular Research Network.

PARTICIPANTS

All members aged 65 and older with HF based on hospital discharge and ambulatory visit diagnoses.

MEASUREMENTS

Participants with a LVEF of 50% or greater were classified as having HF-P. Presence of cardiac and noncardiac comorbidities was obtained from health plan administrative databases.

RESULTS

Of 23,435 individuals identified with HF and LVEF information, 53% (12,407) had confirmed HF-P (mean age 79.6; 60% female). More than three-quarters of the sample had three or more co-occurring conditions in addition to HF, and half had five or more cooccurring conditions. Participants with HF-P had a slightly higher burden of comorbidity than those with HF-R (mean 4.5 vs 4.4, P = .002). Patterns of how specific conditions co-occurred did not vary in participants with preserved or reduced systolic function.

CONCLUSION

There is a high degree of comorbidity and multiple morbidity in individuals with HF. The burden and pattern of comorbidity varies only slightly in individuals with preserved or reduced LVEF.

Medical outcome of patients with dementia in a free-standing psychiatric hospital

BACKGROUND

The hospital outcome of patients with dementia is significantly worse than that of cognitively intact persons of the same age admitted to medical or surgical units but has not been investigated in psychiatric settings.

AIM OF STUDY

To determine the medical outcome of patients with dementia admitted for behavioral disturbance to a free-standing psychiatric hospital.

METHODS

Emergency transfers from the psychiatric setting to a general hospital were used as proxies for medical deteriorations occurring among the 71 patients with dementia (age 78.4 ± 10.4 years; 40.1% males) and 71 age- and gender-matched nondementia control patients. The patients were identified in a cohort of 1000 patients consecutively admitted to a free-standing mental health institution. Logistic regression was used to determine the clinical and laboratory variables independently associated with medical deteriorations.

RESULTS

A total of 30 patients with dementia and 25 nondementia patients were transferred to a general hospital after an acute medical deterioration (42.3% vs 35.2%, P = .38). Febrile illnesses and falls with head trauma were the most common reasons for transfers in the dementia group, in which they constituted more than half of medical deteriorations, a proportion significantly higher than in the control group (P = .011). Admission hemoglobin levels were the only independent predictor of medical deterioration in this geriatric sample.

CONCLUSIONS

Although nearly 50% of patients with dementia admitted for behavioral disturbance to a free-standing psychiatric institution required transfer to a general hospital, their rate of medical deteriorations was similar to age-matched nondementia control patients.

Gender-related differences in hospitalized heart failure patients

AIMS

The burden of heart failure (HF)-related hospitalization and mortality of female patients with HF is substantial. Currently, several gender-specific distinctions have been recognized amongst HF patients, but their relationships to outcomes have not been fully elucidated. Accordingly, in the current work, we aimed to explore gender-specific clinical and echocardiographic measures and to assess their potential impact on outcome.

METHODS AND RESULTS

We studied all consecutive HF patients, aged 50 or older, who had been hospitalized between January 2000 and December 2009, and had undergone at least one echocardiography study. A comparative analysis of clinical and echocardiographic findings was performed between 5228 males and 4107 females. Patients were followed for a mean of 2.8 ± 2.6 years. Females compared with males had less ischaemic heart disease, prior stroke, chronic renal failure, and COPD, and higher rates of hypertension, AF, obesity, valvular abnormalities, and pulmonary hypertension. Unadjusted 30-day and 1-year mortality rates were higher among women, while age-adjusted rates were similar. Predictors of outcomes varied between genders. Female-specific predictors of mortality included aortic stenosis, pulmonary hypertension, and malignancy, whereas diastolic dysfunction and chronic renal failure were found to be male-specific predictors.

CONCLUSIONS

Age-adjusted mortality rates of male and female hospitalized HF patients are similarly high. Predictors of mortality, however, are gender distinctive, and these measures may allow a better identification of high-risk HF patients.

Association between cardiovascular diseases and osteoporosis-reappraisal

Positive association between cardiovascular diseases and osteoporosis is important because it concerns two major public health problems. Men and women with cardiovascular diseases (including severe abdominal aortic calcification (AAC) and peripheral arterial disease) tend to have lower areal and volumetric bone mineral density (BMD) as well as faster bone loss, although findings vary according to skeletal site. On one hand, severe forms of cardiovascular diseases (heart failure, myocardial infarction, hypertension, severe AAC) are associated with higher risk of osteoporotic fracture, especially hip fracture. This link was found in the studies based on healthcare databases and the cohort studies. On the other hand, low BMD, history of fragility fracture, vitamin D deficit and increased bone resorption are associated with higher risk of major cardiovascular events (myocardial infraction, stroke, cardiovascular mortality). Moreover, osteocalcin secreted by osteoblasts may be involved in the regulation of energetic and cardiovascular metabolism. The association between both pathologies depends partially on the shared risk factors, and also on the mechanisms that are involved in the regulation of bone and cardiovascular metabolism. Interpretation of the data should take into account methodological limitations: representativeness of the cohorts, quality of the registers and the information obtained from questionnaires, severity of diseases, number of events (statistical power) and their temporal closeness, availability of the information on potential confounders. It seems that patients with severe form of osteoporosis would benefit from assessment of the cardiovascular status and vice versa. However, official guidelines for the clinical practice are still lacking.

Evaluation of risk equations for prediction of short-term coronary heart disease events in patients with long-standing type 2 diabetes: the Translating Research into Action for Diabetes (TRIAD) study

BACKGROUND

To evaluate the U.K. Prospective Diabetes Study (UKPDS) and Framingham risk equations for predicting short-term risk of coronary heart disease (CHD) events among adults with long-standing type 2 diabetes, including those with and without preexisting CHD.

METHODS

Prospective cohort of U.S. managed care enrollees aged ≥ 18 years and mean diabetes duration of more than 10 years, participating in the Translating Research into Action for Diabetes (TRIAD) study, was followed for the first occurrence of CHD events from 2000 to 2003. The UKPDS and Framingham risk equations were evaluated for discriminating power and calibration.

RESULTS

A total of 8303 TRIAD participants, were identified to evaluate the UKPDS (n = 5914, 120 events), Framingham-initial (n = 5914, 218 events) and Framingham-secondary (n = 2389, 374 events) risk equations, according to their prior CHD history. All of these equations exhibited low discriminating power with Harrell's c-index <0.65. All except the Framingham-initial equation for women and the Framingham-secondary equation for men had low levels of calibration. After adjsusting for the average values of predictors and event rates in the TRIAD population, the calibration of these equations greatly improved.

CONCLUSIONS

The UKPDS and Framingham risk equations may be inappropriate for predicting the short-term risk of CHD events in patients with long-standing type 2 diabetes, partly due to changes in medications used by patients with diabetes and other improvements in clinical care since the Frmaingham and UKPDS studies were conducted. Refinement of these equations to reflect contemporary CHD profiles, diagnostics and therapies are needed to provide reliable risk estimates to inform effective treatment.