Medical and socioenvironmental predictors of hospital readmission in patients with congestive heart failure

Assessing Community Quality of Health Care

OBJECTIVE

To determine the agreement of measures of care in different settings-hospitals, nursing homes (NHs), and home health agencies (HHAs)-and identify communities with high-quality care in all settings.

DATA SOURCES/STUDY SETTING

Publicly available quality measures for hospitals, NHs, and HHAs, linked to hospital service areas (HSAs).

STUDY DESIGN

We constructed composite quality measures for hospitals, HHAs, and nursing homes. We used these measures to identify HSAs with exceptionally high- or low-quality of care across all settings, or only high hospital quality, and compared these with respect to sociodemographic and health system factors.

PRINCIPAL FINDINGS

We identified three dimensions of hospital quality, four HHA dimensions, and two NH dimensions; these were poorly correlated across the three care settings. HSAs that ranked high on all dimensions had more general practitioners per capita, and fewer specialists per capita, than HSAs that ranked highly on only the hospital measures.

CONCLUSION

Higher quality hospital, HHA, and NH care are not correlated at the regional level; regions where all dimensions of care are high differ systematically from regions which score well on only hospital measures and from those which score well on none.

Family member accompaniment to routine medical visits is associated with better self-care in heart failure patients

OBJECTIVES

To examine the association between frequency of family member accompaniment to medical visits and heart failure (HF) self-care maintenance and management and to determine whether associations are mediated through satisfaction with provider communication.

METHODS

Cross-sectional survey of 150 HF patients seen in outpatient clinics. HF self-care maintenance and management were assessed using the Self-Care of Heart Failure Index. Satisfaction with provider communication was assessed using a single question originally included in the American Board of Internal Medicine Patient Satisfaction Questionnaire. Frequency of family member accompaniment to visits was assessed using a single-item question. We performed regression analyses to examine associations between frequency of accompaniment and outcomes. Mediation analysis was conducted using MacKinnon's criteria.

RESULTS

Overall, 61% reported accompaniment by family members to some/most/every visit. Accompaniment to some/most/every visit was associated with higher self-care maintenance (β = 6.4, SE 2.5; p = 0.01) and management (β = 12.7, SE 4.9; p = 0.01) scores. Satisfaction with provider communication may mediate the association between greater frequency of accompaniment to visits and self-care maintenance (1.092; p = 0.06) and self-care management (1.428; p = 0.13).

DISCUSSION

Accompaniment to medical visits is associated with better HF self-care maintenance and management, and this effect may be mediated through satisfaction with provider communication.

Community factors and hospital readmission rates

OBJECTIVE

To examine the relationship between community factors and hospital readmission rates.

DATA SOURCES/STUDY SETTING

We examined all hospitals with publicly reported 30-day readmission rates for patients discharged during July 1, 2007, to June 30, 2010, with acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PN). We linked these to publicly available county data from the Area Resource File, the Census, Nursing Home Compare, and the Neilsen PopFacts datasets.

STUDY DESIGN

We used hierarchical linear models to assess the effect of county demographic, access to care, and nursing home quality characteristics on the pooled 30-day risk-standardized readmission rate.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

The study sample included 4,073 hospitals. Fifty-eight percent of national variation in hospital readmission rates was explained by the county in which the hospital was located. In multivariable analysis, a number of county characteristics were found to be independently associated with higher readmission rates, the strongest associations being for measures of access to care. These county characteristics explained almost half of the total variation across counties.

CONCLUSIONS

Community factors, as measured by county characteristics, explain a substantial amount of variation in hospital readmission rates.

Multidisciplinary intensive education in the hospital improves outcomes for hospitalized heart failure patients in a Japanese rural setting

BACKGROUND

Heart failure (HF) patients living in rural areas have a lack of HF knowledge and poor self-care because of limited medical care access. Multidisciplinary education to improve self-care behavior is indispensable for such patients. The present study evaluated whether intensive inpatient education improved outcomes of hospitalized HF patients in a Japanese rural setting.

METHODS

An inpatient HF management program based on multidisciplinary team intervention was applied to hospitalized HF patients in a Japanese rural area. We defined patients treated within the program from May 2009 to April 2011 as the intervention group (n = 144), and those treated with the usual care from May 2006 to April 2009 as the usual care group (n = 133). The composite endpoints of HF hospitalization and all-cause mortality were compared between the two groups.

RESULTS

Compared with patients in the usual care group, those in the intervention group more often received the optimal interventions such as discharge use of β-blockers, cardiac rehabilitation, pre-discharge diagnostic tests, and multidisciplinary intensive education including nurse-led patient education, pharmacist's medication teaching, and dietitian's nutritional guidance (all P < 0.05). The incidence of the composite endpoints significantly decreased after introducing the program (P < 0.001). Among a number of interventions, multidisciplinary intensive education was the most effective intervention to improve the primary outcome (P < 0.001).

CONCLUSIONS

Multidisciplinary intensive education is a key strategy for helping improve the outcome for Japanese HF patients in a rural setting. Our data may give a positive impact on the improvement of healthcare system in Japan.

Patient Health Questionnaire-9 score and adverse cardiac outcomes in patients hospitalized for acute cardiac disease

OBJECTIVE

The Patient Health Questionnaire-9 (PHQ-9) is increasingly used as a depression assessment tool in cardiac patients. However, in contrast to older depression instruments, there is little data linking PHQ-9 scores to adverse cardiac outcomes. Our goal was to evaluate whether higher PHQ-9 scores were predictive of subsequent cardiac readmissions among depressed patients hospitalized for an acute cardiac event.

METHODS

Patients diagnosed with depression during hospitalization for acute coronary syndrome, heart failure, or arrhythmia were enrolled in a randomized depression management trial. Participants were administered PHQ-9 at enrollment, and data was collected regarding cardiac readmissions and mortality over the next 6months. To evaluate the independent association of PHQ-9 score with subsequent cardiac readmission, Cox regression analysis that included relevant sociodemographic and medical covariates was used. Survival analysis examining time to first event, stratified by quartile of initial PHQ-9 score, was performed using Kaplan-Meier curves and log-rank test for trend. Analyses were then repeated using a composite (cardiac readmission or mortality) outcome.

RESULTS

Among 172 subjects, 62 (36.0%) had a cardiac-related rehospitalization. Higher initial PHQ-9 score predicted cardiac-related rehospitalization, independent of multiple relevant covariates (hazard ratio 1.09 [95% confidence interval=1.02-1.17]; p=0.015). On survival analysis, log-rank test for trend revealed a significant rise in event rates across increasing PHQ-9 quartiles (χ(2)=6.36; p=0.012). Findings were similar (p<.05) for the composite outcome.

CONCLUSION

In depressed cardiac patients, each additional point on the PHQ-9 was independently associated with a 9% greater risk of cardiac readmission over the subsequent 6months.

Home telemonitoring study for Japanese patients with heart failure (HOMES-HF): protocol for a multicentre randomised controlled trial

INTRODUCTION

Despite the encouraging results from several randomised controlled trials (RCTs) and meta-analyses, the ability of home telemonitoring for heart failure (HF) to improve patient outcomes remains controversial as a consequence of the two recent large-scale RCTs. However, it has been suggested that there is a subgroup of patients with HF who may benefit from telemonitoring. The aim of the present study was to investigate whether an HF management programme using telemonitoring could improve outcomes in patients with HF under the Japanese healthcare system.

METHODS AND ANALYSIS

The Home Telemonitoring Study for Japanese Patients with Heart Failure (HOMES-HF) study is a prospective, multicentre RCT to investigate the effectiveness of home telemonitoring on the primary composite endpoint of all-cause death and rehospitalisation due to worsening HF in recently admitted HF patients (aged 20 and older, New York Heart Association classes II-III). The telemonitoring system is an automated physiological monitoring system including body weight, blood pressure and pulse rate by full-time nurses 7 days a week. Additionally, the system was designed to make it a high priority to support patient's self-care instead of an early detection of HF decompensation. A total sample size of 420 patients is planned according to the Schoenfeld and Richter method. Eligible patients are randomly assigned via a website to either the telemonitoring group or the usual care group by using a minimisation method with biased-coin assignment balancing on age, left ventricular ejection fraction and a history of ischaemic heart disease. Participants will be enrolled until August 2013 and followed until August 2014. Time to events will be estimated using the Kaplan-Meier method, and HRs and 95% CIs will be calculated using the Cox proportional hazards models with stratification factors.

TRIAL REGISTRATION

The study is registered at UMIN Clinical Trials Registry (UMIN000006839).

The dilemma, causes and approaches to avoid recurrent hospital readmissions for patients with chronic heart failure

Heart failure is a progressive illness that carries significant morbidity and mortality. This highly prevalent illness leads to frequent, costly hospitalizations with approximately 50% of patients being readmitted within 6 months of initial hospitalization. While rehospitalization has been extensively studied in the past, little progress has been made in terms of reducing readmission rates of heart failure patients in the last decade despite increasing costs with impending resource limitations. We discuss disease-centered, physician-centered, and patient-centered factors that lead to rehospitalization as well as community/resource availability factors that contribute to rehospitalization of patients suffering from chronic heart failure. In addition, predictors of hospitalization and interventions that reduce hospitalization will be critically evaluated. With a complete understanding of heart failure rehospitalization, we hope the future holds more effective ways to prevent heart failure progression and thus rehospitalization, improved risk-stratification models to identify patients high-risk for rehospitalization, and sustained interventions that are customized according to the etiology of the clinical decline of heart failure patients that ultimately results in frequent rehospitalizations.

Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: systematic review

BACKGROUND

Readmission and mortality after hospitalization for community-acquired pneumonia (CAP) and heart failure (HF) are publically reported. This systematic review assessed the impact of social factors on risk of readmission or mortality after hospitalization for CAP and HF-variables outside a hospital's control.

METHODS

We searched OVID, PubMed and PSYCHINFO for studies from 1980 to 2012. Eligible articles examined the association between social factors and readmission or mortality in patients hospitalized with CAP or HF. We abstracted data on study characteristics, domains of social factors examined, and presence and magnitude of associations.

RESULTS

Seventy-two articles met inclusion criteria (20 CAP, 52 HF). Most CAP studies evaluated age, gender, and race and found older age and non-White race were associated with worse outcomes. The results for gender were mixed. Few studies assessed higher level social factors, but those examined were often, but inconsistently, significantly associated with readmissions after CAP, including lower education, low income, and unemployment, and with mortality after CAP, including low income. For HF, older age was associated with worse outcomes and results for gender were mixed. Non-Whites had more readmissions after HF but decreased mortality. Again, higher level social factors were less frequently studied, but those examined were often, but inconsistently, significantly associated with readmissions, including low socioeconomic status (Medicaid insurance, low income), living situation (home stability rural address), lack of social support, being unmarried and risk behaviors (smoking, cocaine use and medical/visit non-adherence). Similar findings were observed for factors associated with mortality after HF, along with psychiatric comorbidities, lack of home resources and greater distance to hospital.

CONCLUSIONS

A broad range of social factors affect the risk of post-discharge readmission and mortality in CAP and HF. Future research on adverse events after discharge should study social determinants of health.

Effect of ivabradine on recurrent hospitalization for worsening heart failure in patients with chronic systolic heart failure: the SHIFT Study

AIMS

We explored the effect of treatment with ivabradine, a pure heart rate-slowing agent, on recurrent hospitalizations for worsening heart failure (HF) in the SHIFT trial.

METHODS AND RESULTS

SHIFT was a double-blind clinical trial in which 6505 patients with moderate-to-severe HF and left ventricular systolic dysfunction, all of whom had been hospitalized for HF during the preceding year, were randomized to ivabradine or to placebo on a background of guideline-recommended HF therapy (including maximized β-blockade). In total, 1186 patients experienced at least one additional HF hospitalization during the study, 472 suffered at least two, and 218 suffered at least 3. Patients with additional HF hospitalizations had more severe disease than those without. Ivabradine was associated with fewer total HF hospitalizations [902 vs. 1211 events with placebo; incidence rate ratio, 0.75, 95% confidence interval (CI), 0.65-0.87, P = 0.0002] during the 22.9-month median follow-up. Ivabradine-treated patients evidenced lower risk for a second or third additional HF hospitalization [hazard ratio (HR): 0.66, 95% CI, 0.55-0.79, P < 0.001 and HR: 0.71, 95% CI, 0.54-0.93, P = 0.012, respectively]. Similar observations were made for all-cause and cardiovascular hospitalizations.

CONCLUSION

Treatment with ivabradine, on a background of guidelines-based HF therapy, is associated with a substantial reduction in the likelihood of recurrent hospitalizations for worsening HF. This benefit can be expected to improve the quality of life and to substantially reduce health-care costs.

The influence of social environmental factors on rehospitalization among patients receiving home health care services

Guided by Orem's theory, this study examined the influence of social environmental factors on rehospitalization among home health care patients. Living arrangement, frequency of caregiving, and type of primary informal care were found to be related to functional ability. Measurable differences in clinical status and functional ability were related to the duration that patients received home health care services until rehospitalization, with the likelihood of rehospitalization increasing proportionately to the magnitude of the differences. Social environmental factors contributed to rehospitalization (self-care deficit) through functional ability (self-care agency) by altering the balance between self-care demand (clinical status) and self-care agency.

Heart failure and socioeconomic status: accumulating evidence of inequality

AIMS

Socioeconomic status (SES) is a powerful predictor of incident coronary disease and adverse cardiovascular outcomes. Understanding the impact of SES on heart failure (HF) development and subsequent outcomes may help to develop effective and equitable prevention, detection, and treatment strategies

METHODS AND RESULTS

A systematic literature review of electronic databases including PubMed, EMBASE, CINAHL, and the Cochrane Library, restricted to human subjects, was carried out. The principal outcomes were incidence, prevalence, hospitalizations, mortality, and treatment of HF. Socioeconomic measures included education, occupation, employment relations, social class, income, housing characteristics, and composite and area level indicators. Additional studies were identified from bibliographies of relevant articles and reviews. Twenty-eight studies were identified. Lower SES was associated with increased incidence of HF, either in the community or presenting to hospital. The adjusted risk of developing HF was increased by ∼30-50% in most reports. Readmission rates following hospitalization were likewise greater in more deprived patients. Although fewer studies examined mortality, lower SES was associated with poorer survival. Evidence defining the equity of medical treatment of patients with HF was scarce and conflicting.

CONCLUSIONS

Socioeconomic deprivation is a powerful independent predictor of HF development and adverse outcomes. However, the precise mechanisms accounting for this risk remain elusive. Heart failure represents the endpoint of numerous different pathophysiological processes and 'chains of events', each modifiable throughout the disease trajectories. The interaction between SES and HF is accordingly complex. Disentangling the many and varied life course processes is challenging. A better understanding of these issues may help attenuate the health inequalities so clearly evident among patients with HF.

Lifetime analysis of hospitalizations and survival of patients newly admitted with heart failure

BACKGROUND

Hospital readmissions for heart failure (HF) contribute to increased morbidity and resource burden. Predictors of hospitalization and patterns of cardiovascular events over the lifetime of patients with HF have not been elucidated.

METHODS AND RESULTS

We examined recurrent hospitalizations, cardiovascular events, and survival among newly discharged (April 1999-March 2001) patients with HF in the Enhanced Feedback For Effective Cardiac Treatment phase 1 study. During 10-year follow-up, we examined all new cardiovascular hospitalizations and selected predictors of readmission. Among 8543 patients (mean age, 77.4±10.5 years; 51.6% women) followed for 22 567 person-years, 60.7% had ischemic etiology, and 67.3% had HF with reduced ejection fraction (left ventricular ejection fraction ≤45% versus >45% [HF with preserved ejection fraction]). Overall, 10-year mortality was 98.8%, with 35 966 hospital readmissions occurring over the lifetime of the cohort. Adjusted hazards ratios (HRs) for first cardiovascular hospitalization were 1.36 for ischemic HF (95% CI, 1.28-1.44; P<0.001), 1.10 for HF with reduced ejection fraction (95% CI; 1.00-1.20; P=0.045), and 1.00 for men (95% CI, 0.94-1.06; P=0.979). On repeated-events time-to-event analysis, ischemic HF was a predictor of cardiovascular (HR, 1.24; 95% CI, 1.18-1.29), HF (HR, 1.20; 95% CI, 1.13-1.27), and coronary heart disease (HR, 2.01; 95% CI, 1.81-2.24) hospitalizations (all P<0.001). Of all recurrent HF hospitalizations, 26.8% occurred in the first and 39.8% in the last deciles of cohort survival duration. Similarly, 29.7% and 52.3% of all cardiovascular readmissions occurred in the first and last deciles of the cohort survival duration, respectively.

CONCLUSIONS

Among newly discharged patients with HF, cardiovascular events were clustered at early postdischarge and prefatal time periods, and were increased among those with ischemic etiology.

Rationale and design of the Japanese heart failure outpatients disease management and cardiac evaluation (J-HOMECARE)

BACKGROUND

Although many studies have demonstrated the efficacy of disease management programs on mortality, morbidity, quality of life (QOL), and medical cost in patients with heart failure (HF), no study has focused on psychological status as an outcome of disease management. In addition, very little information is available on the effectiveness of disease management programs in other areas than the USA and Europe.

METHODS

The Japanese Heart Failure Outpatients Disease Management and Cardiac Evaluation (J-HOMECARE) is a randomized controlled trial in which 156 patients hospitalized with HF will be randomized into usual care or a home-based disease management arm receiving comprehensive advice and counseling by visiting nurses during the initial 2 months and telephone follow-up for the following 4 months after discharge. This study evaluates depression and anxiety (Hospital Anxiety and Depression Scale), mortality, readmission due to HF, and QOL (Short Form-8). Data are collected during index hospitalization and then 2, 6, and 12 months after discharge. This study started in December 2007, and the final results are expected in 2011.

CONCLUSION

The J-HOMECARE will provide important information on the efficacy of disease management for psychological status as well as the effective components of disease management for patients with HF. (ClinicalTrials.gov number, NCT01284400).

Predictors of re-hospitalization in patients with chronic heart failure

Heart failure (HF) is a chronic, progressive illness that is highly prevalent in the United States and worldwide. This morbid illness carries a very poor prognosis, and leads to frequent hospitalizations. Repeat hospitalization in HF is both largely burdensome to the patient and the healthcare system, as it is one of the most costly medical diagnoses among Medicare recipients. For years, investigators have strived to determine methods to reduce hospitalization rates of HF patients. Despite such efforts, recent reports indicate that re-hospitalization rates remain persistently high, without any improvement over the past several years and thus, this topic clearly needs aggressive attention. We performed a key-word search of the literature for relevant citations. Published articles, limited to English abstracts indexed primarily in the PubMed database through the year 2011, were reviewed. This article discusses various clinical parameters, serum biomarkers, hemodynamic parameters, and psychosocial factors that have been reviewed in the literature as predictors of re-hospitalization of HF patients. With this information, our hope is that the future holds better risk-stratification models that will allow providers to identify high-risk patients, and better customize effective interventions according to the needs of each individual HF patient.

The efficacy of a senior outreach program in the reduction of hospital readmissions and emergency department visits among chronically ill seniors

This study reports on the effectiveness of a community-based senior outreach program in decreasing rehospitalizations and emergency department visits among chronically ill seniors. Participants had been repeatedly hospitalized with chronic illnesses and were subsequently served in an in-home program designed to address their psychosocial and medical needs. Participation in the program was found to be related to lower hospital readmission rates and emergency department usage. Clients also reported decreased financial concerns and depression and anxiety and increased social support. The study adds to the growing body of work supporting community-based programs as effective strategies for decreasing health care usage and improving quality of life for chronically ill seniors.

Change in comorbidity prevalence with advancing age among persons with heart failure

BACKGROUND

Comorbidity-a condition that co-exists with a primary illness-is common among older persons with heart failure and can complicate the overall management of this population.

OBJECTIVES

To determine the relationship between advancing age and the prevalence and patterns of comorbidity among older persons with heart failure.

DESIGN

Retrospective longitudinal cohort study

PARTICIPANTS

A total of 201,130 Medicare beneficiaries with heart failure stratified into three age strata in 2001: 66-75, 76-85, and 86+ years, and followed over 5 years.

MEASUREMENTS

(1) Prevalence of 19 conditions as identified by the Chronic Conditions Warehouse from Medicare claims data, characterized as concordant (related to heart failure) or discordant (unrelated to heart failure), and (2) overall comorbidity burden, defined as count of conditions.

RESULTS

The median number of comorbidities rose from four (IQR: 2-5) to five (IQR: 4-7) among the young-old, and from 4 (IQR: 3-6) to 6 (IQR: 5-8) among the middle-old and oldest-old between 2001 and 2006. In 2001, the majority of concordant conditions were more prevalent among the youngest than oldest beneficiaries (e.g., diabetes 46.2% vs 26.9%; kidney disease 21.8% vs 18.4%), while the majority of discordant conditions were more prevalent among the oldest-old than youngest-old beneficiaries (e.g., dementia 39.6% vs 9.9%; hip fracture 9.5% vs 1.9%). Discordant conditions increased in prevalence faster among the oldest than youngest beneficiaries (e.g., dementia 13% points versus 9% points).

CONCLUSION

Among older Medicare beneficiaries with heart failure, there is a higher overall burden of comorbidity and greater prevalence of discordant comorbidity among the oldest old. Comorbidity prevalence increases over time, with discordant comorbidity increasing at the fastest rate among the oldest old. This comorbidity burden highlights the challenge of effectively treating heart failure while simultaneously managing co-existing and unrelated conditions.

Perceptions of hospital safety climate and incidence of readmission

OBJECTIVE

To define the relationship between hospital patient safety climate (a measure of hospitals' organizational culture as related to patient safety) and hospitals' rates of rehospitalization within 30 days of discharge.

DATA SOURCES

A safety climate survey administered to a random sample of hospital employees (n=36,375) in 2006-2007 and risk-standardized hospital readmission rates from 2008.

STUDY DESIGN

Cross-sectional study of 67 hospitals.

DATA COLLECTION

Robust multiple regressions used 30-day risk-standardized readmission rates as dependent variables in separate disease-specific models (acute myocardial infarction [AMI], heart failure [HF], pneumonia), and measures of safety climate as independent variables. We estimated separate models for all hospital staff as well as physicians, nurses, hospital senior managers, and frontline staff.

PRINCIPAL FINDINGS

There was a significant positive association between lower safety climate and higher readmission rates for AMI and HF (p ≤ .05 for both models). Frontline staff perceptions of safety climate were associated with readmission rates (p ≤ .01), but senior management perceptions were not. Physician and nurse perceptions related to AMI and HF readmissions, respectively.

CONCLUSIONS

Our findings indicate that hospital patient safety climate is associated with readmission outcomes for AMI and HF and those associations were management level and discipline specific.

Predictors of preventable hospitalization in chronic disease: priorities for change

Research in the area of preventable hospitalization, hospital admissions that could otherwise be avoided, provides little guidance in terms of priority areas for change. This synthesis of multiple electronic databases searched systematically for studies related to preventable hospitalization identifies six priority areas for future action in three broad conceptual areas: person priorities (symptom management and supportive relationships), programme priorities (self-management supports and service delivery), and place priorities (local infrastructure and socio-economic opportunities). Attention to these priorities could help reduce preventable hospitalization while simultaneously improving health access and quality of care.

Incidence and temporal pattern of hospital readmissions for patients with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is prevalent and has a high cost burden. Among the main drivers of cost is inpatient care; however, little is known about patterns of hospital readmissions for AF.

OBJECTIVE

To evaluate the incidence and temporal pattern of readmission in AF patients.

METHODS

This retrospective, cohort analysis used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database for 2002-2006. Patients hospitalized for AF (primary discharge diagnosis) were identified. Data on the first readmission for AF over 1 year following an index hospitalization were analyzed for chronic AF (any AF-related claims in 1 year before index hospitalization) and newly-diagnosed AF patients (no prior AF-related claims).

RESULTS

Overall, 4174 patients hospitalized with primary AF were identified; 1637 had chronic AF and 2537 newly-diagnosed AF. Mean age of chronic AF patients was 62.4 years and 61.2% were male; for newly-diagnosed AF, mean age was 61.4 years and 57.8% were male. In the year following index hospitalization, 12.5% of chronic AF patients were readmitted for AF, with a mean time to readmission of 142.5 days (median 108 days). Among newly-diagnosed AF patients, 10.1% were readmitted for AF, with a mean time to readmission of 133.8 days (median 112 days). For chronic AF, 17.6%, 43.4%, and 65.8% of readmissions occurred within 1, 3, and 6 months, respectively, versus 22.7%, 44.5%, and 67.2%, respectively, for newly-diagnosed AF.

LIMITATIONS

Limited data were available on patients' clinical profile, treatment patterns, or the reasons for hospitalization/readmission. The term chronic AF only captured patients with a history of AF and data were not available to classify patients according to the presence of paroxysmal, permanent, or persistent AF.

CONCLUSIONS

Patients with newly-diagnosed or chronic AF are often readmitted in the year following hospitalization with most readmissions occurring within 6 months of the index hospitalization.

Predicting emergency room visits and hospitalizations among hospice patients with cardiac disease

BACKGROUND

One goal of quality palliative care in hospice is to limit emergency room visits and/or hospitalizations (ERVH).

PURPOSE

The purpose of this study was to determine predisposing factors that contribute to ERVH and devise a model to predict the probability of hospice cardiac disease patients having ERVH after hospice admission.

METHODS

The study was a retrospective chart review of hospice cardiac patients comparing those with ERVH (n = 65) and those who died in their homes (n = 80). Data reduction strategy included bivariate tests and model-building analyses using logistic regression analysis.

RESULTS

Some factors were associated with decreased odds of having ERVH: older patients (odds ratio [OR] = 0.94; p = 0.001), increased nursing visits (OR = 0.79; p = 0.001) and chaplain visits (OR = 0.48; p = 0.040), patients' medication compliance (OR = 0.27; p = 0.029), patients treated with morphine sulfate (OR = 0.15; p = 0.001), patients with caregiver(s) (OR = 0.09; p = 0.012), patients with hospice emergency kits (OR = 0.33; p = 0.004), interaction of the latter two variables (OR = 0.26; p = 0.001), patients with do-not-resuscitate orders (OR = 0.29; p = 0.001), Caucasian patients (OR = 0.22; p = 0.001), and the interaction of the latter two variables (OR = 0.22; p = 0.001). Other factors were associated with increased odds of having ERVH: patients with diabetes (OR = 2.64; p = 0.009), peripheral vascular disease (OR = 5.30; p = 0.003), hyperlipidemia (OR = 4.52; p = 0.013), chronic pulmonary disease/asthma (OR = 2.83; p = 0.003) as comorbidities; palpitations (OR = 6.61; p = 0.010), and chest pain (OR = 3.78; p = 0.006). The best fitting forecasting model had six independent variables decreasing and two increasing the odds of having ERVH. The final model chosen was: Z = 7.817 + 2.929 (peripheral vascular disease) + 1.513 (diabetes mellitus) - 3.306 (Caucasian) - 1.824 (caregiver presence x hospice emergency kit at home) - 0.212 (frequency of nursing visits) - 3.275 (on morphine) - 4.422 (medication compliance).

CONCLUSION

The forecasting model predicted the probability of ERVH correctly in 87.7% of the patients. The model is simple to use to predict hospice cardiac patients having ERVH. Future studies should validate this model. Interventions should utilize these factors and be evaluated to determine their ability to decrease ERVH in hospice cardiac patients.

Anxiety and poor social support are independently associated with adverse outcomes in patients with mild heart failure

BACKGROUND

The impact of psychosocial states, such as depression or anxiety, and social support on the outcomes of stable outpatients with mild heart failure (HF) has not been evaluated in the "real world" clinical practice.

METHODS AND RESULTS

In the present study, 139 patients with a prior history of admission for HF provided the baseline demographic, clinical, socio-environmental, and psychosocial information. Cardiac death or re-admission because of worsening of HF was monitored during the follow-up period of 1 year. The prevalence of depression and anxiety were 37% and 37%, respectively, in HF patients. Depression was independently associated with male (sbeta=-0.36, P=0.01), social ties (sbeta=0.22, P=0.04) and low social support (sbeta=-0.39, P<0.01). Anxiety was associated with alcohol drinking (sbeta=0.22, P=0.04), brain natriuretic peptide > or =200 pg/dl (sbeta=0.35, P<0.01), and low social support (sbeta=-0.28, P=0.01). Kaplan-Meier analysis demonstrated that patients with anxiety (log-lank test; P<0.01) and lower scores of social support (P<0.01) had a higher rate of HF-related re-admission.

CONCLUSIONS

Anxiety and low social support were independently associated with HF-related re-admission, which indicates the need for their inclusion in the assessment and management of HF.

Validity and Reliability of the Japanese Version of the European Heart Failure Self-Care Behavior Scale

Background: It is important to assess the self-care behavior of patients with heart failure. However, in Japan, there is no valid and reliable scale for this purpose. The European Heart Failure Self-Care Behavior Scale (EHFScBS) is used to measure the self-care behavior of heart failure patients. The purpose of this study was to translate the EHFScBS into Japanese and evaluate its validity and reliability.

Methods and results: A convenience sample of 116 outpatients with heart failure completed the Japanese version of the EHFScBS. Confirmatory factor analysis demonstrated the one-dimensionality of the scale. The Japanese version of the EHFScBS was significantly correlated with another scale, which was considered to evaluate the concept linked with the self-care behavior theoretically. These confirm its construct validity. Cronbach's alpha was 0.71, suggesting that internal consistency was satisfactory. Test–retest reliability was evaluated. The intraclass correlation coefficient of the scale was 0.69 and weighted kappa for individual items was 0.33–0.87, suggesting that test–retest reliability is adequate.

Conclusions: The Japanese version of the EHFScBS was showed acceptable validity and reliability. It can be used to evaluate self-care behavior of Japanese patients with heart failure.

Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems

With growing awareness of medical fallibility, researchers need to develop tools to identify and study medical mistakes. We examined the utility of hospital readmissions for this purpose in a prospective case-control study in a large academic medical center in Israel. All patients with nonelective readmissions to 2 departments of medicine within 30 days of discharge were interviewed, and their medical records were carefully examined with emphasis on the index admission. Patient data were compared to data for age- and sex-matched controls (n = 140) who were not readmitted. Medical records of readmitted and control patients were blindly evaluated by 2 senior clinicians who independently identified potential quality of care (QOC) problems during the index admission. Inhospital and late mortality was determined 6 months after discharge.Over a period of 3 months there were 1988 urgent admissions; 1913 discharges and subsequently 271 unplanned readmissions occurred (14.1% of discharges). Readmissions occurred an average of 10 days after discharge, and readmitted patients were sicker than controls (mean, 4.3 vs. 3.3 diagnoses per patient), although their length of stay was similarly short (3.4 +/- 2.8 d). Analysis of all readmissions revealed QOC problems in 90/271 (33%) of readmissions, 4.5% of hospitalizations. All were deemed preventable. Interobserver agreement was good (83%, kappa = 0.67). Among matched controls, only 8/140 admissions revealed QOC problems (6%, p < 0.001) (k = 0.77). The preventable readmissions mostly involved a vascular event or congestive heart failure; they occurred within a mean of 10 +/- 8 days of the index admission, and their inpatient mortality was 6.7% vs. 1.7% among readmissions that had no QOC problems (odds ratio, 4.1; 95% confidence interval, 1.0-16.7). The main pitfalls identified during the index admission included incomplete workup (33%), too short hospital stay (31%), inappropriate medication (44%), diagnostic error (16%), and disregarding a significant laboratory result (12%). In many patients more than 1 pitfall was identified (mean, 1.5 per patient). Risk factors for preventable readmission include older age and living in an institution (p < 0.05). Almost two-thirds of the readmitted patients with QOC problems were discharged after spending 2 days or fewer at the hospital. In conclusion, unplanned readmissions within 30 days of discharge are frequent, more prevalent in sicker patients, and possibly associated with increased mortality. In a third of readmitted patients a QOC problem can be identified, and these problems are preventable. Thus, readmission may be used as a screening tool for potential QOC problems in the department of medicine. Routine monitoring of all readmissions may provide a simple cost-effective means of identifying and addressing medical mistakes.

Characteristics and outcomes of patients with heart failure in general practices and hospitals

BACKGROUND

The characteristics and outcomes of patients discharged from hospitals with a diagnosis of heart failure (HF) have been described by a number of previous epidemiological studies. However, very little information is available on this issue in general practice in Japan.

METHODS AND RESULTS

The Japanese Cardiac Registry of Heart Failure in General Practice (JCARE-GENERAL) is designed to study the characteristics, treatment and outcomes prospectively in a broad sample of outpatients with HF who were managed by cardiologists in hospital (Hospital-HF) and primary care physicians in general practice (GP-HF). Out of 2,685 patients with HF, 1,280 patients were Hospital-HF and 1,405 GP-HF. Compared to the Hospital-HF patients, GP-HF patients were more likely to be elderly and female, and they had a higher prevalence of hypertensive heart disease as a cause of HF. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and beta-blockers were more prescribed to Hospital-HF than GP-HF patients. At the follow-up of 1.2 year, after adjustment, the mortality was comparable between the Hospital-HF and GP-HF groups, whereas HF-related admission was higher in the Hospital-HF group than in in the GP-HF group.

CONCLUSIONS

Based on the JCARE-GENERAL, the characteristics, treatment and outcomes of GP-HF patients differed from those of Hospital-HFpatients in Japan.

Prediction of Rehospitalization and Death in Severe Heart Failure by Physicians and Nurses of the ESCAPE Trial

BACKGROUND

The predictive accuracy of physician investigators and nurse coordinators in estimating the risk of rehospitalization and death was determined for 373 hospitalized patients with severe advanced heart failure enrolled in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial.

METHODS AND RESULTS

Estimates were made at discharge, and patients were followed for 6 months after hospitalization. A statistical prognostic model was developed from clinical and laboratory data for the end points of rehospitalization and death. Both nurse and physician predictions of death were generally associated with the observed deaths (c-indices of 0.675 and 0.611), although the nurses' prediction was significantly better (chi-square = 4.75, P = .029). The prediction ability of the prognostic model was similar to the physicians' model (c-index = 0.603). The predictions of rehospitalization were much weaker for nurse, physician and prognostic models.

CONCLUSIONS

Nurses' estimations of survival in discharged, advanced-stage heart failure patients were superior to either physicians' or model-based predictions. Not nurses, physicians, or the prognostic model provided useful predictions for rehospitalizations, but this may have resulted from the fact that the rehospitalization estimates did not include the death risk.

The 6-minute walk test predicts clinical outcome in Asian patients with chronic congestive heart failure on contemporary medical therapy: a study of the multiracial population in Singapore

BACKGROUND

We sought the value of the 6-min walk test (6MWT) in predicting morbidity and mortality in Asian patients with congestive heart failure (CHF).

METHODS

668 patients (Age 66+/-12 years, Ejection fraction 29+/-13%, NYHA I to IV) were prospectively followed up for 36+/-12 months. 386 patients (58%) took the 6MWT. Cardiac events, defined as the composite end-point of death or CHF readmission were documented.

RESULTS

188 patients (28%) reached the composite end-point (63 deaths, 125 readmissions). 6MWT distance was an independent predictor of cardiac events (quartile 1 vs quartile 4)(p=0.041), as were beta-blocker or spironolactone use (p=0.008 for both), diabetes (p=0.042), monthly income less than SGD$1000 (p=0.030), and NYHA class (class III vs class I)(p=0.003). A 6MWT distance <340 m predicted occurrence of cardiac events with a sensitivity of 69% and specificity of 48%.

CONCLUSIONS

The 6MWT is a safe and simple clinical tool, which could predict both morbidity and mortality in a large population of Asian patients with CHF of differing etiology and severity (169 words).

Socioeconomic status, treatment, and outcomes among elderly patients hospitalized with heart failure: findings from the National Heart Failure Project

BACKGROUND

Prior studies have reported conflicting findings concerning the association of socioeconomic status (SES), treatment, and outcomes in patients hospitalized with heart failure (HF).

METHODS

We conducted a retrospective analysis of medical record data from a national sample of Medicare beneficiaries hospitalized with HF between March 1998 and April 1999 (n = 25,086) to assess the association of patient SES, treatment, and outcomes. Patients' SES was designated as lower, lower-middle, higher-middle, and higher using residential ZIP code characteristics. Patients were evaluated for left ventricular systolic function assessment, prescription of angiotensin-converting enzyme inhibitors at discharge, readmission within 1 year of discharge, and mortality within 30 days and 1 year of admission. Hierarchical logistic regression models were used to assess the association of SES, quality of care, and outcomes adjusting for patient, physician, and hospital characteristics.

RESULTS

Lower SES patients (relative risk [RR] 0.92, 95% CI 0.87-0.96) were modestly less likely to have had a left ventricular systolic function assessment, but had a similar adjusted likelihood of being prescribed angiotensin-converting enzyme inhibitors (RR 1.03, 95% CI 0.93-1.11) compared with higher SES patients after multivariable adjustment. Socioeconomic status was not associated with 30-day mortality after multivariable adjustment, but lower SES patients had a higher risk of 1-year mortality (RR 1.10, 95% CI 1.02-1.19) and readmission within 1 year of discharge (RR 1.08, 95% CI 1.03-1.12) compared with higher SES patients.

CONCLUSIONS

Socioeconomic status in patients hospitalized with HF was not strongly associated with quality of care or 30-day mortality. However, the increased risk of 1-year mortality and readmission among patients of lower SES suggest SES may influence outcomes after hospitalization for HF.

Effect of socioeconomic deprivation on the population risk of incident heart failure hospitalisation: an analysis of the Renfrew/Paisley Study

BACKGROUND

There are few data describing the effect of socioeconomic deprivation on the risk of developing heart failure (HF).

AIMS

To examine the relationship between socioeconomic deprivation and hospitalisation with HF over 20 years.

METHODS

Between 1972 and 1976, 15,402 individuals, aged 45-64 years, residing in two towns in Scotland, underwent cardiovascular screening. We report hospitalisations with HF over the subsequent 20 years according to Carstairs deprivation category and Social Class.

RESULTS

Following screening, 628 men and women (4.1%) were hospitalised with a primary diagnosis of HF. There was a gradient in the risk of HF hospitalisation with increasing socioeconomic deprivation (P=0.003). Of the most deprived individuals, 6.4% were hospitalised for HF compared to 3.5% of the most affluent group. Cox-proportional Hazard models showed that independent of age, sex and baseline risk factors for cardio-respiratory status, greater socioeconomic deprivation increased the risk of HF admission (P<0.001, overall). The adjusted risk of admission for HF was 39% greater in the most versus least deprived subjects (RR 1.39 95% CI 1.04-2.01; P=0.04).

CONCLUSION

These data show a link between social deprivation and the risk of developing HF, irrespective of baseline cardio-respiratory status and cardiovascular risk factors.

Clinical Characteristics and Outcome of Hospitalized Patients With Heart Failure in Japan Rationale and Design of Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD)

BACKGROUND

Heart failure (HF), defined as a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood, is a leading cause of mortality and hospitalization for adults older than 65 years in the industrialized countries. The characteristics and outcome of patients with HF have been described by several epidemiological studies and large scale clinical trials, performed mainly in the United States and Europe. Very little information is available on this issue in Japan.

METHODS AND RESULTS

The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) is designed to prospectively study the characteristics, treatment, and outcomes of a broad sample of patients hospitalized with HF at teaching hospitals throughout Japan between January 2004 to June 2005 and the outcomes, including death and hospital readmission, will be followed through 2006 (mean follow-up at least 1 year). Participating cardiologists identify patients admitted for worsening of HF symptoms. Demographics, medical history, severity, treatment, and outcome data are collected and entered into a database via secure web browser technology. As of June 2005, baseline data for 2,676 patients with HF have been registered from 164 participating hospitals.

CONCLUSIONS

The JCARE-CARD will provide important insights into the management of patients with HF in routine clinical practice in Japan, thus providing the framework for improved management strategies for these patients.

Functional mitral regurgitation predicts 1-year mortality in elderly patients with systolic chronic heart failure

BACKGROUND AND AIM

Mitral regurgitation (MR) has been demonstrated to be a powerful predictor of adverse outcome in middle-aged patients with chronic heart failure (CHF). In this study, we sought to define the prognostic impact of functional mitral regurgitation in a population of elderly patients with systolic CHF.

METHODS

One hundred seventy-five outpatients aged >70 years with validated CHF and left ventricular ejection fraction <40% underwent clinical and echocardiographic evaluations at baseline. Mitral regurgitation was diagnosed by Color Doppler and quantified in 5 categorical values using a 0-4+ grading system. Outcome measures included 1-year mortality and hospitalization for worsening CHF.

RESULTS

The distribution of patients according to the 5 different degrees of MR detected at baseline was: absent=11%, 1+=31%, 2+=38%, 3+=16%, 4+=4%. The relationship between MR and mortality was direct and approximately linear (r=0.39, p=0.00001). The prevalence of death in the 5 subgroups was 0%, 7%, 15%, 45%, 57%, respectively. Multivariate logistic regression analysis showed that MR was the strongest predictor of death (OR 4.47, 95% CI 1.50-13.0), independently of the presence of diabetes mellitus, older age and larger left ventricular end-diastolic volume. No association was found between MR and hospitalization for worsening CHF (r=0.08, p=0.41).

CONCLUSIONS

This study establishes the direct and independent relationship between MR severity and one-year mortality among elders with systolic CHF. Conversely, MR does not provide useful information regarding the risk of subsequent hospitalization for worsening CHF.

Trial of a disease management program to reduce hospital readmissions of the chronically critically ill

BACKGROUND

Patients requiring prolonged periods of intensive care and mechanical ventilation are termed chronically critically ill. They are prone to continued morbidity and mortality after hospital discharge and are at high risk for hospital readmission. Disease management (DM) programs have been shown to be effective in improving both coordination and efficiency of care after hospital discharge for populations with single-disease diagnoses, but have not been tested with patients with multiple-disease diagnoses, such as the chronically critically ill.

STUDY OBJECTIVES

To test the effect of a DM program on hospital readmission patterns of chronically critically ill patients during the first 2 months after hospital discharge and to estimate the cost-effectiveness of the DM program.

DESIGN

Randomized, controlled trial.

SETTING

Academic medical center, extended care facilities, and participant homes.

PARTICIPANTS

Three hundred thirty-four consenting adults from one academic medical center who underwent > 3 days of mechanical ventilation and survived to hospital discharge.

INTERVENTION

Two hundred thirty-one patients in the experimental group received care coordination, family support, teaching, and monitoring of therapies from a team of advanced-practice nurses, a geriatrician, and a pulmonologist for 2 months post-hospital discharge.

MEASUREMENTS

Rehospitalization rate, time-to-first rehospitalization, duration of rehospitalization, mortality during rehospitalization, and associated costs.

RESULTS

Patients who received DM services had significantly fewer mean days of rehospitalization (11.4; 95% confidence interval [CI], 9.3 to 12.6) compared with the control group (16.7 days; 95% CI, 12.5 to 21.0; p = 0.03). There were no other significant differences between experimental and control groups, although all measures of rehospitalization risk for the experimental group were in a positive direction. Total cost savings associated with the intervention were approximately $481,811 for the 93 subjects who were readmitted to the hospital.

CONCLUSIONS

Chronic critical illness may have a natural trajectory of continued morbidity following hospital discharge that is not affected by the provision of additional care coordination services. Nevertheless, given the high cost of rehospitalization and the additional burden it imposes on patients and families, interventions that can reduce the duration of rehospitalization are cost-effective and merit continued testing.

Predictors of hospital readmission after discharge in patients with congestive heart failure

PURPOSE

The purposes of this study were to (1) describe the characteristics of the population with congestive heart failure (CHF) who were admitted to a large, southeastern, acute-care hospital and (2) determine which patients are at risk for readmissions within 6 months.

METHODS

A descriptive correlational design, using variables maintained in a computerized data bank on patients with CHF (N = 557, 39% were black) who were admitted between October 2000 and March 2002, was used to describe the adult population with CHF and identify variables associated with a likelihood of readmission.

RESULTS

In the 6 months after the index admission, 224 (40%) of the patients were readmitted to the hospital for CHF. Variables significantly associated with readmission included lack of cardiology consult during admission, living status, point of entry of index admission, receiving Medicare, and having pulmonary hypertension. Four models, composed of subsets of variable from the data bank were developed and tested with logistic regression. The model composed of discharge variables was the only model that predicted readmission at a significant level.

CONCLUSIONS

There is a need to develop comprehensive data banks to describe patterns of care and their outcomes. Such data should inform plans to manage this vulnerable population.

Impact of sleep-related breathing disorders on health-related quality of life in patients with chronic heart failure

BACKGROUND

Quality of life in patients with chronic heart failure (HF) is often severely compromised. Sleep-related breathing disorders (SRBD) like Cheyne-Stokes Respiration (CSR) or obstructive sleep apnea (OSAS) are often observed in patients with severe HF resulting in fragmentation of sleep, excessive daytime sleepiness and an increased mortality. While an apnea/hypopnea-index (AHI) >30/h represents an independent predictor of poor prognosis, clinical relevance of even minor SRBD with an AHI <30/h remains unclear with respect to quality of life, exercise capacity or depression rate.

METHODS

Sixty-nine consecutive ambulatory patients with stable HF (NYHA II-III, EF 25%) underwent two night polygraphies with a six-channel ambulatory recording. Spiroergometry was performed, and patients were examined for sleep quality (PSQI), depressed mood (BDI) and health-related quality of life (SF-36). The data were compared to 10 age-matched healthy controls and 11 patients with OSAS (AHI 14-29/h) not suffering from HF.

RESULTS

Fifty-one patients completed follow up. 52% were positively diagnosed for SRBD (AHI 16-30/h: 12 patients CSR, 5 patients OSAS, 9 patients mixed); 25 patients (48%) showed no relevant SRBD. Patients with HF and SRBD had lower quality of life than patients without SRBD and HF. The severity of SRBD as indicated by the AHI significantly correlated with quality of life measures: Bodily pain, physical functioning and social functioning showed largest impairment in patients with HF and SRBD. Furthermore, elevated depression rates in correlation to the AHI were only observed in patients with SRBD similar to patients with OSAS without HF.

CONCLUSION

Even minor SRBD in patients with HF independently influence quality of life and correlate with estimation of depression and sleep disturbances.

Novel pathophysiological insight and treatment strategies for heart failure--lessons from mice and patients--

The ultimate goal of heart failure (HF) treatment is to improve the prognosis of patients. Previous basic, clinical, and population studies have advanced the modern treatment of HF, but efficacy is still limited especially in 'real world' patients. There are 2 approaches to solve this crucial issue. First is the further development of novel therapeutic strategies based on new insight into the pathophysiology of myocardial remodeling and failure. Second is the improvement of the quality of care in routine clinical practice. The basic approach is to develop the treatment of myocardial remodeling by regulating mitochondrial oxidative stress. In the failing heart, oxygen radicals are the result of defects of mitochondrial electron transport, causing mitochondrial DNA damage and functional decline, and further production of oxygen radicals. Oxidative stress causes myocyte hypertrophy, apoptosis, and interstitial fibrosis by activating matrix metalloproteinases, all of which result in myocardial remodeling and failure. Therefore, mitochondrial oxidative stress and DNA damage are good therapeutic targets. The clinical approach is to develop effective strategies of HF management for the 'real world' patients. Readmission because of exacerbation is common in HF patients and further impairs their quality of life. Noncompliance with treatment is the most common precipitating factor for readmission. Regular medical follow-up and social support are important components that should be included in the disease management program of HF patients. These basic and clinical approaches are needed to establish new and effective treatment strategies for Japanese patients with HF.

Minor myocardial damage detected by troponin T is a powerful predictor of long-term prognosis in patients with acute decompensated heart failure

BACKGROUND

The progression of chronic heart failure (CHF) is characterized by frequent exacerbation requiring hospitalization and high mortality. Clinical deterioration is triggered by many factors that could promote ongoing myocytes injury. We sought to determine whether a specific marker of cardiac injury, troponin T (cTnT), is associated with prognosis in acute decompensated heart failure (ADHF).

METHODS

One hundred and eighty-four consecutive patients with ADHF were enrolled in the absence of an acute coronary syndrome. A cTnT value> or =0.1 ng/ml in samples drawn at 6, 12 or 24 h after hospital admission was considered abnormal.

RESULTS

Increased levels of cTnT were found in 58 patients (31.5%, group 1). There were no significant differences between group 1 and patients with cTnT<0.1 ng/ml (group 2) in terms of demographic and clinical characteristics, although ischemic etiology was more prevalent in group 1 (51.7% vs. 31.7%, p=0.009). During follow-up, the mortality in groups 1 and 2 was 31% and 17.5% (p=0.038, OR=2.13, 95% CI: 1.03-4.69), respectively. The 3-year free-CHF readmission survival in group 1 and 2 was 25% and 53% (log rank test p=0.015). In a Cox proportional hazard model, poor tissue perfusion (HR=2.46, 95% CI=1.31-4.6), previous infarction (HR=1.99, 95% CI=1.02-3.9) and cTnT> or =0.1 ng/ml (HR=1.74, 95% CI=1.05-2.9) emerged as the independent predictors of long-term outcome.

CONCLUSIONS

One third of patients with decompensated CHF had elevated levels of cTnT. Troponin T was an independent long-term prognostic marker of morbidity and mortality and it suggests a role of biochemical risk stratification in this setting.

Hemodynamic unloading of the failing left ventricle using an arterial-to-arterial extracorporeal flow circuit

We tested the hypothesis that creation of a constant-flow extracorporeal circuit between the proximal and distal aorta will unload the failing left ventricle. Studies were performed in 14 heart failure dogs produced by intracoronary microembolizations. An extracorporeal circuit incorporating a diagonal pump was placed between a femoral and a carotid artery, with flow directed to the carotid. Hemodynamic measurements were made with the pump delivering 0.25 L/min through the circuit for 4 hours (active group). Measurements obtained from 8 sham-operated heart failure dogs were used for comparison (control group). Heart rate, peak left ventricular systolic pressure, left ventricular end-diastolic pressure, end-diastolic volume, end-systolic volume, and ejection fraction were measured at baseline and at 30, 60, 120, and 240 minutes. There were no differences in any of the hemodynamic values during the 4 hours of follow-up in the control group. In the active group, there was no effect on heart rate or peak systolic pressure, but reductions between baseline and 240 minutes were observed in left ventricular end-diastolic pressure (15 +/- 1 vs 6 +/- 1 mm Hg, p < 0.05), end-diastolic volume (61 +/- 3 vs 50 +/- 3 mL, p < 0.05), and end-systolic volume (44 +/- 2 vs 32 +/- 2 mL, p < 0.05), and an increase in ejection fraction (28 +/- 2 vs 37% +/- 2%, p < 0.05). Acute use of this artery-to-artery extracorporeal system effectively unloads the failing left ventricle. The potential benefits of this approach on long-term myocardial recovery in heart failure require further investigation.

The relationship of medication regimen to hospital readmissions for older adults with heart failure

The purpose of this part of a longitudinal study was to examine whether medication therapy for older adults with heart failure predicted days to readmission post-hospital discharge. Using a prospective, predictive design, a convenience sample included 127 older adults with heart failure who had been recently discharged from two hospitals in northeastern Ohio. One hundred five patients were prescribed diuretics, 49 angiotensin-converting enzyme inhibitors, 23 b blockers, and 47 digoxin. There were no significant differences between readmitted and non-readmitted patients with regard to the use of the specific classes of cardiac medications. None of the specific classes of cardiac medications predicted the number of days between the initial hospital discharge and readmission 3 months later. The use of a small, non-probability sample and exclusion of variables limit the results of the study. Effective case management with teaching about heart failure must address changes involved with heart failure and the use of medication therapy. More research is needed about treatment protocols in various regions of the United States.