Trends in Readmission and Mortality Rates Following Heart Failure Hospitalization in the Veterans Affairs Health Care System From 2007 to 2017

Natriuretic peptide testing in veterans hospitalized with heart failure: Potential differences by sex

BACKGROUND

Natriuretic peptide testing (NPT) is recommended to assist in diagnosis and prognostication during heart failure hospitalization (HFH). NPT on admission for HFH and sex-based variation in NPT are unknown.

OBJECTIVES

We investigated the utilization of NPT among Veterans with HFH, evaluated for sex-based differences, and examined associations with demographic, clinical, and facility characteristics.

METHODS

Among Veterans with HFH in the Veterans Affairs Healthcare System between October 2015-September 2020, we assessed the rate of NPT on admission and sex-based differences in NPT. We determined associations with demographic, clinical covariates, (comorbidities, laboratory values, loop diuretic use), and facility characteristics using logistic regression.

RESULTS

Of 55,935 patients with HFH (women=1237 (2.2 %)), women were younger (68.3 versus 72.8 years, p < 0.001), less likely to have cardiac comorbidities, and more likely to have ejection fraction >40 %. Admission NPT occurred in 78.3 % of patients (men=78.4 %, women=74.7 %; p = 0.002). In adjusted analyses for clinical and facility-related factors, women were 15 % less likely to receive NPT compared with men [odds ratio =0.85, 95 % CI (0.75, 0.98)]. In sex-stratified models, atrial fibrillation and prior loop diuretic use were associated with increased likelihood of NPT and previous NPT was associated with decreased likelihood in both sexes. Overall associations were similar in both sexes.

CONCLUSIONS

Women were less likely to receive NPT during HFH compared to men, potentially risking greater delays in HF diagnosis and treatment. Further investigation should examine the impact of the absence of admission NPT on clinical outcomes and identify strategies to improve obtaining NPT in all patients.

The Quality of Veterans Healthcare Administration Cardiovascular Care

A total of 9 million veterans receive care in a unique healthcare system, the Veterans Healthcare Administration (VHA), with nearly 50% reporting at least one cardiovascular disease. Despite evidence for high quality of health care in the VHA, more veteran care is being moved to the non-VHA community. An assumption of this shift in care is that the quality of non-VHA care is at least comparable to VHA care. This paper reviews the quality of cardiovascular care delivered by the VHA in comparison to community care, which is care delivered in non-VHA facilities by non-VHA providers and is authorized and paid for by VHA, examining quality metrics and highlighting novel national care programs. The critical examination of this data is valuable for deriving health care policy, sharing novel and effective quality initiatives throughout the healthcare sector, and will help veterans and their providers make important healthcare decisions.

State-Level Hospital Quality in the United States: Analyzing Variation and Trends From 2013 to 2021

OBJECTIVE

This study develops a hospital quality index to analyze state-level variations in hospital quality in the United States from 2013 to 2021, using data from 3,000 hospitals from the Centers for Medicare & Medicaid Services (CMS) Hospital Compare data set.

DESIGN

The quality index combines three risk-adjusted measures from the CMS Hospital Compare: 30-day readmission rate, 30-day mortality rate, and patient experience. Each measure is converted into a z-score, weighted by hospital beds, and averaged to form the final index, which has a mean of 0 and a standard deviation of 1.

RESULTS

In 2021, the average U.S. hospital quality measures were 15.1% for readmissions, 11.2% for mortality, and 69.7% for patient experience. There was significant state-level heterogeneity. The quality index ranged from -0.54 to 0.57. Eight states notably outperformed the U.S. average, with Utah leading. Conversely, 14 states underperformed. From 2013 to 2021, there was an average annual improvement in readmissions (0.08pp) and mortality (0.12pp), but a decline in patient experience (0.27pp).

CONCLUSIONS

The study highlights improvements in hospital quality over time but underscores disparities at the state level. The quality index provides a valuable tool for understanding and addressing these variations in hospital care quality.

Predictors and Trends of 30-day Readmissions in Patients With Acute Decompensated Heart Failure With Preserved Ejection Fraction: Insight From the National Readmission Database

Background and Objectives

Hospital readmissions serve as a significant negative prognostic indicator and have a considerable impact on healthcare utilization among individuals diagnosed with heart failure with preserved ejection fraction (HFpEF). For our study, we aimed to elucidate predictors and trends of HFpEF readmissions within a 30-day period.

Methods

The Healthcare Cost and Utilization Project National Readmission Database (NRD) was queried between 2016-2020 to study the 30-day all-cause hospital readmission rate, predictors, duration of hospital stay, and the overall cost of hospitalization. Multivariate/univariate logistic and linear regression analysis were used to analyze the outcomes and adjust for possible confounders.

Results

A total of 3,831,156 index hospitalizations for acute decompensated HFpEF were identified between the years 2016-2020, of which 673,844 (18.4%) patients were readmitted within 30 days. The 30-day all-cause readmissions increased significantly from 17.4% to 19.9% (p<0.001) in the 5-year trend analysis. The most common cardiovascular cause for readmission was hypertensive heart disease with chronic kidney disease stage 1-4 (13.2%). Independent predictors associated with increased rate of readmissions were patients that left against medical advice (adjusted odds ratio [aOR], 2.06; 95% confidence interval [CI], 1.99-2.14; p<0.001), cirrhosis (aOR, 1.33; 95% CI, 1.30-1.36; p<0.001), and chronic obstructive pulmonary disease (aOR, 1.27; 95% CI, 1.25-1.29; p<0.001).

Conclusions

Nearly 1 in 5 patients with acute decompensated HFpEF were readmitted within 30 days (2016-2020), with readmissions rising over time. Identifying at-risk patients is crucial to reducing readmissions and costs.

Influenza vaccination in patients with acute heart failure (PANDA II): study protocol for a hospital-based, parallel-group, cluster randomized controlled trial in China

BACKGROUND

Influenza vaccination confers broad benefits in the elderly and certain high-risk populations, but its effectiveness in patients with acute heart failure (HF) is uncertain. Rates of influenza vaccination are low in China due to poor awareness, cultural misunderstandings, and cost.

AIMS

To determine the effectiveness of influenza vaccination in patients with acute HF admitted to hospitals in China.

METHODS

The second Population Assessment of Influenza and Disease Activity (PANDA II) study is a two-arm, parallel-group, county-level hospital-based, cluster randomized controlled trial to determine the benefits and risks of full access to routine free influenza vaccination before hospital discharge, compared to routine limited use of influenza vaccination, on the primary endpoint of death or hospital readmission. Consecutive hospitalized patients at each site are enrolled to a target of 50 participants in each autumn-winter influenza outbreak period (October to March) over 3 consecutive years to reach the required sample size. Patients are centrally followed up at 1, 3, 6, and 12 months after hospital discharge (or death if earlier). Site numbers varied across year according to predicted influenza activity and logistical reasons.

CONCLUSIONS

This study offers a unique chance to clarify uncertainties surrounding the effectiveness of influenza vaccination in patients with HF and to lay the groundwork for future prevention strategies.

TRIAL REGISTRATION

This trial was registered with the acronym PANDA II (Population Assessment of Influenza and Disease Activity) at ChiCTR.org.cn (ChiCTR2100053264). Registered on 17 November 2021.

Individual heart failure patient variability in nocturnal hypoxia and arrhythmias

Traditional heart failure research often uses daytime population parameter estimates to assess hypoxia and arrhythmias. This approach might not accurately represent heart failure patients as nighttime cardiac behaviors offer crucial insights into their health, especially regarding oxygen levels and heart rhythms. We conducted a prospective study on nocturnal oxygen saturation and heart rate in home-dwelling heart failure patients over 6 nights. Patients were recruited from the Walter Reed National Military Medical Center heart failure clinic. Criteria included a clinical diagnosis of heart failure, a New York Heart Association (NYHA) classification of I to III, ages between 21 to 90, cognitive intactness, capability to use the wearable device, and willingness to use the device for 6 consecutive nights. Average oxygen saturation was 92% with individual readings ranging from 40% to 100%. The mean heart rate was 72 beats per minute (bpm), but individual rates ranged from 18 bpm to a high of 296 bpm. A significant drop in oxygen levels and sleep arrhythmias were consistently observed among participants. Heart failure patients demonstrate notable and variable desaturations and arrhythmias across multiple nights. A single-night sleep study or a 24-hour heart rate monitor may not comprehensively depict patients' oxygenation and heart rate irregularities. Our research highlights wearable devices' potency in medical research for capturing essential nocturnal data. In only 6 nights, we gleaned invaluable clinical insights for optimizing patient care. This study is pioneering, being the first to intensively examine nighttime oxygen levels and heart rates in home-based heart failure patients.

The Effect of Recurrent Heart Failure Hospitalizations on the Risk of Cardiovascular and all-Cause Mortality: a Systematic Review and Meta-Analysis

INTRODUCTION

Heart failure (HF) is a significant worldwide concern due to its substantial impact on mortality rates and recurrent hospitalizations. The relationship between recurrent hospitalizations and mortality in individuals diagnosed with heart failure has been the subject of conflicting findings in previous studies. A meta-analysis was conducted to investigate the association between recurrent heart failure hospitalizations (HFHs) and mortality.

METHODS

We conducted a systematic search across various online databases, such as PubMed, Embase, Web of Science, ProQuest, Scopus, Science Direct, and Google Scholar, to locate studies that examined the connection between recurrent HFHs and cardiovascular (CV) mortality as well as all-cause mortality until January 2023. To evaluate the heterogeneity among the studies, we employed I2 and Cochran's Q test.

RESULTS

In total, 143,867 participants from seven studies were included in the analysis. Recurrent HFHs were found to be strongly associated with elevated risks of both cardiovascular (CV) mortality and all-cause mortality. The pooled hazard ratios (HRs) indicated a non-significant association for CV mortality (HR = 4.28, 95% CI: 0.86-7.71) but a significant association for all-cause mortality (HR = 2.76, 95% CI: 2.05-3.48). Subgroup analyses revealed a reduction in heterogeneity when stratified by factors such as quality score, sample size, hypertension comorbidity, number of recurrent HFHs, and follow-up time. A clear correlation was observed between the frequency of HFH and the mortality risk. Various subgroups, including those with diabetes, atrial fibrillation, and chronic kidney disease, showed significant associations between recurrent HFHs and all-cause mortality. Additionally, recurrent HFHs were significantly associated with CV mortality in subgroups such as heart failure with reduced ejection fraction (HFrEF), atrial fibrillation, and diabetes.

CONCLUSION

This meta-analysis provides evidence of an association between recurrent HFH and elevated risk of both CV mortality and all-cause mortality. The findings consistently indicate that a higher frequency of HFH is strongly associated with an increased likelihood of mortality.

Management and outcomes of heart failure hospitalization among older adults in the United States and Japan

AIMS

Despite advances in therapies, the disease burden of heart failure (HF) has been rising globally. International comparisons of HF management and outcomes may reveal care patterns that improve outcomes. Accordingly, we examined clinical management and patient outcomes in older adults hospitalized for acute HF in the United States (US) and Japan.

METHODS

We identified patients aged >65 who were hospitalized for HF in 2013 using US Medicare data and the Japanese Registry of Acute Decompensated Heart Failure (JROADHF). We described patient characteristics, management, and healthcare utilization and compared outcomes using multivariable Cox regression during and after HF hospitalization.

RESULTS

Among 11 193 Japanese and 120 289 US patients, age and sex distributions were similar, but US patients had higher comorbidity rates. The length of stay was longer in Japan (median 18 vs. 5 days). While Medicare patients had higher use of implantable cardioverter defibrillator or cardiac resynchronization therapy during hospitalization (1.32% vs. 0.6%), Japanese patients were more likely to receive cardiovascular medications at discharge and to undergo cardiac rehabilitation within 3 months of HF admission (31% vs. 1.6%). Physician follow-up within 30 days was higher in Japan (77% vs. 57%). Cardiovascular readmission, cardiovascular mortality and all-cause mortality were 2.1-3.7 times higher in the US patients. The per-day cost of hospitalization was lower in Japan ($516 vs. $1323).

CONCLUSIONS

We observed notable differences in the management, outcomes and costs of HF hospitalization between the US and Japan. Large differences in length of hospitalization, cardiac rehabilitation rate and outcomes warrant further research to determine the optimal length of stay and assess the benefits of inpatient cardiac rehabilitation to reduce rehospitalization and mortality.

Current approaches to preventing heart failure readmissions and decompensated disease

Heart failure is a resource-intensive condition to manage and typically involves a multi-disciplinary and multi-modality approach leading to an expensive treatment paradigm. It is worth noting that hospital admissions constitute over 80% of heart failure management costs. In the past two decades, healthcare systems have developed new ways of following patients remotely to prevent them from being readmitted to the hospital. However, despite these efforts, hospital admissions have still increased. Many successful readmission reduction programs prioritize education and self-care to increase patients' awareness of their disease and promote lasting lifestyle changes. While socioeconomic factors impact success, interventions tend to be effective when medication adherence and guideline-directed medical therapy are emphasized. Monitoring intracardiac pressure can improve resource allocation efficiency and has demonstrated significant reductions in readmissions with improved quality of life in outpatient and remote settings. Data from several studies focused on remote monitoring devices strongly suggest that understanding congestion using physiological biomarkers is an effective management strategy. Since most cases of heart failure are first presented in acute hospitalization settings, immediate access to intracardiac pressure for treatment and decision-making purposes could result in substantial management improvements. However, a notable technology gap needs to be addressed to enable this at a low cost with less reliability on scarce specialist care resources. Contemporary evidence is conclusive that direct hemodynamic are the vital signs in heart failure with the highest clinical utility. Therefore, future ability to obtain these insights reliably using non-invasive methods will be a paradigm-changing technology.

Treatment Patterns, Outcomes, and Persistence to Newly Started Heart Failure Medications in Patients with Worsening Heart Failure: A Cohort Study from the United States and Germany

BACKGROUND

Data are limited regarding guideline-directed medical therapy (GDMT) treatment patterns in patients with worsening heart failure (HF).

METHODS

We used administrative claims databases in Germany and the USA to conduct a retrospective cohort study of patients with worsening HF. Two cohorts of patients with prevalent HF and a HF hospitalization (HFH) from 2016 to 2019, alive at discharge (N = 75,140 USA; N = 47,003 Germany) were identified. Index date was the first HFH during the study period. One-year HF rehospitalization and mortality rates were calculated and a composite endpoint of both outcomes assessed using Kaplan-Meier estimation. We evaluated HF medication patterns in the 6 months before and after the index date. New users of a HF medication (at discharge/after index HFH) were followed for 1 year to evaluate persistence (no treatment gaps > 2 months) RESULTS: One-year HF rehospitalization rates were 36.2% (USA) and 47.7% (Germany). One year mortality rates were 30.0% (USA) and 23.0% (Germany), and the composite endpoint (mortality/HF rehospitalization) was reached in 55.1 % (USA) and 56.6% (Germany). Kaplan-Meier plots showed the risk for the composite endpoint was high in the early post discharge period. Comparison of patterns pre- and postindex HFH showed some increase in use of mineralocorticoid receptor antagonists (MRAs), angiotensin receptor-neprilysin inhibitor (ARNI), and triple therapy; use of angiotensin-converting enzyme (ACE) inhibitor/ angiotensin receptor blocker (ARB) plus beta-blockers remained constant/slightly declined; < 20% patients received triple therapy (ACE inhibitor/ARB plus beta-blocker plus MRA). A third of patients were new users; 1 year persistence rates were often low.

CONCLUSIONS

Morbidity, mortality, and rehospitalization risk is high among patients with worsening HF; uptake and continuation of GDMT is suboptimal.

Initiation and continuation of pharmacological therapies in patients hospitalized for heart failure in Japan

Currently, the utilization patterns of medications for heart failure (HF) after worsening HF events remain unelucidated in Japan. Here, we conducted a retrospective cohort study evaluating the changes in HF drug utilization patterns in 6 months before and after hospitalizations for HF. The adherence to newly initiated HF medications was evaluated based on the proportion of days covered (PDC) and persistence as continuous treatment episodes among new users. The study included 9091 patients hospitalized for HF between January 2016 and September 2019, including 2735 (30.1%) patients who were newly prescribed at least one HF medication after hospitalization. Despite increases in the use of foundational HF therapy (beta-blockers, angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers, or mineralocorticoid receptor antagonists), 35.6% and 7.6% of patients were treated with the HF foundational monotherapy or diuretics alone after hospitalization, respectively. The mean PDC of newly initiated HF medications ranged from 0.57 for thiazide diuretics to 0.77 for sodium-glucose cotransporter-2 inhibitors. Continuous use of HF medications during the first year after initiation was observed in 30-60% of patients. The mean PDC and one-year continuous HF medication use were consistently lower in patients aged ≥ 75 years and in patients with a history of HF hospitalization for all HF medication classes except for tolvaptan and digoxin. Despite the guideline recommendations of HF pharmacotherapy, both treatment and adherence were suboptimal after HF hospitalization, especially in vulnerable populations such as older patients and those with prior HF hospitalizations.

Association of Posttraumatic Stress Disorder and Race on Readmissions After Stroke

BACKGROUND

There is limited research on outcomes of patients with posttraumatic stress disorder (PTSD) who also develop stroke, particularly regarding racial disparities. Our goal was to determine whether PTSD is associated with the risk of hospital readmission after stroke and whether racial disparities existed.

METHODS

The analytical sample consisted of all veterans receiving care in the Veterans Health Administration who were identified as having a new stroke requiring inpatient admission based on the International Classification of Diseases codes. PTSD and comorbidities were identified using the International Classification of Diseases codes and given the date of first occurrence. The retrospective cohort data were obtained from the Veterans Affairs Corporate Data Warehouse. The main outcome was any readmission to Veterans Health Administration with a stroke diagnosis. The hypothesis that PTSD is associated with readmission after stroke was tested using Cox regression adjusted for patient characteristics including age, sex, race, PTSD, smoking status, alcohol use, and comorbidities treated as time-varying covariates.

RESULTS

Our final cohort consisted of 93 651 patients with inpatient stroke diagnosis and no prior Veterans Health Administration codes for stroke starting from 1999 with follow-up through August 6, 2022. Of these patients, 12 916 (13.8%) had comorbid PTSD. Of the final cohort, 16 896 patients (18.0%) with stroke were readmitted. Our fully adjusted model for readmission found an interaction between African American veterans and PTSD with a hazard ratio of 1.09 ([95% CI, 1.00-1.20] P=0.047). In stratified models, PTSD has a significant hazard ratio of 1.10 ([95% CI, 1.02-1.18] P=0.01) for African American but not White veterans (1.05 [95% CI, 0.99-1.11]; P=0.10).

CONCLUSIONS

Among African American veterans who experienced stroke, preexisting PTSD was associated with increased risk of readmission, which was not significant among White veterans. This study highlights the need to focus on high-risk groups to reduce readmissions after stroke.

Benchmarking System Monitoring on Quality Improvement in Percutaneous Coronary Intervention: A Nationwide Registry in Japan

Background

Quality indicators (QIs) have been developed to improve and standardize care quality in percutaneous coronary intervention (PCI). In Japan, consecutive PCI procedures are registered in a nationwide database (the Japanese Percutaneous Coronary Intervention registry), which introduces a benchmarking system for comparing individual institutional performance against the national average.

Objectives

The aim of this study was to assess the impact of the benchmarking system implementation on QI improvement at the hospital level.

Methods

A total of 734,264 PCIs were conducted at 1,194 institutions between January 2019 and December 2021. In January 2018, a web-based benchmarking system encompassing 7 QIs for PCI at the institutional level, including door-to-balloon time and rate of transradial intervention, was introduced. The process by which institutions tracked their QIs was centrally monitored.

Results

During the 3-year study period, the benchmarking system was reviewed at least once at 742 institutions (62.1%) (median 4 times; Q1-Q3: 2-7 times). The institutions that reviewed their records had higher PCI volumes. Among these institutions, although door-to-balloon time was not directly associated, the proportion of transradial intervention increased by 2.3% in the system review group during the initial year compared with 0.7% in their counterparts. However, in the subsequent year, the association between system reviews and QI improvement was attenuated.

Conclusions

The implementation of a benchmarking system, reviewed by participating institutions in Japan, was partially associated with improved QIs during the first year; however, this improvement was attenuated in the subsequent year, highlighting the need for further efforts to develop effective and sustainable interventions to enhance care quality in PCI.

Risk of readmission and death after hospitalization for worsening heart failure: Role of post-discharge follow-up visits in a real-world study from the Grand Est Region of France

AIMS

Patients who experience hospitalizations due to heart failure (HF) face a significant risk of readmission and mortality. Our objective was to evaluate whether the risk of hospitalization and mortality following discharge from HF hospitalization differed based on adherence to the outpatient follow-up (FU) protocol comprising an appointment with a general practitioner (GP) within 15 days, a cardiologist within 2 months or both (termed combined FU).

METHODS AND RESULTS

We studied all adults admitted for a first HF hospitalization from 2016 to 2020 in France's Grand Est region. Association between adherence to outpatient FU and outcomes were assessed with time-dependent survival analysis model. Among 67 476 admitted patients (mean age 80.3 ± 11.3 years, 53% women), 62 156 patients (92.2%) were discharged alive and followed for 723 (317-1276) days. Combined FU within 2 months was used in 21.1% of patients, with lower rates among >85 years, women, and those with higher comorbidity levels (p < 0.0001 for all). Combined FU was associated with a lower 1-year death or rehospitalization (adjusted hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.88-0.94, p < 0.0001) mostly related to lower mortality (adjusted HR 0.65, 95% CI 0.62-0.68, p < 0.0001) whereas HF readmission was higher (adjusted HR 1.19, 95% CI 1.15-1.24, p < 0.0001). When analysing components of combined FU separately, 1-year mortality was more related to cardiologist FU (HR 0.65, 95% CI 0.62-0.67, p < 0.0001), than GP FU (HR 0.87, 95% CI 0.85-0.90, p < 0.0001).

CONCLUSION

Combined FU is carried out in a minority of patients following HF hospitalization, yet it is linked to a substantial reduction in 1-year mortality, albeit at the expense of an increase in HF hospitalizations.

Temporal Trends in Heart Failure Management and Outcomes: Insights From a Japanese Multicenter Registry of Tertiary Care Centers

Background The management of heart failure (HF) has markedly changed, due to changes in demographics and the emergence of novel pharmacotherapies. However, detailed analyses on the temporal trends in characteristics and outcomes among patients with HF are scarcely available. This study aimed to assess the temporal trends over 11 years in clinical management and outcomes in patients with HF. Methods and Results We analyzed data from a multicenter registry of hospitalized patients with acute HF, including 6877 patients registered from 2011 to 2021. Age-adjusted mortality was calculated using standardized mortality ratios. During the study period, mean age increased from 75.2 years in 2011 to 2012 to 76.4 years in 2020 to 2021 (P for trend <0.001). The proportion of HF with reduced ejection fraction (HFrEF, left ventricular ejection fraction <40%) remained constant (from 43.4% to 42.7%, P for trend=0.38). The median duration of hospital stays (from 15 to 17 days, P for trend<0.001) had increased. As for the implementation of guideline-directed medical therapy, the use of mineralocorticoid receptor antagonist at discharge increased in patients with HFrEF (from 44.3% to 60.2%, P for trend<0.001). There was also an increase in the use of sodium-glucose cotransporter-2 inhibitors following their approval for use. The age-adjusted 1-year mortality decreased in patients with HFrEF (from 18.0% to 9.3%, P for trend<0.001) but not in patients with non-HFrEF (left ventricular ejection fraction ≥40%; from 9.2% to 9.5%, P for trend=0.79). Conclusions Hospitalized patients with HF have been aging over the past decade. Their long-term outcomes after discharge have improved predominantly because of decreased mortality in patients with HFrEF.

DASH-HF Study: A Pragmatic Quality Improvement Randomized Implementation Trial for Patients With Heart Failure With Reduced Ejection Fraction

BACKGROUND

Heart failure is a prevailing diagnosis of hospitalization and readmission within 6 months, and nearly a quarter of these patients die within a year. Guideline-directed medication therapies reduce risk of mortality by 73% over 2 years; however, the implementation of these therapies to their target dose in clinical practice continues to be challenging. In 2020, the Veterans Affairs (VA) Health Care System developed a HF dashboard to monitor and improve outpatient HF management. The DASH-HF (Dashboard Activated Services and Telehealth for Heart Failure) study is a randomized, pragmatic clinical trial to evaluate proactive dashboard-directed telehealth clinics to improve the use and dosing of guideline-directed medication therapy for patients with heart failure with reduced ejection fraction not on optimal guideline-directed medication therapy within the VA.

METHODS

Three hundred veterans with heart failure with reduced ejection fraction met inclusion criteria with an optimization potential score (OPS) of 5 or less out of 10, representing nonoptimal guideline-directed medication therapy. The primary outcome was a composite score of guideline-directed medical therapy, the OPS, 6 months after the end of the intervention. Secondary outcomes included active prescriptions for each individual guideline-directed medical therapy class, HF-related hospitalizations, deaths, and clinician time per patient during the intervention clinics.

RESULTS

There was no significant difference between the intervention arm and usual care group in the primary outcome (OPS, 2.9; SD=2.1 versus OPS, 2.6, SD=2.1); adjusted mean difference 0.3 (95% CI, -0.1 to 0.7) or in the prespecified secondary outcomes for hospitalization and all-cause mortality for the intervention of proactive dashboard-based clinics.

CONCLUSIONS

A dashboard-based clinic intervention did not improve the OPS or secondary outcomes of hospitalization and all-cause mortality. There remains a larger opportunity to better target patients and provide more intensive follow-up to further evaluate the utility of proactive dashboard-based clinics for HF management and quality improvement.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT05001165.

"And if my goal is never to leave Casey House?": The significance of place attachment for patients at a specialty HIV hospital in Toronto, Canada

The current healthcare context prioritizes shorter hospital stays and fewer readmissions. However, these measures may not fully capture care experiences for people living with HIV, especially those experiencing medical, psychosocial, and economic complexity. As part of a larger study, we conducted seven focus groups with people living with HIV (n = 52), who were current/former patients at a Toronto-based specialty hospital, examining their desires/needs for hospital programs. Using a novel place attachment lens, we conducted a thematic analysis focusing on the emotional bond between person (patient) and place (hospital). Our findings show that participants wanted an ongoing connection to hospital to fulfill their need(s) for control, security, restoration and belonging. Indeed, continual attachment to hospital may be beneficial for patients with complex care needs. Our research has implications for care engagement and retention frameworks.

Prognostic role of renal replacement therapy among hospitalized patients with heart failure in the Brazilian national public health system

Introduction

Data on patients hospitalized with acute heart failure in Brazil scarce.

Methods

We performed a cross-sectional, retrospective, records-based study using data retrieved from a large public database of heart failure admissions to any hospital from the Brazilian National Public Health System (SUS) (SUS Hospital Information System [SIHSUS] registry) to determine the in-hospital all-cause mortality rate, in-hospital renal replacement therapy rate and its association with outcome.

Results

In total, 910,128 hospitalizations due to heart failure were identified in the SIHSUS registry between April 2017 and August 2021, of which 106,383 (11.7%) resulted in in-hospital death. Renal replacement therapy (required by 8,179 non-survivors [7.7%] and 11,496 survivors [1.4%, p < 0.001]) was associated with a 56% increase in the risk of death in the univariate regression model (HR 1.56, 95% CI 1.52 -1.59), a more than threefold increase of the duration of hospitalization, and a 45% or greater increase of cost per day. All forms of renal replacement therapy remained independently associated with in-hospital mortality in multivariable analysis (intermittent hemodialysis: HR 1.64, 95% CI 1.60 -1.69; continuous hemodialysis: HR 1.52, 95% CI 1.42 -1.63; peritoneal dialysis: HR 1.47, 95% CI 1.20 -1.88).

Discussion

The in-hospital mortality rate of 11.7% observed among patients with acute heart failure admitted to Brazilian public hospitals was alarmingly high, exceeding that of patients admitted to North American and European institutions. This is the first report to quantify the rate of renal replacement therapy in patients hospitalized with acute heart failure in Brazil.

Cost-Effectiveness of Dapagliflozin vs Empagliflozin for Treating Heart Failure With Reduced Ejection Fraction in the United States

PURPOSE

Evidence suggests that adding dapagliflozin to the prior standard of care is cost-effective compared with the standard of care alone. The latest guideline by the American Heart Association/American College of Cardiology/Heart Failure Society of America now recommends the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors for patients with heart failure with reduced ejection fraction (HFrEF). However, the relative cost-effectiveness of different SGLT2 inhibitors, including dapagliflozin and empagliflozin, has not been fully characterized. Therefore, we conducted a cost-effectiveness analysis to compare dapagliflozin and empagliflozin in patients with HFrEF from the US health care perspective.

METHODS

To compare the cost-effectiveness of dapagliflozin and empagliflozin in treating HFrEF, we used a state-transition Markov model. This model was used to estimate the expected lifetime costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) for both medications. The model incorporated patients who were 65 years of age at entry and simulated their health outcomes over a lifetime horizon. The perspective of the analysis was based on the US health care system. To determine the health state transition probabilities, we used a network meta-analysis. All future costs and QALYs were discounted at an annual rate of 3%, and the costs were presented in 2022 US dollars.

FINDINGS

The base case analysis found that the incremental expected lifetime cost of treating patients with dapagliflozin vs empagliflozin was $37,684, resulting in an ICER of $44,763 per QALY. A price threshold analysis indicated that for empagliflozin to be the most cost-effective SGLT2 inhibitor at a willingness-to-pay threshold of $50,000 per QALY, it may require a 12% discount on its current annual prices.

IMPLICATIONS

The findings of this study indicate that dapagliflozin may offer greater lifetime economic value when compared with empagliflozin. Given that the current clinical practice guideline does not recommend one SGLT2 inhibitor over the other, it is essential to implement scalable strategies to ensure affordable access to both medications. By doing so, patients and health care practitioners can make informed decisions about their treatment options without being constrained by financial barriers.

The incremental value of multi-organ assessment of congestion using ultrasound in outpatients with heart failure

AIMS

We investigated the prevalence and clinical value of assessing multi-organ congestion by ultrasound in heart failure (HF) outpatients.

METHODS AND RESULTS

Ultrasound congestion was defined as inferior vena cava of ≥21 mm, highest tertile of lung B-lines, or discontinuous renal venous flow. Associations with clinical characteristics and prognosis were explored. We enrolled 310 HF patients [median age: 77 years, median NT-proBNP: 1037 ng/L, 51% with a left ventricular ejection fraction (LVEF) <50%], and 101 patients without HF. There were no clinical signs of congestion in 224 (72%) patients with HF, of whom 95 (42%) had at least one sign of congestion by ultrasound (P < 0.0001). HF patients with ≥2 ultrasound signs were older, and had greater neurohormonal activation, lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range: 6-15) months, 77 patients (19%) died or were hospitalized for HF. HF patients without ultrasound evidence of congestion had a similar outcome to patients without HF [reference; hazard ratio (HR) 1.02, 95% confidence interval (CI) 0.86-1.35], while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4-63.6), even after adjusting for multiple clinical variables and NT-proBNP. Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a net reclassification improvement of 28% (P = 0.03).

CONCLUSION

Simultaneous assessment of pulmonary, venous, and kidney congestion by ultrasound is feasible, fast, and identifies a high prevalence of sub-clinical congestion associated with poor outcomes.

New Strategies to Prevent Rehospitalizations for Heart Failure

Purpose of review

Heart failure (HF) hospitalizations are common, costly, associated with poor outcomes and potentially avoidable. Reducing HF hospitalizations is therefore a major objective of US healthcare. This review aims to outline causes for HF hospitalizations and provides actionable strategies for HF hospitalization prevention.

Recent findings

Heart failure hospitalizations often have multifactorial and diverse etiologies associated with medical and social patient factors leading to increased congestion. The most recently updated American Heart Association/American College of Cardiology/Heart Failure Society of America Guidelines for the Management of HF were published in 2022 and utilize high-quality evidence to offer a framework for analyzing and preventing HF hospitalizations.

Summary

Prevention of hospitalizations can be achieved by optimizing guideline-directed medical therapies, incorporating appropriate device-based technologies, and utilizing systems-based practices. By identifying treatment gaps and opportunities for improved HF care, this review comprehensively defines the challenges associated with HF rehospitalizations as well as potential solutions.

Repurposing Probenecid for the Treatment of Heart Failure (Re-Prosper-HF): a study protocol for a randomized placebo-controlled clinical trial

BACKGROUND

Improving contractility in heart failure with reduced ejection fraction (HFrEF) has resurfaced as a potential treatment goal. Inotropic therapy is now better understood through its underlying mechanism as opposed to the observed effect of increasing contractility. Calcitropes are a subgroup of inotropes that largely depend on the stimulation of adenylyl cyclase to transform ATP into cyclic adenosine monophosphate (cAMP). At least two clinically relevant calcitropes-istaroxime and probenecid-improve contractility through an increase in systolic intracellular calcium without activating cAMP production. Probenecid, which has been safely used clinically for decades in non-cardiac conditions, has recently been identified as an agonist of the transient receptor potential vanilloid 2 channel. Translational studies have shown that it improves calcium cycling and contractility without activating noxious pathways associated with cAMP-dependent calcitropes and can improve cardiac function in patients with HFrEF.

METHODS

The Re-Prosper-HF study (Repurposing Probenecid for the Treatment of Heart Failure with Reduced Ejection Fraction) is a three-site double-blinded randomized-controlled trial that will test the hypothesis that probenecid can improve cardiac function in patients with HFrEF. Up to 120 patients will be randomized in this double-blind, placebo-controlled study that will assess whether oral probenecid administered at 1 g orally twice per day for 180 days in patients with NYHA II-III HFrEF improves systolic function (aim 1), functional status (aim 2), and self-reported health status (aim 3).

DISCUSSION

Findings from this study will provide data informing its use for improving symptomatology in patients with HFrEF as well as exploratory data for outcomes such as hospital admission rates.

TRIAL TEGISTRATION

The Re-Prosper HF Study (Re-Prosper HF) is registered on ClinicalTrials.gov with the identifier as NCT04551222. Registered on 9 September 2020.

Trends for Readmission and Mortality After Heart Failure Hospitalisation in Malaysia, 2007 to 2016

Background and objectives:

Data on population-level outcomes after heart failure (HF) hospitalisation in Asia is sparse. This study aimed to estimate readmission and mortality after hospitalisation among HF patients and examine temporal variation by sex and ethnicity.

Methods:

Data for 105,399 patients who had incident HF hospitalisations from 2007 to 2016 were identified from a national discharge database and linked to death registration records. The outcomes assessed here were 30-day readmission, in-hospital, 30-day and one-year all-cause mortality.

Results:

Eighteen percent of patients (n = 16786) were readmitted within 30 days. Mortality rates were 5.3% (95% confidence interval (CI) 5.1–5.4%), 11.2% (11.0–11.4%) and 33.1% (32.9–33.4%) for in-hospital, 30-day and 1-year mortality after the index admission. Age, sex and ethnicity-adjusted 30-day readmissions increased by 2% per calendar year while in-hospital and 30-day mortality declined by 7% and 4% per year respectively. One-year mortality rates remained constant during the study period. Men were at higher risk of 30-day readmission (adjusted rate ratio (RR) 1.16, 1.13–1.20) and one-year mortality (RR 1.17, 1.15–1.19) than women. Ethnic differences in outcomes were evident. Readmission rates were equally high in Chinese and Indians relative to Malays whereas Others, which mainly comprised Indigenous groups, fared worst for in-hospital and 30-day mortality with RR 1.84 (1.64–2.07) and 1.3 (1.21–1.41) relative to Malays.

Conclusions:

Short-term survival was improving across sex and ethnic groups but prognosis at one year after incident HF hospitalisation remained poor. The steady increase in 30-day readmission rates deserves further investigation.

Investigating the effect of multimedia education in combination with teach-back method on quality of life and cardiac anxiety in patients with heart failure: a randomized clinical trial

BACKGROUND

Education can contribute to promotion of the quality of life and reduction of heart anxiety in patients with heart failure, so it is important to find a suitable educational method for these patients. Therefore, the present study was an attempt to determine the effect of multimedia education using teach-back method on the life quality and cardiac anxiety in patients with heart failure.

METHODS

The present study was a randomized clinical trial. 120 patients with heart failure class I to III and aged less than 60 years old were selected using sequential sampling; then, they were assigned randomly into two intervention groups and one control group. Group A (multimedia education), group B (education using multimedia together with teach-back method), and group C (control). The quality of life and cardiac anxiety were evaluated in the participants of the three groups before, after, 1 month, and 3 months after the intervention. Data were analyzed using descriptive tests, Pearson correlation, Kolmogorov-Smirnov, chi square and ANOVA test in SPSS 22. The significance level was set at P < 0.05.

RESULTS

No significant differences were found in the mean scores of the quality of life and cardiac anxiety in the control and two intervention groups before the educational intervention. However, immediately after, 1 month and 3 months after the educational intervention, a significant difference was observed between the mean scores of the quality of life and cardiac anxiety in the intervention groups (P < 0.05).

CONCLUSION

Multimedia education together with Teach-Back method is effective in promoting the quality of life and reducing cardiac anxiety in patients with heart failure. Therefore, it is recommended that health policymakers should use this educational method in providing treatment programs.

IRANIAN REGISTRY OF CLINICAL TRIALS

20190917044802N1. Registration date: 5/2/2020.

National Trends in Heart Failure Hospitalizations and Readmissions From 2010 to 2017

Importance

Previous studies have described the secular trends of overall heart failure (HF) hospitalizations, but the literature describing the national trends of unique index hospitalizations and readmission visits for the primary management of HF is lacking.

Objectives

To examine contemporary overall and sex-specific trends of unique primary HF (grouped by number of visits for the same patient in a given year) and 30-day readmission visits in a large national US administrative database from 2010 to 2017.

Design, Setting, and Participants

This cohort study used data from all adult hospitalizations in the Nationwide Readmission Database from January 1, 2010, to December 31, 2017, with a primary diagnosis of HF. Data analyses were conducted from March to November 2020.

Exposures

Admission for a primary diagnosis of HF at discharge.

Main Outcomes and Measures

Unique and overall hospitalizations with a primary diagnosis of HF and postdischarge readmissions. Unique primary HF hospitalizations were grouped by number of visits for the same patient in a given year.

Results

There were 8 273 270 primary HF hospitalizations with a single primary HF admission present in 5 092 626 unique patients, and 1 269 109 had 2 or more HF hospitalizations. The mean age was 72.1 (95% CI, 72.0-72.3) years, and 48.9% (95% CI, 48.7-49.0) were women. The primary HF hospitalization rates per 1000 US adults declined from 4.4 in 2010 to 4.1 in 2013 and then increased from 4.2 in 2014 to 4.9 in 2017. The rates per 1000 US adults for postdischarge HF readmissions (1.0 in 2010 to 0.9 in 2014 to 1.1 in 2017) and all-cause 30-day readmissions (0.8 in 2010 to 0.7 in 2014 to 0.9 in 2017) had similar trends.

Conclusions and Relevance

In this analysis of a nationally representative administrative data set, for primary HF admissions, crude rates of overall and unique patient hospitalizations declined from 2010 to 2014 followed by an increase from 2014 to 2017. Additionally, readmission visits after index HF hospitalizations followed a similar trend. Future studies are needed to verify these findings to improve policies for HF management.

Disparity in the Setting of Incident Heart Failure Diagnosis

BACKGROUND

Early heart failure (HF) recognition can reduce morbidity, yet HF is often initially diagnosed only after a patient clinically worsens. We sought to identify characteristics that predict diagnosis in the acute care setting versus the outpatient setting.

METHODS

We estimated the proportion of incident HF diagnosed in the acute care setting (inpatient hospital or emergency department) versus outpatient setting based on diagnostic codes from a claims database covering commercial insurance and Medicare Advantage between 2003 and 2019. After excluding new-onset HF potentially caused by a concurrent acute cause (eg, acute myocardial infarction), we identified demographic, clinical, and socioeconomic predictors of diagnosis setting. Patients were linked to their primary care clinicians to evaluate diagnosis setting variation across clinicians.

RESULTS

Of 959 438 patients with new HF, 38% were diagnosed in acute care. Of these, 46% had potential HF symptoms in the prior 6 months. Over time, the relative odds of acute care diagnosis increased by 3.2% annually after adjustment for patient characteristics (95% CI, 3.1%-3.3%). Acute care diagnosis setting was more likely for women compared with men (adjusted odds ratio, 1.11 [95% CI, 1.10-1.12]) and for Black patients compared with White patients (adjusted odds ratio, 1.18 [95% CI, 1.16-1.19]). The proportion of acute care diagnosis varied substantially (interquartile range: 24%-39%) among clinicians after adjusting for patient-level risk factors.

CONCLUSIONS

A large proportion of first HF diagnoses occur in the acute care setting, particularly among women and Black patients, yet many had potential HF symptoms in the months before acute care visits. These results raise concerns that many HF diagnoses are missed in the outpatient setting. Earlier diagnosis could allow for timelier high-value interventions, addressing disparities and reducing the progression of HF.

Stability over time of the "hospital effect" on 30-day unplanned readmissions: Evidence from administrative data

Past studies showed that hospital characteristics affect hospital performance in terms of 30-day unplanned readmissions, proving the existence of a "hospital effect". However, the stability over time of this effect has been under-investigated. This study offers new evidence about the stability over time of the hospital effect on 30-day unplanned readmissions. Using 78,907 heart failure (HF) records collected from 116 hospitals in the Lombardy Region (Northern Italy) over three years (2010-2012), this study analysed hospital performance in terms of 30-day unplanned readmissions. Hospitals with unusually high and low readmission rates were identified through multi-level regression that combined both patient and hospital covariates in each year. Our results confirm that although hospital covariates - and the connected managerial choices - affect the 30-day unplanned readmissions of a specific year, their effect is not stable in the short-term (3 years). This has important implications for pay-for-performance schemes and quality improvement initiatives.

Epidemiology of Heart Failure: A Contemporary Perspective

Designated as an emerging epidemic in 1997, heart failure (HF) remains a major clinical and public health problem. This review focuses on the most recent studies identified by searching the Medline database for publications with the subject headings HF, epidemiology, prevalence, incidence, trends between 2010 and present. Publications relevant to epidemiology and population sciences were retained for discussion in this review after reviewing abstracts for relevance to these topics. Studies of the epidemiology of HF over the past decade have improved our understanding of the HF syndrome and of its complexity. Data suggest that the incidence of HF is mostly flat or declining but that the burden of mortality and hospitalization remains mostly unabated despite significant ongoing efforts to treat and manage HF. The evolution of the case mix of HF continues to be characterized by an increasing proportion of cases with preserved ejection fraction, for which established effective treatments are mostly lacking. Major disparities in the occurrence, presentation, and outcome of HF persist particularly among younger Black men and women. These disturbing trends reflect the complexity of the HF syndrome, the insufficient mechanistic understanding of its various manifestations and presentations and the challenges of its management as a chronic disease, often integrated within a context of aging and multimorbidity. Emerging risk factors including omics science offer the promise of discovering new mechanistic pathways that lead to HF. Holistic management approaches must recognize HF as a syndemic and foster the implementation of multidisciplinary approaches to address major contributors to the persisting burden of HF including multimorbidity, aging, and social determinants of health.