Post-acute Care for Patients with Heart Failure

New Antipsychotic Prescribing Continued into Skilled Nursing Facilities Following a Heart Failure Hospitalization: a Retrospective Cohort Study

BACKGROUND

Multimorbidity and polypharmacy are common among individuals hospitalized for heart failure (HF). Initiating high-risk medications such as antipsychotics may increase the risk of poor clinical outcomes, especially if these medications are continued unnecessarily into skilled nursing facilities (SNFs) after hospital discharge.

OBJECTIVE

Examine how often older adults hospitalized with HF were initiated on antipsychotics and characteristics associated with antipsychotic continuation into SNFs after hospital discharge.

DESIGN

Retrospective cohort.

PARTICIPANTS

Veterans without prior outpatient antipsychotic use, who were hospitalized with HF between October 1, 2010, and September 30, 2015, and were subsequently discharged to a SNF.

MAIN MEASURES

Demographics, clinical conditions, prior healthcare utilization, and antipsychotic use data were ascertained from Veterans Administration records, Minimum Data Set assessments, and Medicare claims. The outcome of interest was continuation of antipsychotics into SNFs after hospital discharge.

KEY RESULTS

Among 18,008 Veterans, antipsychotics were newly prescribed for 1931 (10.7%) Veterans during the index hospitalization. Among new antipsychotic users, 415 (21.5%) continued antipsychotics in skilled nursing facilities after discharge. Dementia (adjusted OR (aOR) 1.48, 95% CI 1.11-1.98), psychosis (aOR 1.62, 95% CI 1.11-2.38), proportion of inpatient days with antipsychotic use (aOR 1.08, 95% CI 1.07-1.09, per 10% increase), inpatient use of only typical (aOR 0.47, 95% CI 0.30-0.72) or parenteral antipsychotics (aOR 0.39, 95% CI 0.20-0.78), and the day of hospital admission that antipsychotics were started (day 0-4 aOR 0.36, 95% CI 0.23-0.56; day 5-7 aOR 0.54, 95% CI 0.35-0.84 (reference: day > 7 of hospital admission)) were significant predictors of continuing antipsychotics into SNFs after hospital discharge.

CONCLUSIONS

Antipsychotics are initiated fairly often during HF admissions and are commonly continued into SNFs after discharge. Hospital providers should review antipsychotic indications and doses throughout admission and communicate a clear plan to SNFs if antipsychotics are continued after discharge.

Impact of Transitioning Patients to Oral Diuretics 24 Hours Before Discharge from Heart Failure Hospitalization on 30 Day Outcomes

BACKGROUND

Patients hospitalized for heart failure (HF) are at high risk for post-discharge events. Although transition from intravenous to oral diuretics for >24 hours is commonly practiced to reduce post-discharge risk, evidence supporting this strategy is limited. We investigated the impact of this practice on 30 day post-discharge outcomes following HF hospitalization at our institution.

METHODS

Retrospective chart review of patients hospitalized with a primary HF diagnosis, discharged on oral diuretic, and followed at our institution. Admission, in-hospital, and pre-discharge characteristics of patients discharged with >24-hour observation were compared to those of patients observed for <24-hours on oral diuretics. Differences between groups in composite 30 day all-cause mortality and rehospitalization, each component, and HF rehospitalization were assessed.

RESULTS

Of 285 patients meeting entry criteria, 178 received oral diuretics >24 hours prior to discharge and 107 were discharged <24 hours after transitioning to oral diuretics. Baseline characteristics were similar between groups. Patients with >24 hours observation on oral diuretics had longer in-hospital stays and greater weight and net volume loss than those observed <24 hours. Patients receiving oral diuretics for <24 hours were more likely to have had neurohormonal drugs and diuretic dose changed within 24-hours of discharge. Oral diuretic treatment for >24 hours failed to reduce any study endpoint.

CONCLUSIONS

Transitioning patients to oral diuretics for >24 hours prior to discharge following HF hospitalization failed to improve 30-day outcomes. These results question this strategy for all patients hospitalized for worsening HF.

Gerotechnology for Older Adults With Cardiovascular Diseases: JACC State-of-the-Art Review

The growing population of older adults (age ≥65 years) is expected to lead to higher rates of cardiovascular disease. The expansion of digital health (encompassing telehealth, telemedicine, mobile health, and remote patient monitoring), Internet access, and cellular technologies provides an opportunity to enhance patient care and improve health outcomes-opportunities that are particularly relevant during the current coronavirus disease-2019 pandemic. Insufficient dexterity, visual impairment, and cognitive dysfunction, found commonly in older adults should be taken into consideration in the development and utilization of existing technologies. If not implemented strategically and appropriately, these can lead to inequities propagating digital divides among older adults, across disease severities and socioeconomic distributions. A systematic approach, therefore, is needed to study and implement digital health strategies in older adults. This review will focus on current knowledge of the benefits, barriers, and use of digital health in older adults for cardiovascular disease management.