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Suo E, Driscoll A, Dinh D, Brennan A, Kaye DM, Stub D, Lefkovits J, Reid CM, Hopper I. Comparison of Characteristics and Outcomes in Patients With Acute Decompensated Heart Failure Admitted Under General Medicine and Cardiology Units. Heart Lung Circ 2024; 33:983-989. [PMID: 38458933 DOI: 10.1016/j.hlc.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/12/2023] [Accepted: 01/11/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Acute decompensated heart failure (ADHF) is a leading cause of cardiovascular disease hospitalisations associated with significant morbidity and mortality. In hospitals, HF patients are typically managed by cardiology or physician teams, with differences in patient demographics and clinical outcomes. This study utilises contemporary HF registry data to compare patient characteristics and outcomes in those with ADHF admitted into General Medicine and Cardiology units. METHODS The Victorian Cardiac Outcomes Registry was utilised to identify patients hospitalised with ADHF 30-day period in each of four consecutive years. We compared patient characteristics, pharmacological management and outpatient follow-up of patients admitted to General Medicine and Cardiology units. Primary outcome measures included in-hospital mortality, 30-day readmission, and 30-day mortality. RESULTS Between 2014 and 2017, a total of 1,253 patients with ADHF admissions were registered, with 53% admitted in General Medicine units and 47% in Cardiology units. General Medicine patients were more likely to be older (82 vs 71 years; p<0.001), female (51% vs 34%; p<0.001), and have higher prevalence of comorbidities and preserved left ventricular function (p<0.001). There were no differences in primary outcome measures between General Medicine and Cardiology in terms of: in-hospital mortality (5.0% vs 3.9%; p=0.35), 30-day readmission (23.4% vs 23.6%; p=0.93), and 30-day mortality (10.0% vs 8.0%; p=0.21). CONCLUSIONS Hospitalised patients with HF continue to have high mortality and rehospitalisation rates. The choice of treatment by General Medicine or Cardiology units, based on the particular medical profile and individual needs of the patients, provides equivalent outcomes.
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Affiliation(s)
| | - Andrea Driscoll
- Deakin University, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Diem Dinh
- Monash University, Melbourne, Vic, Australia
| | | | - David M Kaye
- The Alfred Hospital, Melbourne, Vic, Australia; Baker IDI Heart Diabetes Institute, Melbourne, Vic, Australia
| | - Dion Stub
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia; Baker IDI Heart Diabetes Institute, Melbourne, Vic, Australia
| | - Jeffrey Lefkovits
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia; The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Christopher M Reid
- Monash University, Melbourne, Vic, Australia; Curtin University, Perth, WA, Australia
| | - Ingrid Hopper
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia.
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Lu DY, Kanduri J, Yeo I, Goyal P, Krishnan U, Horn EM, Karas MG, Sobol I, Majure DT, Naka Y, Minutello RM, Cheung JW, Uriel N, Kim LK. Impact of Advanced Therapy Centers on Characteristics and Outcomes of Heart Failure Admissions. Circ Heart Fail 2024; 17:e011115. [PMID: 38456308 DOI: 10.1161/circheartfailure.123.011115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 01/08/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Although much attention has been paid to admission and transfer patterns for cardiogenic shock, contemporary data are lacking on decompensated heart failure (HF) admissions and transfers and the impact of advanced therapy centers (ATCs) on outcomes. METHODS HF hospitalizations were obtained from the Nationwide Readmissions Database 2016 to 2019. Centers performing at least 1 heart transplant or left ventricular assist device were classified as ATCs. Patient characteristics, outcomes, and procedural volume were compared among 3 cohorts: admissions to non-ATCs, admissions to ATCs, and transfers to ATCs. A secondary analysis evaluated outcomes for severe HF hospitalizations (cardiogenic shock, cardiac arrest, and mechanical ventilation). Multivariable logistic regression was performed to adjust for the presence of HF decompensations and significant clinical variables during univariate analysis. RESULTS A total of 2 331 690 hospitalizations (81.2%) were admissions to non-ATCs (94.5% of centers), 525 037 (18.3%) were admissions to ATCs (5.5% of centers), and 15 541 (0.5%) were transferred to ATCs. Patients treated at ATCs (especially those transferred) had higher rates of HF decompensations, procedural frequency, lengths of stay, and costs. Unadjusted mortality was 2.6% at non-ATCs and was higher at ATCs, both for directly admitted (2.9%, P<0.001) and transferred (11.2%, P<0.001) patients. However, multivariable-adjusted mortality was significantly lower at ATCs, both for directly admitted (odds ratio, 0.82 [95% CI, 0.78-0.87]; P<0.001) and transferred (odds ratio, 0.66 [95% CI, 0.57-0.78]; P<0.001) patients. For severe HF admissions, unadjusted mortality was 37.2% at non-ATCs and was lower at ATCs, both for directly admitted (25.3%, P<0.001) and transferred (25.2%, P<0.001) patients, with similarly lower multivariable-adjusted mortality. CONCLUSIONS Patients with HF treated at ATCs were sicker but associated with higher procedural volume and lower adjusted mortality.
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Affiliation(s)
- Daniel Y Lu
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
- Weill Cornell Cardiovascular Outcomes Research Group, Weill Cornell Medical College, New York (D.Y.L., I.Y., U.K., J.W.C., L.K.K.)
| | - Jaya Kanduri
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
| | - Ilhwan Yeo
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
- Weill Cornell Cardiovascular Outcomes Research Group, Weill Cornell Medical College, New York (D.Y.L., I.Y., U.K., J.W.C., L.K.K.)
| | - Parag Goyal
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
| | - Udhay Krishnan
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
- Weill Cornell Cardiovascular Outcomes Research Group, Weill Cornell Medical College, New York (D.Y.L., I.Y., U.K., J.W.C., L.K.K.)
| | - Evelyn M Horn
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
| | - Maria G Karas
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
| | - Irina Sobol
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
| | - David T Majure
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
| | - Yoshifumi Naka
- Department of Cardiac Surgery (Y.N.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
| | - Robert M Minutello
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
- Weill Cornell Cardiovascular Outcomes Research Group, Weill Cornell Medical College, New York (D.Y.L., I.Y., U.K., J.W.C., L.K.K.)
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University, New York Presbyterian Hospital, New York (N.U.)
| | - Luke K Kim
- Division of Cardiology, Department of Medicine (D.Y.L., J.K., I.Y., P.G., U.K., E.M.H., M.G.K., I.S., D.T.M., R.M.M., J.W.C., L.K.K.), Weill Cornell Medical College, New York Presbyterian Hospital, New York
- Weill Cornell Cardiovascular Outcomes Research Group, Weill Cornell Medical College, New York (D.Y.L., I.Y., U.K., J.W.C., L.K.K.)
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Amin K, Bethel G, Jackson LR, Essien UR, Sloan CE. Eliminating Health Disparities in Atrial Fibrillation, Heart Failure, and Dyslipidemia: A Path Toward Achieving Pharmacoequity. Curr Atheroscler Rep 2023; 25:1113-1127. [PMID: 38108997 PMCID: PMC11044811 DOI: 10.1007/s11883-023-01180-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE OF REVIEW Pharmacoequity refers to the goal of ensuring that all patients have access to high-quality medications, regardless of their race, ethnicity, gender, or other characteristics. The goal of this article is to review current evidence on disparities in access to cardiovascular drug therapies across sociodemographic subgroups, with a focus on heart failure, atrial fibrillation, and dyslipidemia. RECENT FINDINGS Considerable and consistent disparities to life-prolonging heart failure, atrial fibrillation, and dyslipidemia medications exist in clinical trial representation, access to specialist care, prescription of guideline-based therapy, drug affordability, and pharmacy accessibility across racial, ethnic, gender, and other sociodemographic subgroups. Researchers, health systems, and policy makers can take steps to improve pharmacoequity by diversifying clinical trial enrollment, increasing access to inpatient and outpatient cardiology care, nudging clinicians to increase prescription of guideline-directed medical therapy, and pursuing system-level reforms to improve drug access and affordability.
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Affiliation(s)
- Krunal Amin
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Garrett Bethel
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Larry R Jackson
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Utibe R Essien
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | - Caroline E Sloan
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
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Zhang DT, Onyebeke C, Nahid M, Balkan L, Musse M, Pinheiro LC, Sterling MR, Durant RW, Brown TM, Levitan EB, Safford MM, Goyal P. Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure. JAMA Netw Open 2023; 6:e2344070. [PMID: 37983029 PMCID: PMC10660170 DOI: 10.1001/jamanetworkopen.2023.44070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/10/2023] [Indexed: 11/21/2023] Open
Abstract
Importance Involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF. Objective To determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF. Design, Setting, and Participants This retrospective cohort study used data from the Reasons for Geographic and Racial Difference in Stroke (REGARDS) cohort. Participants included adults who experienced an adjudicated hospitalization for HF between 2009 and 2017 in all 48 contiguous states in the US. Data analysis was performed from November 2022 to January 2023. Exposures A total of 9 candidate SDOH, aligned with the Healthy People 2030 conceptual model, were examined: Black race, social isolation, social network and/or caregiver availability, educational attainment less than high school, annual household income less than $35 000, living in rural area, living in a zip code with high poverty, living in a Health Professional Shortage Area, and living in a state with poor public health infrastructure. Main Outcomes and Measures The primary outcome was cardiologist involvement, defined as involvement of a cardiologist as the primary responsible clinician or as a consultant. Bivariate associations between each SDOH and cardiologist involvement were examined using Poisson regression with robust SEs. Results The study included 1000 participants (median [IQR] age, 77.8 [71.5-84.0] years; 479 women [47.9%]; 414 Black individuals [41.4%]; and 492 of 876 with low income [56.2%]) hospitalized at 549 unique US hospitals. Low annual household income (<$35 000) was the only SDOH with a statistically significant association with cardiologist involvement (relative risk, 0.88; 95% CI, 0.82-0.95). In a multivariable analysis adjusting for age, race, sex, HF characteristics, comorbidities, and hospital characteristics, low income remained inversely associated with cardiologist involvement (relative risk, 0.89; 95% CI, 0.82-0.97). Conclusions and Relevance This cohort study found that adults with low household income were 11% less likely than adults with higher incomes to have a cardiologist involved in their care during a hospitalization for HF. These findings suggest that socioeconomic status may bias the care provided to patients hospitalized for HF.
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Affiliation(s)
- David T. Zhang
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | | | - Musarrat Nahid
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Lauren Balkan
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Laura C. Pinheiro
- Department of Health Policy and Management, Weill Cornell Medicine, New York, New York
| | | | - Raegan W. Durant
- Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Todd M. Brown
- Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | | | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Program for the Care and Study of the Aging Heart, Weill Cornell Medicine, New York, New York
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Godfrey S, Peng Y, Lorusso N, Sulistio M, Mentz RJ, Pandey A, Warraich H. Palliative Care for Patients With Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2023; 16:e010802. [PMID: 37869880 DOI: 10.1161/circheartfailure.123.010802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/31/2023] [Indexed: 10/24/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) has become the leading form of heart failure worldwide, particularly among elderly patient populations. HFpEF is associated with significant morbidity and mortality that may benefit from incorporation of palliative care (PC). Patients with HFpEF have similarly high mortality rates to patients with heart failure with reduced ejection fraction. PC trials for heart failure have shown improvement in quality of life, quality of death, and health care utilization, although most trials defined heart failure clinically without differentiating between HFpEF and heart failure with reduced ejection fraction. As such, the timing and role of PC for HFpEF care remains uncertain, and PC referral rates for HFpEF are very low despite potential improvements in important patient-centered outcomes. Specific barriers to referral include limited data, prognostic uncertainty, provider misconceptions about PC, inadequate specialty PC workforce, complexities of treating multimorbidity, and limited home care options for patients with heart failure. While there are many barriers to integration of PC into HFpEF care, there are multiple potential benefits to patients with HFpEF throughout their disease course. As this population continues to grow, targeted efforts to study and implement PC interventions are needed to improve patient quality of life and death.
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Affiliation(s)
- Sarah Godfrey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.G., M.S., A.P.)
| | | | - Nicholas Lorusso
- Department of Natural Sciences, University of North Texas at Dallas (N.L.)
| | - Melanie Sulistio
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.G., M.S., A.P.)
| | - Robert J Mentz
- Duke University Medical Center, Division of Cardiology, Durham, NC (R.J.M.)
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.G., M.S., A.P.)
| | - Haider Warraich
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA (H.W.)
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Osuagwu C, Khinkar RM, Zheng A, Wien M, Decopain J, Desai S, McElrath E, Hinchey E, Mueller SK, Schnipper JL, Boxer R, Shannon EM. A Public Health Critical Race Praxis Informed Congestive Heart Failure Quality Improvement Initiative on Inpatient General Medicine. J Gen Intern Med 2023; 38:2236-2244. [PMID: 36849864 PMCID: PMC9970115 DOI: 10.1007/s11606-023-08086-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 02/07/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Prior evaluation at our hospital demonstrated that, compared to White patients, Black and Latinx patients with congestive heart failure (CHF) were less likely to be admitted to the cardiology service rather than the general medicine service (GMS). Patients admitted to GMS (compared to cardiology) had inferior rates of cardiology follow-up and 30-day readmission. OBJECTIVE To develop and test the feasibility and impacts of using quality improvement (QI) methods, in combination with the Public Health Critical Race Praxis (PHCRP) framework, to engage stakeholders in developing an intervention for ensuring guideline-concordant inpatient CHF care across all patient groups. METHODS We compared measures for all patients admitted with CHF to GMS between September 2019 and March 2020 (intervention group) to CHF patients admitted to GMS in the previous year (pre-intervention group) and those admitted to cardiology during the pre-intervention and intervention periods (cardiology group). Our primary measures were 30-day readmissions and 14- and 30-day post-discharge cardiology follow-up. RESULTS There were 79 patients admitted with CHF to GMS during the intervention period, all of whom received the intervention. There were similar rates of Black and Latinx patients across the three groups. Compared to pre-intervention, intervention patients had a significantly lower 30-day readmission rate (18.9% vs. 24.8%; p=0.024), though the cardiology group also had a decrease in 30-day readmissions from the pre-intervention to intervention period. Compared to pre-intervention, intervention patients had significantly higher 14-day and 30-day post-discharge follow-up visits scheduled with cardiology (36.7% vs. 24.8%, p=0.005; 55.7% vs. 42.3%, p=0.0029), but no improvement in appointment attendance. CONCLUSION This study provides a first test of applying the PHCRP framework within a stakeholder-engaged QI initiative for improving CHF care across races and ethnicities. Our study design cannot evaluate causation. However, the improvements in 30-day readmission, as well as in processes of care that may affect it, provide optimism that inclusion of a racism-conscious framework in QI initiatives is feasible and may enhance QI measures.
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Affiliation(s)
- Chidinma Osuagwu
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Roaa M Khinkar
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Amy Zheng
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew Wien
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Jennifer Decopain
- School of Nursing, MGH Institute of Health Professions, Charlestown, MA, USA
| | - Sonali Desai
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Erin McElrath
- Department of Medicine, Brigham and Woman's Hospital, Boston, MA, USA
| | - Emily Hinchey
- Department of Medicine, Brigham and Woman's Hospital, Boston, MA, USA
| | - Stephanie K Mueller
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Robert Boxer
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Evan Michael Shannon
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, 1100 Glendon Ave, Suite 850, Room, Los Angeles, CA, 812, USA.
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Bazmpani MA, Papanastasiou CA, Giampatzis V, Kamperidis V, Zegkos T, Zebekakis P, Savopoulos C, Karvounis H, Efthimiadis GK, Ziakas A, Karamitsos TD. Differences in Demographics, in-Hospital Management and Short-Term Prognosis in Admissions for Acutely Decompensated Heart Failure to Cardiology vs. Internal Medicine Departments: A Prospective Study. J Cardiovasc Dev Dis 2023; 10:315. [PMID: 37623328 PMCID: PMC10455388 DOI: 10.3390/jcdd10080315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/26/2023] Open
Abstract
Heart failure (HF) is among the leading causes of unplanned hospital admissions worldwide. Patients with HF carry a high burden of comorbidities; hence, they are frequently admitted for non-cardiac conditions and managed in Internal Medicine Departments (IMD). The aim of our study was to investigate differences in demographics, in-hospital management, and short-term outcomes of HF patients admitted to IMD vs. cardiology departments (CD). A prospective cohort study enrolling consecutive patients with acutely decompensated HF either as primary or as secondary diagnosis during the index hospitalization was conducted. Our primary endpoint was a combined endpoint of in-hospital mortality and 30-day rehospitalization for HF. A total of 302 patients participated in the study, with 45% of them admitted to IMD. Patients managed by internists were older with less pronounced HF symptoms on admission. In-hospital mortality was higher for patients admitted to IMD vs. CD (21% vs. 6%, p < 0.001). The composite endpoint of in-hospital death and heart failure hospitalizations at 30 days post-discharge was higher for patients admitted to IMD both in univariate [OR: 3.2, 95% CI (1.8-5.7); p < 0.001] and in multivariate analysis [OR 3.74, 95% CI (1.72-8.12); p = 0.001]. In addition, the HF rehospitalization rate at 6 months after discharge was higher in IMD patients [HR 1.65, 95% CI (1.1, 2.4), p = 0.01]. Overall, HF patients admitted to IMD have worse short-term outcomes compared to patients admitted to CD.
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Affiliation(s)
- Maria-Anna Bazmpani
- First Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece; (M.-A.B.); (C.A.P.); (V.K.); (T.Z.); (H.K.); (G.K.E.); (A.Z.)
| | - Christos A. Papanastasiou
- First Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece; (M.-A.B.); (C.A.P.); (V.K.); (T.Z.); (H.K.); (G.K.E.); (A.Z.)
| | - Vasilios Giampatzis
- Cardiology Department, General Hospital of Kavala, 65500 Thessaloniki, Greece;
| | - Vasileios Kamperidis
- First Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece; (M.-A.B.); (C.A.P.); (V.K.); (T.Z.); (H.K.); (G.K.E.); (A.Z.)
| | - Thomas Zegkos
- First Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece; (M.-A.B.); (C.A.P.); (V.K.); (T.Z.); (H.K.); (G.K.E.); (A.Z.)
| | - Pantelis Zebekakis
- Fisrt Department of Internal Medicine, School of Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece;
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, School of Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece;
| | - Haralambos Karvounis
- First Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece; (M.-A.B.); (C.A.P.); (V.K.); (T.Z.); (H.K.); (G.K.E.); (A.Z.)
| | - Georgios K. Efthimiadis
- First Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece; (M.-A.B.); (C.A.P.); (V.K.); (T.Z.); (H.K.); (G.K.E.); (A.Z.)
| | - Antonios Ziakas
- First Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece; (M.-A.B.); (C.A.P.); (V.K.); (T.Z.); (H.K.); (G.K.E.); (A.Z.)
| | - Theodoros D. Karamitsos
- First Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece; (M.-A.B.); (C.A.P.); (V.K.); (T.Z.); (H.K.); (G.K.E.); (A.Z.)
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8
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Manla Y, Ghalib HH, Badarin FA, Ferrer R, Lee-St John T, Abdalla K, Soliman M, Gabra G, Bader F. Implementation of a multidisciplinary inpatient heart failure service and its association with hospitalized patient outcomes: First experience from the Middle East and North Africa region. Heart Lung 2023; 61:92-97. [PMID: 37196385 DOI: 10.1016/j.hrtlng.2023.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Multidisciplinary care models have been associated with improved clinical outcomes and an increase in adherence to guideline-directed medical therapy among patients hospitalized with heart failure (HF). OBJECTIVE This study aims to evaluate the association between the creation of a multidisciplinary inpatient HF service and patient outcomes at a tertiary care center in the Middle East/ North Africa. METHODS We used electronic health records to retrospectively identify patients hospitalized for acute HF between June-2015 and June-2018. Patients were categorized by whether they were hospitalized before (n = 71) or after (n = 86) the implementation of a multidisciplinary HF team (HF-MDT), starting on 1/1/2017. The groups were compared for optimal use of guideline-directed medical therapy, hospital length of stay, 30-day hospital readmission, and in-hospital mortality. RESULTS The creation of the HF-MDT was associated with significantly better adherence to GDMT at discharge (27.5% vs. 55.4%, (OR 3.3, 95% CI [1.65-6.5]), P<0.001), shorter median hospital length of stay (8, IQR [4.8 - 19] vs. 5, IQR [3- 9], P = 0.02) and a reduction in 30-day hospital readmission (26.5% vs. 11%; OR 0.3, 95% CI [0.1-0.8], P = 0.02). However, there was no difference in-hospital mortality (10.5% vs. 3.5%; OR 0.3, 95% CI [0.1-1.2], P = 0.1). CONCLUSIONS Implementing an HF-MDT in the care of patients hospitalized with HF is associated with better adherence to GDMT on discharge, reduced hospital length of stay, and lower 30-day readmission rates. The current data support the broader adoption of dedicated HF programs in the Middle East to improve outcomes of patients with HF.
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Affiliation(s)
- Yosef Manla
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Academic Office, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Hussam H Ghalib
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Firas Al Badarin
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Richard Ferrer
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - Khalid Abdalla
- Department of Internal Medicine, University of Missouri-Kansas City
| | - Medhat Soliman
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Guirgis Gabra
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Feras Bader
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
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9
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Zhang DT, Onyebeke C, Nahid M, Balkan L, Musse M, Pinheiro LC, Sterling MR, Durant RW, Brown TM, Levitan EB, Safford MM, Goyal P. Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.23.23287671. [PMID: 36993687 PMCID: PMC10055565 DOI: 10.1101/2023.03.23.23287671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Introduction The involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF. Since reasons for this are not entirely clear, we sought to determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF. We hypothesized that SDOH would be inversely associated with cardiologist involvement in the care of adults hospitalized for HF. Methods We included adult participants from the national REasons for Geographic And Racial Difference in Stroke (REGARDS) cohort, who experienced an adjudicated hospitalization for HF between 2009 and 2017. We excluded participants who were hospitalized at institutions that lacked cardiology services (n=246). We examined nine candidate SDOH, which align with the Healthy People 2030 conceptual model: Black race, social isolation (0-1 visits from a family or friend in the past month), social network/caregiver availability (having someone to care for them if ill), educational attainment < high school, annual household income < $35,000, living in rural areas, living in a zip code with high poverty, living in a Health Professional Shortage Area, and residing in a state with poor public health infrastructure. The primary outcome was cardiologist involvement, a binary variable which was defined as involvement of a cardiologist as the primary responsible clinician or as a consultant, collected via chart review. We examined associations between each SDOH and cardiologist involvement using Poisson regression with robust standard errors. Candidate SDOH with statistically significant associations (p<0.10) were retained for multivariable analysis. Potential confounders/covariates for the multivariable analysis included age, race, sex, HF characteristics, comorbidities, and hospital characteristics. Results We examined 876 participants hospitalized at 549 unique US hospitals. The median age was 77.5 years (IQR 71.0-83.7), 45.9% were female, 41.4% were Black, and 56.2% had low income. Low household income (<$35,000/year) was the only SDOH that had a statistically significant association with cardiologist involvement in a bivariate analysis (RR: 0.88 [95% CI: 0.82-0.95]). After adjusting for potential confounders, low income remained inversely associated (RR: 0.89 [95% CI: 0.82-0.97]). Conclusions Adults with low household income were 11% less likely to have a cardiologist involved in their care during a hospitalization for HF. This suggests that socioeconomic status may implicitly bias the care provided to patients hospitalized for HF.
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Affiliation(s)
- David T. Zhang
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | | | - Musarrat Nahid
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Lauren Balkan
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Laura C. Pinheiro
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Madeline R. Sterling
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Raegan W. Durant
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Todd M. Brown
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Parag Goyal
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
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10
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Sharma Y, Horwood C, Hakendorf P, Thompson C. Characteristics and outcomes of patients with heart failure discharged from different speciality units in Australia: an observational study. QJM 2022; 115:727-734. [PMID: 35176164 DOI: 10.1093/qjmed/hcac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/02/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Previous studies have reported differing clinical outcomes among hospitalized heart failure (HF) patients admitted under cardiology and general medicine (GM) without consideration of patients' frailty. AIMS To explore outcomes in patients admitted under the two specialities after taking into account their frailty and other characteristics. METHODS This retrospective study included all HF patients ≥18 years admitted between 1 January 2013 and 31 December 2019 at two Australian tertiary hospitals. Frailty was determined by use of the Hospital Frailty Risk Score (HFRS) and patients with HFRS ≥ 5 were classified as frail. Propensity score matching (PSM) was used to match 11 variables between the two specialities. The primary outcomes included the days-alive-and-out-of-hospital (DAOH90) at 90 days of discharge, 30-day mortality and readmissions. RESULTS Of 4913 HF patients, mean age 76.2 (14.1) years, 51% males, 2653 (54%) were admitted under cardiology compared to 2260 (46%) under GM. Patients admitted under GM were more likely to be older females, with a higher Charlson index and poor renal function than those admitted under cardiology. Overall, 23.8% patients were frail and frail patients were more likely to be admitted under GM than cardiology (33.6% vs. 15.3%, P < 0.001). PSM created 1532 well-matched patients in each group. After PSM, the DAOH90 was not significantly different among patients admitted in GM when compared to cardiology (coefficient -5.36, 95% confidence interval -11.73 to 1.01, P = 0.099). Other clinical outcomes were also similar between the two specialities. CONCLUSIONS Clinical characteristics of HF patients differ between GM and cardiology; however, clinical outcomes were not significantly different after taking into account frailty and other variables.
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Affiliation(s)
- Y Sharma
- From the College of Medicine and Public Health, Flinders University, Sturt Road, Bedford Park, Adelaide, SA 5042, Australia
- Division of Medicine, Cardiac and Critical Care, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia
| | - C Horwood
- Department of Clinical Epidemiology, Flinders Medical Centre, Adelaide, SA 5042, Australia
| | - P Hakendorf
- Department of Clinical Epidemiology, Flinders Medical Centre, Adelaide, SA 5042, Australia
| | - C Thompson
- Discipline of Medicine, The University of Adelaide, Adelaide, SA 5005, Australia
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11
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Maymon SL, Moravsky G, Marcus G, Shuvy M, Pereg D, Epstein D, Litovchik I, Fuchs S, Minha S. Disparities in the characteristics and outcomes of patients hospitalized with acute decompensated heart failure admitted to internal medicine and cardiology departments: a single-centre, retrospective cohort study. ESC Heart Fail 2020; 8:390-398. [PMID: 33232585 PMCID: PMC7835581 DOI: 10.1002/ehf2.13084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/08/2020] [Accepted: 10/14/2020] [Indexed: 12/28/2022] Open
Abstract
Aims Efforts are constantly made to decrease the rates of readmission after acute decompensated heart failure (ADHF). ADHF admissions to internal medicine departments (IMD) were previously associated with higher risk for readmission compared with those admitted to cardiology departments (CD). It is unknown if the earlier still applies after recent advancement in care over the last decade. This contemporary cohort compares characteristics and outcomes of ADHF patients admitted to IMD with those admitted to CD. Methods and results The data for this single‐centre, retrospective study utilized a cohort of 8332 ADHF patients admitted between 2007 and 2017. We compared patients' baseline characteristics and clinical and laboratory indices of patients admitted to CD and IMD with the outcome defined as 30 day readmission rate. In comparison with those admitted to CD, patients admitted to IMD (89.5% of patients) were older (79 [70–86] vs. 69 [60–78] years; P < 0.001) and had a higher incidence of co‐morbidities and a higher ejection fraction. Readmission rates at 30 days were significantly lower in patients admitted to CD (15.9% vs. 19.6%; P = 0.01). Conflicting results of three statistical models failed to associate between the admitting department and 30 day readmission (odds ratio for 30 day readmission in CD: forced and backward stepwise logistic regression 0.8, 95% confidence interval 0.65–0.97, P = 0.02; stabilized inverse probability weights model odds ratio 1.0, confidence interval 0.75–1.37, P = 0.96). Conclusions This contemporary analysis of ADHF patient cohort demonstrates significant differences in the characteristics and outcomes of patients admitted to IMD and CD. Thus, focusing strategies for readmission prevention in patients admitted to IMD may be beneficial.
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Affiliation(s)
- Shiri Lea Maymon
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Gil Moravsky
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Cardiology, Shamir Medical Center, Be'er Yaakov, Zerifin, 70300, Israel
| | - Gil Marcus
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Cardiology, Shamir Medical Center, Be'er Yaakov, Zerifin, 70300, Israel
| | - Mony Shuvy
- Heart Institute, Hadassah University Hospital, Jerusalem, Israel
| | - David Pereg
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Cardiology, Meir Medical Centre, Kfar Saba, Israel
| | - Danny Epstein
- Department of Internal Medicine 'B', Rambam Medical Center, Haifa, Israel
| | - Ilya Litovchik
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Cardiology, Shamir Medical Center, Be'er Yaakov, Zerifin, 70300, Israel
| | - Shmuel Fuchs
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Cardiology, Shamir Medical Center, Be'er Yaakov, Zerifin, 70300, Israel
| | - Sa'ar Minha
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Cardiology, Shamir Medical Center, Be'er Yaakov, Zerifin, 70300, Israel
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12
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Dow AW, Chopski B, Cyrus JW, Paletta-Hobbs LE, Qayyum R. A STEEEP Hill to Climb: A Scoping Review of Assessments of Individual Hospitalist Performance. J Hosp Med 2020; 15:599-605. [PMID: 32966195 DOI: 10.12788/jhm.3445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/11/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although ensuring high-quality care requires assessment of individual hospitalist performance, current assessment approaches lack consistency and coherence. The Institute of Medicine's STEEEP framework for quality healthcare conceptualizes quality through domains of "Safe," "Timely," "Effective," "Efficient," "Equitable," and "Patient Centered." This framework may be applicable to assessing individual hospitalists. OBJECTIVE This scoping review sought to identify studies that describe variation in individual hospitalist performance and to code this data to the domains of the STEEEP framework. METHODS Via a systematic search of peer-reviewed literature that assessed the performance of individual hospitalists in the Medline database, we identified studies that described measurement of individual hospitalist performance. Forty-two studies were included in the final review and coded into one or more domains of the STEEEP framework. RESULTS Studies in the Safe domain focused on transitions of care, both at discharge and within the hospital. Many studies were coded to more than one domain, especially Timely, Effective, and Efficient. Examples include adherence to evidence-based guidelines or Choosing Wisely recommendations. The Patient Centered domain was most frequently coded, but approaches were heterogeneous. No included studies addressed the domain Equitable. CONCLUSIONS Applying the STEEEP framework to the published literature on assessment of individual hospitalist performance revealed strengths and weaknesses. Areas of strength were assessments of transitions of care and application of consensus guidelines. Other areas, such as equity and some components of safe practice, need development. All domains would benefit from more practical approaches. These findings should stimulate future work on feasibility of multidimensional assessment approaches.
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Affiliation(s)
- Alan W Dow
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Benjamin Chopski
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - John W Cyrus
- Tompkins-McCaw Library for the Health Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Laura E Paletta-Hobbs
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Rehan Qayyum
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
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13
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Luk A, Wang VN, Almazroa L, Foroutan F, Huebener N, Hillyer AG, Billia F, Ross H, Overgaard CB. Management of Acute Decompensated Heart Failure in the Cardiac Intensive Care Unit: The Importance of Co-management With a Heart Failure Specialist. CJC Open 2020; 2:229-235. [PMID: 32695973 PMCID: PMC7365826 DOI: 10.1016/j.cjco.2020.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background Heart failure (HF) is a common reason for admission to the cardiac intensive care unit. We sought to identify the role of an HF consultation service in improving the management of this patient population. Methods We identified all adult patients admitted to the cardiac intensive care unit (2014-2015) at the University Health Network with a diagnosis of acute decompensated HF ± cardiogenic shock (CS). Clinical characteristics and course were recorded. We calculated a propensity score–adjusted association between HF consultation and in-hospital mortality. Results A total of 285 unique patients were identified in our cohort. Of these, 82 (28.7%) died. A total of 150 patients (52.6%) were co-managed by an HF service, and 135 patients (47.3%) were not. Patients who were managed by an HF team were younger (52.5 vs 68.0 years, P < 0.0001), were more likely to be admitted with CS (61.3 vs 41.5%, P < 0.0009), and had higher rates of vasoactive medications during their admission (69.3% vs 52.6%, P < 0.005). At discharge, there were higher rates of discharge to a HF clinic (52.0% vs 27.5%, P < 0.0001) and prescription of guideline-directed medical therapy. In-hospital mortality was lower in those co-managed by a HF team (16.7% vs 42.2%, P < 0.0001). HF consultation reduced the odds of readmission by 76% (odds ratio, 0.24; 95% confidence interval, 0.13-0.47). Conclusions Patients managed by a HF team were more likely to be in CS at admission, to survive to discharge from hospital, and to be initiated on guideline-directed medical therapy with HF follow-up.
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14
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Saxon DT, Kennel PJ, Guyer HM, Goyal P, Hummel SL, Konerman MC. Specialty-Based Variability in Diagnosing and Managing Heart Failure With Preserved Ejection Fraction. Mayo Clin Proc 2020; 95:669-675. [PMID: 32247341 DOI: 10.1016/j.mayocp.2019.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/13/2019] [Accepted: 09/17/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To quantify differences in the diagnosis and treatment of heart failure with preserved ejection fraction (HFpEF) between cardiologists and noncardiologists, who often diagnose and manage HFpEF. METHODS Cardiologists and noncardiologists (internal medicine, medicine/pediatrics, family medicine, geriatrics) were anonymously surveyed between January 16, 2018, and March 2, 2018, regarding practices related to diagnosing and managing HFpEF at the University of Michigan and Weill Cornell Medical Center. Response data were compared using χ2 analysis. RESULTS Of 1010 physicians surveyed, 211 completed a significant portion of the survey: 32 cardiologists and 179 noncardiologists. Most noncardiologists were unaware of HFpEF diagnostic guidelines and commonly used left ventricular diastolic dysfunction and natriuretic peptides to diagnose HFpEF. Noncardiologists (32.3%, n=52) were less likely than cardiologists (64.5%, n= 20) to prescribe an aldosterone antagonist for HFpEF (P=.001). Both groups reported similar use of β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and exercise programs. Noncardiologists were more likely to refer patients with HFrEF to cardiology (63.1%, n=111) compared with patients with HFpEF (33.5%, n=59; P<.001). Noncardiologists were more likely to discuss prognosis and goals of care with patients with HFrEF (84.4%, n=151) than with patients with HFpEF (65.9%, n=118; P<.001). CONCLUSION Cardiologists and noncardiologists vary significantly in their HFpEF diagnosis and treatment practices. As diagnostic criteria continue to be evaluated for HFpEF, dissemination of these guidelines to noncardiologists, with an emphasis on the morbidity and mortality associated with HFpEF, is imperative.
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Affiliation(s)
- David T Saxon
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Peter J Kennel
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Heidi M Guyer
- Survey Research Center, University of Michigan, Ann Arbor, MI; RTI International, Durham, NC
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Scott L Hummel
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Ann Arbor Veterans Affairs Health System, Ann Arbor, MI
| | - Matthew C Konerman
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
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15
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Eberly LA, Richterman A, Beckett AG, Wispelwey B, Marsh RH, Cleveland Manchanda EC, Chang CY, Glynn RJ, Brooks KC, Boxer R, Kakoza R, Goldsmith J, Loscalzo J, Morse M, Lewis EF, Abel S, Adams A, Anaya J, Andrews EH, Atkinson B, Avutu V, Bachorik A, Badri O, Bailey M, Baird K, Bakshi S, Balaban D, Barshop K, Baumrin E, Bayomy O, Beamesderfer J, Becker N, Berg DD, Berman AN, Blum SM, Boardman AP, Boden K, Bonacci RA, Brown S, Campbell K, Case S, Cetrone E, Charrow A, Chiang D, Clark D, Cohen AJ, Cooper A, Cordova T, Cuneo CN, de Feria AA, Deffenbacher K, DeFilippis EM, DeGregorio G, Deutsch AJ, Diephuis B, Divakaran S, Dorschner P, Downing N, Drescher C, D'Silva KM, Dunbar P, Duong D, Earp S, Eckhardt C, Elman SA, England R, Everett K, Fedotova N, Feingold-Link T, Ferreira M, Fisher H, Foo P, Foote M, Franco I, Gilliland T, Greb J, Greco K, Grewal S, Grin B, Growdon ME, Guercio B, Hahn CK, Hasselfeld B, Haydu EJ, Hermes Z, Hildick-Smith G, Holcomb Z, Holroyd K, Horton L, Huang G, Jablonski S, Jacobs D, Jain N, Japa S, Joseph R, Kalashnikova M, Kalwani N, Kang D, Karan A, Katz JT, Kellner D, Kidia K, Kim JH, Knowles SM, Kolbe L, Kore I, Koullias Y, Kuye I, Lang J, Lawlor M, Lechner MG, Lee K, Lee S, Lee Z, Limaye N, Lin-Beckford S, Lipsyc M, Little J, Loewenthal J, Logaraj R, Lopez DM, Loriaux D, Lu Y, Ma K, Marukian N, Matias W, Mayers JR, McConnell I, McLaughlin M, Meade C, Meador C, Mehta A, Messenger E, Michaelidis C, Mirsky J, Mitten E, Mueller A, Mullur J, Munir A, Murphy E, Nagami E, Natarajan A, Nsahlai M, Nze C, Okwara N, Olds P, Paez R, Pardo M, Patel S, Petersen A, Phelan L, Pimenta E, Pipilas D, Plovanich M, Pong D, Powers BW, Rao A, Ramirez Batlle H, Ramsis M, Reichardt A, Reiger S, Rengarajan M, Rico S, Rome BN, Rosales R, Rotenstein L, Roy A, Royston S, Rozansky H, Rudder M, Ryan CE, Salgado S, Sanchez P, Schulte J, Sekar A, Semenkovich N, Shannon E, Shaw N, Shorten AB, Shrauner W, Sinnenberg L, Smithy JW, Snyder G, Sreekrishnan A, Stabenau H, Stavrou E, Stergachis A, Stern R, Stone A, Tabrizi S, Tanyos S, Thomas C, Thun H, Torres-Lockhart K, Tran A, Treasure C, Tsai FD, Tsaur S, Tschirhart E, Tuwatananurak J, Venkateswaran RV, Vishnevetsky A, Wahl L, Wall A, Wallace F, Walsh E, Wang P, Ward HB, Warner LN, Weeks LD, Weiskopf K, Wengrod J, Williams JN, Winkler M, Wong JL, Worster D, Wright A, Wunsch C, Wynter JS, Yarbrough C, Yau WY, Yazdi D, Yeh J, Yialamas MA, Yozamp N, Zambrotta M, Zon R. Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center. Circ Heart Fail 2019; 12:e006214. [PMID: 31658831 DOI: 10.1161/circheartfailure.119.006214] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. RESULTS Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. CONCLUSIONS Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.
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Affiliation(s)
- Lauren A Eberly
- University of Pennsylvania, Department of Medicine, Division of Cardiovascular Medicine, Philadelphia, PA (L.A.E.)
| | - Aaron Richterman
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Anne G Beckett
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Bram Wispelwey
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Regan H Marsh
- Department of Emergency Medicine (R.H.M., E.C.C.M., C.Y.C), Brigham and Women's Hospital, Boston, MA
| | | | - Cindy Y Chang
- Department of Emergency Medicine (R.H.M., E.C.C.M., C.Y.C), Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA (C.Y.C)
| | - Robert J Glynn
- Division of Preventive Medicine, Department of Medicine (R.J.G.), Brigham and Women's Hospital, Boston, MA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (R.J.G)
| | - Katherine C Brooks
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Robert Boxer
- Division of General Internal Medicine, Department of Medicine (R.B.), Brigham and Women's Hospital, Boston, MA
| | - Rose Kakoza
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Jennifer Goldsmith
- Division of Global Health Equity, Department of Medicine (J.G., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Joseph Loscalzo
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Michelle Morse
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA.,Division of Global Health Equity, Department of Medicine (J.G., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, and Department of Medicine (E.F..L.), Brigham and Women's Hospital, Boston, MA
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16
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Abstract
PURPOSE OF REVIEW Heart failure (HF) is the first cause of hospitalization in the elderly in Western countries, generating tremendous healthcare costs. Despite the spread of multidisciplinary post-discharge programs, readmission rates have remained unchanged over time. We review the recent developments in this setting. RECENT FINDINGS Recent data plead for global reorganization of HF care, specifically targeting patients at high risk for further readmission, as well as a stronger involvement of primary care providers (PCP) in patients' care plan. Besides, tools, devices, and new interdisciplinary expertise have emerged to support and be integrated into those programs; they have been greeted with great enthusiasm, but their routine applicability remains to be determined. HF programs in 2018 should focus on pragmatic assessments of patients that will benefit the most from the multidisciplinary care; delegating the management of low-risk patients to trained PCP and empowering the patient himself, using the newly available tools as needed.
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Affiliation(s)
- Nadia Bouabdallaoui
- Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000, Belanger East, Montreal, Quebec, H1T1C8, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000, Belanger East, Montreal, Quebec, H1T1C8, Canada.
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