Trends in heart failure hospitalizations, patient characteristics, in-hospital and 1-year mortality: A population study, from 2000 to 2012 in Lombardy

Trends in age-specific and sex-specific pulmonary hypertension mortality in Italy between 2005 and 2017

AIMS

Data regarding the pulmonary hypertension (PH)-related mortality and relative trends in the Italian population remain scant. We sought to assess the PH mortality rates and relative trends among the Italian population between 2005 and 2017.

METHODS

Data regarding the cause-specific mortality and population size by sex in 5-year age groups were extracted from the WHO global mortality database. The age-standardized mortality rates, with relative 95% confidence intervals (CIs), also stratified by sex, were using the direct method. Joinpoint regression analyses were used to identify periods with statistically distinct log linear trends in PH-related death rates. To calculate nationwide annual trends in DCM-related mortality, we assessed the average annual percentage change (AAPC) and relative 95% CIs.

RESULTS

In Italy, the PH age-standardized annual mortality rate decreased from 2.34 (95% CI: 2.32-2.36) deaths per 100 000 to 1.51 (95% CI: 1.48-1.53) deaths per 100 000 population. Over the entire period, men had higher PH-related mortality rates than women. Moreover, the PH-related mortality trend rose with a seemingly exponential distribution with a similar trend among male and female individuals. Joinpoint regression analysis revealed a linear significant decrease in age-standardized PH-related mortality from 2005 to 2017 [AAPC: -3.1% (95% CI: -3.8 to -2.5), P  < 0.001] in the entire Italian population. However, the decline was more pronounced among men [AAPC: -5.0 (95% CI: -6.1 to -3.9), P  < 0.001] compared with women [AAPC: -1.5 (95% CI: -2.3 to -0.7), P  = 0.001].

CONCLUSION

In Italy, the PH-related mortality rates linearly declined from 2005 to 2017.

Head-to-head comparison of diagnostic scores for acute heart failure in the emergency department: results from the PARADISE cohort

BREST and PREDICA scores have recently emerged for the diagnosis of acute heart failure (AHF) in the emergency department (ED). This study aimed to perform a head-to-head comparison in a large contemporary cohort. BREST and PREDICA scores were calculated from, respectively, 11 and 8 routine clinical variables recorded in the ED in 1386 patients from the PArADIsE cohort. The diagnostic performance of the scores for adjudicated AHF diagnosis was assessed by the area under the ROC curve (AUC). Acute HF diagnosis was adjudicated according to the European Society of Cardiology criteria and BNP levels. A BREST score ≤ 3 or PREDICA score ≤ 1 was associated with low probabilities of AHF (5.7% and 2.6%, respectively). Conversely, a BREST score ≥ 9 or PREDICA score ≥ 5 was associated with a high risk of AHF diagnosis (77.3% and 66.9%, respectively) although more than half of the population was within the "gray zone" (4-8 and 2-4 for the BREST and PREDICA scores, respectively). Diagnostic performances of both scores were good (AUC 79.1%, [66.1-82.1] for the BREST score and 82.4%, [79.8-85.0] for the PREDICA score). PREDICA score had significantly higher diagnostic performance than BREST score (increase in AUC 3.3 [0.8-5.8], p = 0.009). Our study emphasizes the good diagnostic performance of both BREST and PREDICA scores, albeit with a significantly higher diagnostic performance of the PREDICA score. Yet, more than half of the population was classified within the "gray zone" by these scores; additional diagnostic tools are needed to ascertain AHF diagnosis in the ED in a majority of patients. Clinical trial registration: NCT02800122.

Increasing home-time after a first diagnosis of heart failure in Sweden, 20 years trends

AIMS

This study was performed to compare trends in home-time for patients with heart failure (HF) between those of working age and those of retirement age in Sweden from 1992 to 2012.

METHODS AND RESULTS

The National Inpatient Register (IPR) was used to identify all patients aged 18 to 84 years with a first hospitalization for HF in Sweden from 1992 to 2012. Information on date of death, comorbidities, and sociodemographic factors were collected from the Swedish National Register on Cause of Death, the IPR, and the longitudinal integration database for health insurance and labour market studies, respectively. The patients were divided into two groups according to their age: working age (<65 years) and retirement age (≥65 years). Follow-up was 4 years. In total, following exclusions, 388 775 patients aged 18 to 84 years who were alive 1 day after discharge from a first hospitalization for HF were included in the study. The working age group comprised 62 428 (16%) patients with a median age of 58 (interquartile range, 53-62) years and 31.2% women, and the retirement age group comprised 326 347 (84%) patients with a median age of 77 (interquartile range, 73-81) years and 47.4% women. Patients of working age had more home-time than patients of retirement age (83.8% vs. 68.2%, respectively), mainly because of their lower 4 year mortality rate (14.2% vs. 29.7%, respectively). Home-time increased over the study period for both age groups, but the increase levelled off for older women after 2007, most likely because of less reduction in mortality in older women than in the other groups.

CONCLUSIONS

This nationwide study showed increasing home-time over the study period except for women of retirement age and older for whom the increase stalled after 2007, mainly because of a lower mortality reduction in this group. Efforts to improve patient-related outcome measures specifically targeted to this group may be warranted.

Treatment prescription, adherence, and persistence after the first hospitalization for heart failure: A population-based retrospective study on 100785 patients

BACKGROUND

This study evaluates, in a real-world setting, to what extent the recommended therapies by international guidelines, are prescribed after a first hospitalization for heart failure (HF), and to analyse adherence and persistence, and the effect of treatment adherence on mortality and re-hospitalization.

METHODS

From the Lombardy healthcare administrative database, we analysed patients discharged after their incident HF, from 2000 to 2012. Adherence was defined as the proportion of days covered (PDC) ≥80% adjusted for hospitalizations and persistence as the absence of discontinuation of therapy for >30 days. A logit model was used to determine the effect of patients' adherence on mortality and readmissions.

RESULTS

Of 100422 HF patients (52% males, age 75 ± 12 years), 86846 (87%) had a prescription for angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACE/ARBs), 64135 (64%) for beta-blockers (BB), and 36893 (37%) for mineralocorticoid receptor antagonists (MRAs), as mono-, bi- or tri-therapy. In patients on monotherapy, PDC was 78 ± 22% for ACE/ARBs, 69 ± 29% for BB and 54 ± 29% for MRAs; in those on bi-therapy, PDC was 63 ± 31% for ACEI/ARBs+BB, 41 ± 29% for ACEI/ARBs+MRAs, and 40 ± 26% for MRAs+BB; for patients on tri-therapy, PDC was 42 ± 28%. Medication persistence was present in 47% of patients treated with ACEI/ARBs, in 35% of patients treated with BB and in 14% of patients treated with MRAs. Re-hospitalizations and in mortality were significantly reduced in adherent patients (p < 0.000).

CONCLUSIONS

Polypharmacy is associated with an increased rate of non-adherence and non-persistence in incident HF. Non-adherence is associated with an increased risk of mortality and re-hospitalizations.

Non-parametric frailty Cox models for hierarchical time-to-event data

We propose a novel model for hierarchical time-to-event data, for example, healthcare data in which patients are grouped by their healthcare provider. The most common model for this kind of data is the Cox proportional hazard model, with frailties that are common to patients in the same group and given a parametric distribution. We relax the parametric frailty assumption in this class of models by using a non-parametric discrete distribution. This improves the flexibility of the model by allowing very general frailty distributions and enables the data to be clustered into groups of healthcare providers with a similar frailty. A tailored Expectation-Maximization algorithm is proposed for estimating the model parameters, methods of model selection are compared, and the code is assessed in simulation studies. This model is particularly useful for administrative data in which there are a limited number of covariates available to explain the heterogeneity associated with the risk of the event. We apply the model to a clinical administrative database recording times to hospital readmission, and related covariates, for patients previously admitted once to hospital for heart failure, and we explore latent clustering structures among healthcare providers.

Multi-level models for heart failure patients' 30-day mortality and readmission rates: the relation between patient and hospital factors in administrative data

Background

This study aims at gathering evidence about the relation between 30-day mortality and 30-day unplanned readmission and patient and hospital factors. By definition, we refer to 30-day mortality and 30-day unplanned readmission as the number of deaths and non-programmed hospitalizations for any cause within 30 days after the incident heart failure (HF). In particular, the focus is on the role played by hospital-level factors.

Methods

A multi-level logistic model that combines patient- and hospital-level covariates has been developed to better disentangle the role played by the two groups of covariates. Later on, hospital outliers in term of better-than-expected/worst-than-expected performers have been identified by comparing expected cases vs. observed cases. Hospitals performance in terms of 30-day mortality and 30-day unplanned readmission rates have been visualized through the creation of funnel plots. Covariates have been selected coherently to past literature. Data comes from the hospital discharge forms for Heart Failure patients in the Lombardy Region (Northern Italy). Considering incident cases for HF in the timespan 2010–2012, 78,907 records for adult patients from 117 hospitals have been collected after quality checks.

Results

Our results show that 30-day mortality and 30-day unplanned readmissions are explained by hospital-level covariates, paving the way for the design and implementation of evidence-based improvement strategies. While the percentage of surgical DRG (OR = 1.001; CI (1.000–1.002)) and the hospital type of structure (Research hospitals vs. non-research public hospitals (OR = 0.62; CI (0.48–0.80)) and Non-research private hospitals vs. non-research hospitals OR = 0.75; CI (0.63–0.90)) are significant for mortality, the mean length of stay (OR = 0.96; CI (0.95–0.98)) is significant for unplanned readmission, showing that mortality and readmission rates might be improved through different strategies.

Conclusion

Our results confirm that hospital-level covariates do affect quality of care, and that 30-day mortality and 30-day unplanned readmission are affected by different managerial choices. This confirms that hospitals should be accountable for their “added value” to quality of care.

Significant and constant increase in hospitalization due to heart failure in Spain over 15 year period

BACKGROUND

To examine trends in the incidence, characteristics, and in-hospital outcomes of heart failure (HF) hospitalizations from 2001 to 2015 in Spain.

METHODS

Using the Spanish National Hospital Discharge Database (SNHDD) we selected admissions with a primary or secondary diagnosis of HF. The primary end points were trends in the incidence of hospitalizations and in-hospital mortality (IHM). Trends with primary and secondary diagnosis of HF were evaluated separately.

RESULTS

The incidence of HF coding increased significantly from 466.16 cases per 100,000 inhabitants in 2001-03 to 780.4 in 2013-15 (p < .001). Age increased over time (76.33 ± 10.92 years in 2001-03 vs. 79.4 ± 10.78 years in 2013-15; p < .001). We found a decrease in the percentage of women over the study period (53.07% vs. 52%; p < .001). We detected a significant increase in comorbidity according to the Charlson Comorbidity Index over time (mean 2.17 ± 0.98 in 2001-03 vs. 2.46 ± 1.04 in 2013-15). The most common associated comorbidities were atrial fibrillation (42.23%), hypertension (38.87%) and type 2 diabetes (34.3%). For the total time period, IHM was 12.79%. IHM decreased significantly over time from 13.47% in 2001-03 to 12.30% in 2013-15. Patients with HF coded as a secondary diagnosis have 66% higher risk of dying in the hospital that those with HF coded as a primary diagnosis.

CONCLUSIONS

This research shows an increase of hospitalizations due to HF in Spain, particularly in patients with HF as a secondary diagnosis. Advance age and comorbidity in acute HF has increased in the recent years. However, IHM is decreasing while readmissions remain stable.

Impact of in-hospital cardiac rehabilitation on mortality and readmissions in heart failure: A population study in Lombardy, Italy, from 2005 to 2012

Aims

The 2016 European guidelines for the diagnosis and treatment of heart failure classified cardiac rehabilitation as a mandatory class I intervention. We aimed to analyse in heart failure patients the impact of an in-hospital cardiac rehabilitation programme on all-cause mortality and readmissions.

Methods

From the Lombardy healthcare administrative database, we analysed in patients with incident heart failure, from 2005 to 2012, the number of all hospitalisations, cardiac rehabilitation admissions, post-discharge deaths, outpatient drug prescriptions and visits. We divided patients into hospitalised for heart failure in acute care only (group A) versus patients with one or more admission to cardiac rehabilitation for an in-hospital cardiac rehabilitation programme (group B).

Results

Of 140,552 incident cases, 100,843 (71%) were in group A and 39,709 (29%) in group B. Patients in group B had 3.26 ± 1.78 admissions to acute care before referral to an in-hospital cardiac rehabilitation programme. Male gender, age in women and comorbidities (more than two) were higher in group B ( P < 0.0001). Patients in group B had a higher number of interventional procedures ( P < 0.0001), drug prescription and outpatient visit rate ( P < 0.0001). Total mortality was 30% in group A versus 29% in group B. At Cox and logistic regression analyses, after adjustment for covariates, group B had a significantly lower risk of mortality (hazard ratio 0.5768, 95% confidence interval 0.5650–0.5888, P < 0.0001) and readmissions (0.7997, 0.7758–0.8244, P < 0.0001) than group A.

Conclusion

This study showed in a large population of heart failure patients that in-hospital cardiac rehabilitation is associated with a reduction of all-cause mortality and rehospitalisations in heart failure. Given its potential significant benefit, referral of heart failure patients to an in-hospital cardiac rehabilitation programme should be promoted.

Moving From Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients With Multiple Comorbidities and Older Age

This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.

Population-based Study of First Hospitalizations for Heart Failure and the Interaction Between Readmissions and Survival

INTRODUCTION AND OBJECTIVES

Disease progression in patients after a first hospitalization for heart failure (HF), in particular the interaction between survival and rehospitalizations, is not well established.

METHODS

We studied all patients with a first hospitalization and main diagnosis of HF from 2009 to 2013 by analyzing the Minimum Data Set of the Region of Murcia. Both incident and recurrent patients were studied, and the trend in hospitalization rates was calculated by joinpoint regression. Patients were followed-up through their health cards until the end of 2015. Mortality and readmissions, including causes and chronology in relation to the time of death, were assessed.

RESULTS

A total of 8258 incident patients were identified, with annual rates increasing (+2.3%, P <.05) up to 1.24 patients per 1000 inhabitants, representing 71% of hospitalized individuals and 57% of total discharges due to HF. In the first year, 22% were readmitted due to HF, 31% due to cardiovascular causes, and 54% due to any cause. Five-year survival was 40%, which was significantly lower than age- and sex-adjusted expected survival for the general population (76%) (P <.001). Among patients who died during follow-up, readmissions (1.5 per patient/y, 0.4 due to HF) showed a "J" pattern, with 48% of rehospitalizations being concentrated in the last 3 deciles of survival prior to death.

CONCLUSIONS

Rates of first hospitalization due to HF continue to increase, with high mortality and rehospitalizations during follow-up, which are concentrated mainly in the period prior to death.

Female gender and mortality risk in decompensated heart failure

BACKGROUND

Still there is conflicting evidence about gender-related differences in prognosis among patients with heart failure. This prognostic uncertainty may have implications for risk stratification and planning management strategy. The aim of the present study was to explore the association between gender and one-year mortality in patients admitted with acute decompensated heart failure (ADHF).

METHODS

We studied 1513 patients. The Cumulative Incidence Function (CIF) method was used to estimate the absolute rate of mortality, heart transplantation (HT)/ventricular assist device (VAD) implantation, and survival free of HT/VAD implantation at 1year. An interaction analysis was performed to assess the association between covariates, gender, and mortality risk. Propensity score matching and Cox regression were used to compare mortality rates in the gender subgroups.

RESULTS

The CIF estimates of 1-year mortality, HT/VAD implantation, and survival free of HT/VAD implantation at 1year were 33.1%, 7.0%, and 59.9% for women and 30.2%, 10.2%, and 59.6% for men, respectively. Except for diabetes, there was no significant interaction between gender, covariates, and mortality risk. In the matched cohort, the hazard ratio of death for women was 1.19 (95% confidence intervals [CIs]: 0.90-1.59; p=.202). After adjusting for age and baseline risk, the hazard ratio of death for women was 1.18 (95% CIs: 0.95-1.43; p=.127). The use of gender-specific predictive models did not allow improving the accuracy of risk prediction.

CONCLUSIONS

Our data strongly suggest that women and men have comparable outcome in the year following a hospitalization for ADHF.

Hyponatraemia, hyperglycaemia and worsening renal function at first blood sample on emergency department admission as predictors of in-hospital death in patients with dyspnoea with suspected acute heart failure: retrospective observational analysis of the PARADISE cohort

OBJECTIVES

To assess the prognostic value of hyponatraemia, hyperglycaemia and impaired estimated glomerular filtration rate (eGFR) in predicting in-hospital death in patients with acute heart failure (AHF) admitted for acute dyspnoea in the emergency department.

DESIGN

Retrospective observational study.

SETTING

Emergency Department of the University Hospital of Nancy. Data were collected from August 2013 to October 2015.

PARTICIPANTS

The analysis included 405 patients with AHF admitted for acute dyspnoea in an emergency department.

RESULTS

The population was elderly (mean age 82 years), 20.1% had hyponatraemia, 45.1% had hyperglycaemia and 48.6% had eGFR <50 mL/min/1.73 m². Sixty-one patients (15.1%) died in hospital, mostly due to cardiac aetiology (58.3%). In multivariable analysis adjusted for key potential confounders, adjusted hyponatraemia (OR=2.40, (1.16 to 4.98), p=0.02), hyperglycaemia (OR=2.00, 1.06 to 3.76, p=0.03) and eGFR <50 mL/min/1.73 m² (OR=1.97 (1.00 to 3.80), p=0.04*) were all identified as significant independent predictors of in-hospital death.

CONCLUSIONS

Results of basic routine laboratory tests (hyponatraemia, hyperglycaemia and impaired eGFR) performed on admission in the emergency department are independently associated with in-hospital death. These inexpensive tests, performed as early as patient admission in the emergency department, could allow the early identification of patients admitted for AHF who are at high risk of in-hospital death.

TRIAL REGISTRATION NUMBER

NCT02800122.