Oropharyngeal microbiome profiling and its association with age and heart failure in the elderly population from the northernmost province of China

Respiratory tract infections are the most common triggers for heart failure in elderly people. The healthy respiratory commensal microbiota can prevent invasion by infectious pathogens and decrease the risk of respiratory tract infections. However, upper respiratory tract (URT) microbiome in the elderly is not well understood. To comprehend the profiles of URT microbiota in the elderly, and the link between the microbiome and heart failure, we investigated the oropharyngeal (OP) microbiome of these populations in Heilongjiang Province, located in the North-East of China, a high-latitude and cold area with a high prevalence of respiratory tract infection and heart failure. Taxonomy-based analysis showed that six dominant phyla were represented in the OP microbial profiles. Compared with young adults, the OP in the elderly exhibited a significantly different microbial community, mainly characterized by highly prevalent Streptococcus, unidentified_Saccharibacteria, Veillonella, unidentified_Pre votellaceae, and Neisseria. While unidentified_Prevotellaceae dominated in the young OP microbiome. There was competition for niche dominance between Streptococcus and member of Prevotellaceae in the OP. Correlation analysis revealed that the abundance of unidentified_Saccharibacteria was positive, while Streptococcus was negatively correlated to age among healthy elderly. The bacterial structure and abundance in the elderly with heart failure were much like healthy controls. Certain changes in microbial diversity indicated the potential OP microbial disorder in heart failure patients. These results presented here identify the respiratory tract core microbiota in high latitude and cold regions, and reveal the robustness of OP microbiome in the aged, supplying the basis for microbiome-targeted interventions.IMPORTANCETo date, we still lack available data on the oropharyngeal (OP) microbial communities in healthy populations, especially the elderly, in high latitude and cold regions. A better understanding of the significantly changed respiratory tract microbiota in aging can provide greater insight into characteristics of longevity and age-related diseases. In addition, determining the relationship between heart failure and OP microbiome may provide novel prevention and therapeutic strategies. Here, we compared OP microbiome in different age groups and elderly people with or without heart failure in northeastern China. We found that OP microbial communities are strongly linked to healthy aging. And the disease status of heart failure was not a powerful factor affecting OP microbiome. The findings may provide basic data to reveal respiratory bacterial signatures of individuals in a cold geographic region.

Comparison and use of explainable machine learning-based survival models for heart failure patients

Objective

Explainable machine learning (XAI) was introduced in this study to improve the interpretability, explainability and transparency of the modelling results. The survex package in R was used to interpret and compare two survival models - the Cox proportional hazards regression (coxph) model and the random survival forest (rfsrc) model - and to estimate overall survival (OS) and its determinants in heart failure (HF) patients using these models.

Methods

We selected 1159 HF patients hospitalised at the First Affiliated Hospital of Kunming Medical University. First, the performance of the two models was investigated using the C-index, the integrated C/D AUC, and the integrated Brier score. Second, a global explanation of the whole cohort was carried out using the time-dependent variable importance and the partial dependence survival profile. Finally, the SurvSHAP(t) and SurvLIME plots and the ceteris paribus survival profile were used to obtain a local explanation for each patient.

Results

By comparing the C-index, the C/D AUC, and the Brier score, this study showed that the model performance of rfsrc was better than coxph. The global explanation of the whole cohort suggests that the C-reactive protein, lg BNP (brain natriuretic peptide), estimated glomerular filtration rate, albumin, age and blood chloride were significant unfavourable predictors of OS in HF patients in both the cxoph and the rfsrc models. By including individual patients in the model, we can provide a local explanation for each patient, which guides the clinician in individualising the patient's treatment.

Conclusion

By comparison, we conclude that the model performance of rfsrc is better than that of coxph. These two predictive models, which address not only the whole population but also selected patients, can help clinicians personalise the treatment of each HF patient according to his or her specific situation.

Advanced lung cancer inflammation index combined with geriatric nutritional risk index predict all-cause mortality in heart failure patients

BACKGROUND

This study was undertaken to explore the predictive value of the advanced lung cancer inflammation index (ALI) combined with the geriatric nutritional risk index (GNRI) for all-cause mortality in patients with heart failure (HF).

METHODS AND RESULTS

We enrolled 1123 patients with HF admitted to our cardiology department from January 2017 to October 2021. Patients were divided into four groups, according to the median ALI and GNRI. From the analysis of the relationship between the ALI and GNRI, we concluded that there was a mild positive linear correlation (r = 0.348, p < 0.001) and no interaction (p = 0.140) between the ALI and GNRI. Kaplan‒Meier analysis showed that the cumulative incidence of all-cause mortality in patients with HF was highest in Group 1 (log-rank χ2 126.244, p < 0.001). Multivariate Cox proportional hazards analysis revealed that ALI and GNRI were independent predictors of all-cause mortality in HF patients (ALI: HR 0.407, 95% CI 0.296-0.560, p < 0.001; GNRI: HR 0.967, 95% CI 0.954-0.980, p < 0.001). The area under the curve (AUC) for ALI combined with GNRI was 0.711 (p < 0.001), according to the time-dependent ROC curve.

CONCLUSION

ALI and GNRI were independent predictors of all-cause mortality in HF patients. Patients with HF had the highest risk of all-cause mortality when the ALI was < 24.60 and the GNRI was < 94.41. ALI combined with the GNRI has good predictive value for the prognosis of HF patients.

Regulatory Relationships of Demographic, Clinical Characteristics and Quality of Care for Heart Failure Patients in Southern China

BACKGROUND

Quality of care for Chinese patients with heart failure was substandard. It is of utmost value to ascertain the characteristics related to quality of care to narrow the gap.

METHODS

Data from 2,064 heart failure patients between 1 January 2012 and 31 December 2015 at a hospital in Fujian Province were analyzed. Bayesian Network was used to assess the regulatory relationships between demographic, clinical characteristics and compliance with quality indicators.

RESULTS

The compliance with quality indicators ranged from 42.5% to 90.2%. The compliance with recommended doses for medications all reached or was close to 100% except indapamide. In Bayesian network, residence place, hypertension, troponin, B-type natriuretic peptide, heart rate, lung disease, number of emergency treatment, ejection fraction directly regulated the compliance and gender, age, medical payment method, myocardiopathy, coronary heart disease, arrhythmia had indirectly effect. The lower compliance was found in patients under emergency treatment, patients with abnormal testing indicators, patients without specific comorbidities and patients with NRCMS or self-paying. Patients with lung disease and those who lived in urban area had longer length of stay.

CONCLUSIONS

The compliance with medication indicators for heart failure were suboptimal, but recommended doses were prescribed in patients who received medications. A series of strategies should be developed to improve the quality of care, such as expanding the scope and depth of knowledge of guidelines and clinical pathway, integrating the reminder and quality assessment model into hospital medical record information system, paying more attention to vulnerable population and improving the medical security system.

Association between compliance with quality indicators and hospitalisation expenses in patients with heart failure: a retrospective study using quantile regression model in China

OBJECTIVE

To explore the association between compliance with quality indicators and hospitalisation expenses in patients with heart failure.

DESIGN

Generalised linear model and quantile regression model were used to examine the association between compliance with five quality indicators and hospitalisation expenses.

SETTING

Grade A hospital in Fujian Province, China.

PARTICIPANTS

Data on 2568 heart failure admissions between 2010 and 2015 were analysed.

RESULTS

The median (IQR) of hospitalisation expenses of 2568 patients was ¥10.9 (¥6.9-¥31.6) thousand. The rates of compliance with five quality indicators were 90.3% for evaluation of left ventricular function, 43.8% for diuretics, 62.0% for ACE inhibitors (ACEI) or angiotensin receptor blockers (ARB), 67.4% for beta-blockers, and 58.9% for aldosterone receptor antagonists. After adjustment for gender, age, residence, method of payment, number of diseases before admission, number of diseases at admission, number of emergency treatments during hospital stay and length of stay, patients who received evaluation for left ventricular function, diuretics, or ACEI or ARB had lower hospitalisation expenses, and patients who received beta-blockers had higher hospitalisation expenses, compared with their counterparts in generalised linear models. Differences in hospitalisation expenses between compliance and non-compliance with quality indicators became larger across quantile levels of hospitalisation expenses, and were found to be statistically significant when quantile level exceeded 0.80 (¥39.7 thousand) in quantile regression models.

CONCLUSIONS

The quality of care for patients with heart failure was below the target level. There was a negative relationship between compliance with quality indicators and hospitalisation expenses at the extreme quantile of expenses. More attention should be given to patients who may experience extreme expenses, and effective measures should be taken to improve the quality of care they receive.

Characteristics, Management, and Outcomes of Patients Hospitalized for Heart Failure in China: The China PEACE Retrospective Heart Failure Study

Background Heart failure (HF) is an emerging epidemic in China and accounts for significant healthcare resource utilization in the inpatient setting. To create evidence-based, life-saving, and cost-saving hospitalization systems, the first step is to characterize the contemporary national landscape of inpatient HF care. Methods and Results In the China PEACE 5r-HF study (China Patient-centered evaluative Assessment of Cardiac Events Retrospective Study of Heart Failure), we used 2-stage random sampling to create a nationally representative cohort of 10 004 admissions for HF from 189 hospitals in 2015 in China. Data on patient characteristics, management, and outcomes were obtained through centralized medical record abstraction. The median age of the cohort was 73 years (interquartile range, 65-80), and 48.9% were women. More than half (56.2%) of the patients were hospitalized in rural areas. Prevalence of ejection fraction ≥50%, 40% to 50%, and <40% was 60.3%, 17.7%, and 22.0%, respectively. We identified substantial gaps in care, including underutilization of diagnostic tests such as echocardiograms (63.6%), chest imaging (75.2%), and biomarker testing (56.4%), low prescription rates of guideline-recommended medications during hospitalization and at discharge, suboptimal rates of follow-up appointments (24.3%), and widespread utilization of traditional Chinese medicine (74.8%). The combined rate of in-hospital mortality and treatment withdrawal in our study was 3.5%, and median length-of-stay was 9 days (interquartile range, 7-13). Conclusions Patients admitted with acute HF in China have distinctive epidemiology and receive substandard care, but have low inpatient mortality despite long length of stay. These findings provide opportunities for streamlining efficiencies while improving quality of inpatient HF care in China. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02877914.

Palliative care needs of heart failure patients in China: putting people first

PURPOSE OF REVIEW

Recognizing the rising prevalence of heart failure in China, patients with heart failure have substantial palliative needs. This review highlights recent evidence on the epidemic of heart failure, identifies needs and potential benefit of palliative care in heart failure, and sets future strategic policy and research directions in China.

RECENT FINDINGS

Epidemiological studies demonstrate the prevalence of heart failure among women is higher than men in China and increases substantially with age. However, few studies have addressed the palliative needs of Chinese heart failure patients. The main themes from this review include: Healthcare providers should be culturally sensitive whenever assessing symptoms and needs. Locally validated, brief outcome measures are called for to identify symptoms and needs of Chinese heart failure patients. Palliative care should be better integrated into the management of heart failure through increased training for healthcare providers, policy development, financial support, and cultural acceptance of palliative care.

SUMMARY

Large-scale epidemiological studies are urgently needed to assess the current situation of heart failure in China, alongside interventional studies to drive the development of innovative palliative care services to address the needs of Chinese heart failure patients.

The China Patient-centred Evaluative Assessment of Cardiac Events (PEACE) prospective heart failure study design

INTRODUCTION

China faces the prospect of a large growth in the prevalence of heart failure (HF). However, there is limited knowledge about outcomes in patients after HF hospitalisations, including patient-reported outcomes (PROs). This paper is to present the study goal, methodology and data collection of the China Patient-centred Evaluative Assessment of Cardiac Events Prospective Heart Failure Study (China PEACE 5p-HF Study).

METHODS AND ANALYSIS

The China PEACE 5p-HF Study, a prospective cohort study, will enrol 5000 patients with HF during 2016-2018 from 52 diverse hospitals throughout China and the follow-up period will be 12 months. Information on patients' medical history, in-hospital treatment and in-hospital outcomes are being abstracted from medical records. Details of patients' demographics, socioeconomic status, cardiovascular risk factors, access to healthcare services are being collected through comprehensive baseline interviews. Generic and disease-specific health status, depression, stress, anxiety and cognitive function are being administered using validated PRO instruments. Follow-up interviews will capture PROs and hospitalisation events at 1, 6 and 12 months follow-up. Standardised transthoracic echocardiograms and 6 min walk tests are being done in patients who enrolled in hospitals with these facilities at baseline and at 1 and 12 months after discharge. Collection of blood and urine samples are also being conducted at baseline, 1 and 12 months follow-up and stored for future analyses.

ETHICS AND DISSEMINATION

The National Center for Cardiovascular Diseases/Fuwai Hospital ethics committee approved this study, and all collaborating hospitals received approval from their local ethics committee. Written informed consent will be obtained from all patients. Findings will be disseminated in future peer-reviewed papers and will help to support improvements in the quality of care for HF nationwide.

TRIAL REGISTRATION NUMBER

NCT02878811.

The China Patient-centered Evaluative Assessment of Cardiac Events (China PEACE) retrospective heart failure study design

INTRODUCTION

Heart failure (HF) is a leading cause of hospitalisation in China, which is experiencing a rapid increase in cardiovascular disease prevalence. Yet, little is known about current burden of disease, quality of care and treatment outcomes of HF in China. The objective of this paper is to describe the study methodology, data collection and abstraction, and progress to date of the China Patient-centered Evaluative Assessment of Cardiac Events 5 Retrospective Heart Failure Study (China PEACE 5r-HF).

METHODS AND ANALYSIS

The China PEACE 5r-HF Study will examine a nationally representative sample of more than 10 000 patient records hospitalised for HF in 2015 in China. The study is a retrospective cohort study. Patients have been selected using a two-stage sampling design stratified by economic-geographical regions. We will collect patient characteristics, diagnostic testing, treatments and in-hospital outcomes, including death and complications, and charges of hospitalisation. Data quality will be monitored by a central coordinating centre and will address case ascertainment, data abstraction and data management. As of October 2017, we have sampled 15 538 medical records from 189 hospitals, and have received 15 057 (96.9%) of these for data collection, and completed data abstraction and quality control on 7971.

ETHICS AND DISSEMINATION

The Central Ethics Committee at the Chinese National Center for Cardiovascular Diseases approved the study. All collaborating hospitals accepted central ethics committee approval with the exception of 15 hospitals, which obtained local approval by internal ethics committees. Findings will be disseminated in future peer-reviewed papers and will serve as a foundation for improving the care for HF in China.

TRIAL REGISTRATION NUMBER

NCT02877914.

Hospital quality measures: are process indicators associated with hospital standardized mortality ratios in French acute care hospitals?

Background

Results of associations between process and mortality indicators, both used for the external assessment of hospital care quality or public reporting, differ strongly across studies. However, most of those studies were conducted in North America or United Kingdom. Providing new evidence based on French data could fuel the international debate on quality of care indicators and help inform French policy-makers. The objective of our study was to explore whether optimal care delivery in French hospitals as assessed by their Hospital Process Indicators (HPIs) is associated with low Hospital Standardized Mortality Ratios (HSMRs).

Methods

The French National Authority for Health (HAS) routinely collects for each hospital located in France, a set of mandatory HPIs. Five HPIs were selected among the process indicators collected by the HAS in 2009. They were measured using random samples of 60 to 80 medical records from inpatients admitted between January 1st, 2009 and December 31, 2009 in respect with some selection criteria. HSMRs were estimated at 30, 60 and 90 days post-admission (dpa) using administrative health data extracted from the national health insurance information system (SNIIR-AM) which covers 77% of the French population. Associations between HPIs and HSMRs were assessed by Poisson regression models corrected for measurement errors with a simulation-extrapolation (SIMEX) method.

Results

Most associations studied were not statistically significant. Only two process indicators were found associated with HSMRs. Completeness and quality of anesthetic records was negatively associated with 30 dpa HSMR (0.72 [0.52–0.99]). Early detection of nutritional disorders was negatively associated with all HSMRs: 30 dpa HSMR (0.71 [0.54–0.95]), 60 dpa HSMR (0.51 [0.39–0.67]) and 90 dpa HSMR (0.52 [0.40–0.68]).

Conclusion

In absence of gold standard of quality of care measurement, the limited number of associations suggested to drive in-depth improvements in order to better determine associations between process and mortality indicators. A smart utilization of both process and outcomes indicators is mandatory to capture aspects of the hospital quality of care complexity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2534-3) contains supplementary material, which is available to authorized users.

Understanding the economic burden of heart failure in China: impact on disease management and resource utilization

INTRODUCTION AND OBJECTIVES

This study has two objectives: (1) to examine healthcare resource utilization in heart failure (HF) patients; and (2) to examine the treatment costs associated with HF in China.

METHODS

The data used in this study was from the 2014 national insurance database sponsored by the China Health Insurance Research Association (CHIRA), that covers national urban employees and residents. ICD-10 codes and keywords indicating heart failure diagnoses were used to identify patients with heart failure. Drug utilization, hospital visits, re-admission, and treatment costs in different service categories were examined.

RESULTS

A total of 7,847 patients were included in this analysis, of which 1,157 patients had a 1-year complete follow-up period. In total, 48.16% of patients received the combination treatment of angiotensin-converting-enzyme inhibitor (ACEI)/angiotensin II receptor blockers (ARB) and beta-blockers (BB); and 22.87% of patients received the combination treatment of ACEI/ARB, beta-blockers and Mineralocorticoid receptor antagonists (MRAs). The annual treatment cost per patient with HF diagnosis was RMB 28,974, of which 66% was for inpatient care. The cost on HF medications accounted for 8.2% of annual cost. Treatment cost was much higher in provincial-level municipalities than that of prefecture-level and other cities.

DISCUSSION AND CONCLUSION

Hospitalization is a major driver of HF treatment cost. Compared to the requirements in international treatment guidelines, HF standard of care medication treatment was under-utilized among HF patients in China. The high re-admission rate among Chinese patients indicates that the management of HF needs to be improved. The percentage of GDP spent on treating HF patients was much lower than that in the developed countries.

Heart failure in low- and middle-income countries: background, rationale, and design of the INTERnational Congestive Heart Failure Study (INTER-CHF)

BACKGROUND

Although heart failure (HF) has been referred to as a global epidemic, most HF information comes from high-income countries, with little information about low-income countries (LIC) and middle-income countries (MIC) in Africa, Asia, the Middle East, and South America, which make up the majority of the world's population.

METHODS

The INTERnational Congestive Heart Failure Study is a cohort study of 5,813 HF patients enrolled in 108 centers in 16 LIC and MIC. At baseline, data were recorded on sociodemographic and clinical risk factors, HF etiology, laboratory variables, management, and barriers to evidence-based HF care at the patient, physician, and system levels. We sought to enroll consecutive and consenting patients ≥18 years of age with a clinical diagnosis of HF seen in outpatient clinics (2/3 of patients) or inpatient hospital wards (1/3 of patients). Patients were followed up at 6 and 12 months post-enrollment to record clinical status, treatments, and clinical outcomes such as death and hospitalizations. In the 5,813 enrolled HF patients, the mean age was 59 ± 15 years, 40% were female, 62% had a history of hypertension, 30% had diabetes, 21% had prior myocardial infarction, 64% were recruited from outpatient clinics, 36% lived in rural areas, and 29% had HF with preserved left ventricular ejection fraction.

CONCLUSIONS

This unique HF registry aims to systematically gather information on sociodemographic and clinical risk factors, etiologies, treatments, barriers to evidence-based care, and outcomes of HF in LIC and MIC. This information will help improve the management of HF globally.