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Pang PS, Berger DA, Mahler SA, Li X, Pressler SJ, Lane KA, Bischof JJ, Char D, Diercks D, Jones AE, Hess EP, Levy P, Miller JB, Venkat A, Harrison NE, Collins SP. Short-Stay Units vs Routine Admission From the Emergency Department in Patients With Acute Heart Failure: The SSU-AHF Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2350511. [PMID: 38198141 PMCID: PMC10782263 DOI: 10.1001/jamanetworkopen.2023.50511] [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: 09/06/2023] [Accepted: 11/15/2023] [Indexed: 01/11/2024] Open
Abstract
Importance More than 80% of patients who present to the emergency department (ED) with acute heart failure (AHF) are hospitalized. With more than 1 million annual hospitalizations for AHF in the US, safe and effective alternatives are needed. Care for AHF in short-stay units (SSUs) may be safe and more efficient than hospitalization, especially for lower-risk patients, but randomized clinical trial data are lacking. Objective To compare the effectiveness of SSU care vs hospitalization in lower-risk patients with AHF. Design, Setting, and Participants This multicenter randomized clinical trial randomly assigned low-risk patients with AHF 1:1 to SSU or hospital admission from the ED. Patients received follow-up at 30 and 90 days post discharge. The study began December 6, 2017, and was completed on July 22, 2021. The data were analyzed between March 27, 2020, and November 11, 2023. Intervention Randomized post-ED disposition to less than 24 hours of SSU care vs hospitalization. Main Outcomes and Measures The study was designed to detect at least 1-day superiority for a primary outcome of days alive and out of hospital (DAOOH) at 30-day follow-up for 534 participants, with an allowance of 10% participant attrition. Due to the COVID-19 pandemic, enrollment was truncated at 194 participants. Before unmasking, the primary outcome was changed from DAOOH to an outcome with adequate statistical power: quality of life as measured by the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). The KCCQ-12 scores range from 0 to 100, with higher scores indicating better quality of life. Results Of the 193 patients enrolled (1 was found ineligible after randomization), the mean (SD) age was 64.8 (14.8) years, 79 (40.9%) were women, and 114 (59.1%) were men. Baseline characteristics were balanced between arms. The mean (SD) KCCQ-12 summary score between the SSU and hospitalization arms at 30 days was 51.3 (25.7) vs 45.8 (23.8) points, respectively (P = .19). Participants in the SSU arm had 1.6 more DAOOH at 30-day follow-up than those in the hospitalization arm (median [IQR], 26.9 [24.4-28.8] vs 25.4 [22.0-27.7] days; P = .02). Adverse events were uncommon and similar in both arms. Conclusions and Relevance The findings show that the SSU strategy was no different than hospitalization with regard to KCCQ-12 score, superior for more DAOOH, and safe for lower-risk patients with AHF. These findings of lower health care utilization with the SSU strategy need to be definitively tested in an adequately powered study. Trial Registration ClinicalTrials.gov Identifier: NCT03302910.
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Affiliation(s)
- Peter S. Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - David A. Berger
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Simon A. Mahler
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | | | - Kathleen A. Lane
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Douglas Char
- Department of Emergency Medicine, Washington University in St Louis, St Louis, Missouri
| | - Deborah Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson
| | - Erik P. Hess
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Phillip Levy
- Wayne State University School of Medicine and Integrative Biosciences Center, Detroit, Michigan
| | - Joseph B. Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nicholas E. Harrison
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine and Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, Tennessee
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Savitz ST, Chamberlain AM, Dunlay S, Manemann SM, Weston SA, Kurani S, Roger VL. Co-Occurrence of Social Risk Factors and Associated Outcomes in Patients With Heart Failure. J Am Heart Assoc 2023:e028734. [PMID: 37421274 PMCID: PMC10382086 DOI: 10.1161/jaha.122.028734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 05/15/2023] [Indexed: 07/10/2023]
Abstract
Background Among patients with heart failure (HF), social risk factors (SRFs) are associated with poor outcomes. However, less is known about how co-occurrence of SRFs affect all-cause health care utilization for patients with HF. The objective was to address this gap using a novel approach to classify co-occurrence of SRFs. Methods and Results This was a cohort study of residents living in an 11-county region of southeast Minnesota, aged ≥18 years with a first-ever diagnosis for HF between January 2013 and June 2017. SRFs, including education, health literacy, social isolation, and race and ethnicity, were obtained via surveys. Area-deprivation index and rural-urban commuting area codes were determined from patient addresses. Associations between SRFs and outcomes (emergency department visits and hospitalizations) were assessed using Andersen-Gill models. Latent class analysis was used to identify subgroups of SRFs; associations with outcomes were examined. A total of 3142 patients with HF (mean age, 73.4 years; 45% women) had SRF data available. The SRFs with the strongest association with hospitalizations were education, social isolation, and area-deprivation index. We identified 4 groups using latent class analysis, with group 3, characterized by more SRFs, at increased risk of emergency department visits (hazard ratio [HR], 1.33 [95% CI, 1.23-1.45]) and hospitalizations (HR, 1.42 [95% CI, 1.28-1.58]). Conclusions Low educational attainment, high social isolation, and high area-deprivation index had the strongest associations. We identified meaningful subgroups with respect to SRFs, and these subgroups were associated with outcomes. These findings suggest that it is possible to apply latent class analysis to better understand the co-occurrence of SRFs among patients with HF.
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Affiliation(s)
- Samuel T Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN USA
- Division of Health Care Delivery Research Mayo Clinic Rochester MN USA
| | - Alanna M Chamberlain
- Division of Epidemiology, Department of Quantitative Health Sciences Mayo Clinic Rochester MN USA
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | - Shannon Dunlay
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN USA
- Division of Health Care Delivery Research Mayo Clinic Rochester MN USA
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | - Sheila M Manemann
- Division of Epidemiology, Department of Quantitative Health Sciences Mayo Clinic Rochester MN USA
| | - Susan A Weston
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences Mayo Clinic Rochester MN USA
| | - Shaheen Kurani
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN USA
- Division of Health Care Delivery Research Mayo Clinic Rochester MN USA
| | - Véronique L Roger
- Division of Epidemiology, Department of Quantitative Health Sciences Mayo Clinic Rochester MN USA
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
- National Heart, Lung, and Blood Institute Bethesda MD USA
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Solnick RE, Vijayasiri G, Li Y, Kocher KE, Jenq G, Bozaan D. Emergency department returns and early follow-up visits after heart failure hospitalization: Cohort study examining the role of race. PLoS One 2022; 17:e0279394. [PMID: 36548344 PMCID: PMC9778499 DOI: 10.1371/journal.pone.0279394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
Health disparities in heart failure (HF) show that Black patients face greater ED utilization and worse clinical outcomes. Transitional care post-HF hospitalization, such as 7-day early follow-up visits, may prevent ED returns. We examine whether early follow-up is associated with lower ED returns visits within 30 days and whether Black race is associated with receiving early follow-up after HF hospitalization. This was a retrospective cohort analysis of all Black and White adult patients at 13 hospitals in Michigan hospitalized for HF from October 1, 2017, to September 30, 2020. Adjusted risk ratios (aRR) were estimated from multivariable logistic regressions. The analytic sample comprised 6,493 patients (mean age = 71 years (SD 15), 50% female, 37% Black, 9% Medicaid). Ten percent had an ED return within 30 days and almost half (43%) of patients had 7-day early follow-up. Patients with early follow-up had lower risk of ED returns (aRR 0.85 [95%CI, 0.71-0.98]). Regarding rates of early follow-up, there was no overall adjusted association with Black race, but the following variables were related to lower follow-up: Medicaid insurance (aRR 0.90 [95%CI, 0.80-1.00]), dialysis (aRR 0.86 [95%CI, 0.77-0.96]), depression (aRR 0.92 [95%CI, 0.86-0.98]), and discharged with opioids (aRR 0.94 [95%CI, 0.88-1.00]). When considering a hospital-level interaction, three of the 13 sites with the lowest percentage of Black patients had lower rates of early follow-up in Black patients (ranging from 15% to 55% reduced likelihood). Early follow-up visits were associated with a lower likelihood of ED returns for HF patients. Despite this potentially protective association, certain patient factors were associated with being less likely to receive scheduled follow-up visits. Hospitals with lower percentages of Black patients had lower rates of early follow-up for Black patients. Together, these may represent missed opportunities to intervene in high-risk groups to prevent ED returns in patients with HF.
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Affiliation(s)
- Rachel E. Solnick
- Department of Emergency Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States of America
- Now at Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States of America
- * E-mail:
| | - Ganga Vijayasiri
- Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT), Michigan Medicine, Ann Arbor, MI, United States of America
| | - Yiting Li
- Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT), Michigan Medicine, Ann Arbor, MI, United States of America
| | - Keith E. Kocher
- Department of Emergency Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States of America
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States of America
- Department of Learning Health Sciences, School of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Grace Jenq
- Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT), Michigan Medicine, Ann Arbor, MI, United States of America
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - David Bozaan
- Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT), Michigan Medicine, Ann Arbor, MI, United States of America
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, United States of America
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
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Berkman ND, Chang E, Seibert J, Ali R. Characteristics of High-Need, High-Cost Patients : A "Best-Fit" Framework Synthesis. Ann Intern Med 2022; 175:1728-1741. [PMID: 36343343 DOI: 10.7326/m21-4562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Accurately identifying high-need, high-cost (HNHC) patients to reduce their preventable or modifiable health care use for their chronic conditions is a priority and a challenge for U.S. policymakers, health care delivery systems, and payers. PURPOSE To identify characteristics and criteria to distinguish HNHC patients. DATA SOURCES Searches of multiple databases and gray literature from 1 January 2000 to 22 January 2022. STUDY SELECTION English-language studies of characteristics and criteria to identify HNHC adult patients, defined as those with high use (emergency department, inpatient, or total services) or high cost. DATA EXTRACTION Independent, dual-review extraction and quality assessment. DATA SYNTHESIS The review included 64 studies comprising multivariate exposure studies (n = 47), cluster analyses (n = 11), and qualitative studies (n = 6). A National Academy of Medicine (NAM) taxonomy was an initial "best-fit" framework for organizing the synthesis of the findings. Patient characteristics associated with being HNHC included number and severity of comorbid conditions and having chronic clinical conditions, particularly heart disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and hypertension. Patients' risk for being HNHC was often amplified by behavioral health conditions and social risk factors. The reviewers revised the NAM taxonomy to create a final framework, adding chronic pain and prior patterns of high health care use as characteristics associated with an increased risk for being HNHC. LIMITATION Little evidence distinguished potentially preventable or modifiable health care use from overall use. CONCLUSION A combination of characteristics can be useful for identifying HNHC patients. Because of the complexity of their conditions and circumstances, improving their quality of care will likely also require an individualized assessment of care needs and availability of support services. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality. (PROSPERO: CRD42020161179).
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Affiliation(s)
- Nancy D Berkman
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, North Carolina (N.D.B., R.A.)
| | - Eva Chang
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, North Carolina, and Advocate Aurora Health, Advocate Aurora Research Institute, Downers Grove, Illinois (E.C.)
| | - Julie Seibert
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, and North Carolina Department of Health and Human Services, Division of Mental Health, Developmental Disability and Substance Abuse Services, Raleigh, North Carolina (J.S.)
| | - Rania Ali
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, North Carolina (N.D.B., R.A.)
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Ro A, Huynh MP, Bruckner TA, Du S, Young A. COVID-19 case counts and COVID-19 related Emergency Department visits: differences by immigration status, March-December 2020. BMC Public Health 2022; 22:1965. [PMID: 36289476 PMCID: PMC9607655 DOI: 10.1186/s12889-022-14345-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/08/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022] Open
Abstract
Background Undocumented immigrants face barriers to health care access, which may have been exacerbated during the early days of the COVID-19 pandemic. We test whether undocumented immigrants in Los Angeles County accessed COVID-19 related medical care by examining their Emergency Department (ED) patterns through high and low periods of COVID-19 infection. If undocumented immigrants were underutilizing or foregoing health care, we expect null or weaker associations between COVID-19 cases and COVID-19 related ED visits relative to Medi-Cal patients. Methods We analyzed all ED visits to the Los Angeles County + University of Southern California (LAC + USC) Medical Center between March - December 2020 (n = 85,387). We conducted logistic regressions with Los Angeles County weekly COVID-19 case counts as our main independent variable and an interaction between case counts and immigration status, stratified by age (over and under 65 years). Results We found that undocumented immigrants under 65 years old had a higher odds for a COVID-19 related ED visit compared to Medi-Cal patients and that both undocumented and Medi-Cal patients had higher odds of a COVID-19 related ED visit as COVID-19 cases in Los Angeles County increased. For patients over 65 years, Medi-Cal patients actually had a weaker association between ED visits and county COVID-19 counts; as COVID-19 case counts rose, the odds of a COVID-19 related ED visit increased for the undocumented patients. Conclusion While the overall likelihood of undocumented patients having a COVID-19 related ED visit varies compared to Medi-Cal patients - for younger patients, the odds is higher; for older patients, the odds is lower - it does not appear that undocumented patients underutilized the ED during the early COVID-19 pandemic relative to Medi-Cal patients. The ED may be a viable source of contact for this high-risk population for future outreach.
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Affiliation(s)
- Annie Ro
- grid.266093.80000 0001 0668 7243UC Irvine Program in Public Health, Department of Health, Society, and Behavior Anteater Instruction and Research Building (AIRB), Room 2036 653 E. Peltason Road, 92597 Irvine, CA USA
| | - Michael Pham Huynh
- grid.266093.80000 0001 0668 7243UC Irvine Program in Public Health, Department of Health, Society, and Behavior Anteater Instruction and Research Building (AIRB), Room 2036 653 E. Peltason Road, 92597 Irvine, CA USA
| | - Tim A. Bruckner
- grid.266093.80000 0001 0668 7243UC Irvine Program in Public Health, Department of Health, Society, and Behavior Center for Population, Inequality, and Policy, Anteater Instruction and Research Building (AIRB), 653 E. Peltason Road, 92597 Irvine, CA USA
| | - Senxi Du
- grid.42505.360000 0001 2156 6853Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | - Andrew Young
- grid.42505.360000 0001 2156 6853Division of Geriatric, Hospital, Palliative and General Internal Medicine, Department of Medicine, Keck School of Medicine of USC, Los Angeles, CA USA
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6
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Molina M, Evans J, Montoy JC, Cawley C, Graham-Squire D, Perez K, Raven M, Kanzaria HK. Analysis of Emergency Department Encounters Among High Users of Health Care and Social Service Systems Before and During the COVID-19 Pandemic. JAMA Netw Open 2022; 5:e2239076. [PMID: 36306131 PMCID: PMC9617170 DOI: 10.1001/jamanetworkopen.2022.39076] [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] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Although the general US population had fewer emergency department (ED) visits during the COVID-19 pandemic, patterns of use among high users are unknown. OBJECTIVES To examine natural trends in ED visits among high users of health and social services during an extended period and assess whether these trends differed during COVID-19. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study combined data from 9 unique cohorts, 1 for each fiscal year (July 1 to June 30) from 2012 to 2021, and used mixed-effects, negative binomial regression to model ED visits over time and assess ED use among the top 5% of high users of multiple systems during COVID-19. Data were obtained from the Coordinated Care Management System, a San Francisco Department of Public Health platform that integrates medical and social information with service use. EXPOSURES Fiscal year 2020 was defined as the COVID-19 year. MAIN OUTCOMES AND MEASURES Measured variables were age, gender, language, race and ethnicity, homelessness, insurance status, jail health encounters, mental health and substance use diagnoses, and mortality. The main outcome was annual mean ED visit counts. Incidence rate ratios (IRRs) were used to describe changes in ED visit rates both over time and in COVID-19 vs non-COVID-19 years. RESULTS Of the 8967 participants, 3289 (36.7%) identified as White, 3005 (33.5%) as Black, and 1513 (16.9%) as Latinx; and 7932 (88.5%) preferred English. The mean (SD) age was 46.7 (14.2) years, 6071 (67.7%) identified as men, and 7042 (78.5%) had experienced homelessness. A statistically significant decrease was found in annual mean ED visits among high users for every year of follow-up until year 8, with the largest decrease occurring in the first year of follow-up (IRR, 0.41; 95% CI, 0.40-0.43). However, during the pandemic, ED visits decreased 25% beyond the mean reduction seen in prepandemic years (IRR, 0.75; 95% CI, 0.72-0.79). CONCLUSIONS AND RELEVANCE In this study, multiple cohorts of the top 5% of high users of multiple health care systems in San Francisco had sustained annual decreases in ED visits from 2012 to 2021, with significantly greater decreases during COVID-19. Further research is needed to elucidate pandemic-specific factors associated with these findings and understand how this change in use was associated with health outcomes.
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Affiliation(s)
- Melanie Molina
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Jennifer Evans
- Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations, University of California, San Francisco
| | - Juan Carlos Montoy
- Department of Emergency Medicine, University of California, San Francisco
| | - Caroline Cawley
- Department of Emergency Medicine, University of California, San Francisco
- Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations, University of California, San Francisco
- Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Dave Graham-Squire
- Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations, University of California, San Francisco
| | - Kenneth Perez
- Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations, University of California, San Francisco
| | - Maria Raven
- Department of Emergency Medicine, University of California, San Francisco
- Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
- Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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Zhang X, Qiu P, Prushinskaya A, Jiang Y, Fan H, Yang S. Characteristics of emergency department admissions with congestive heart failure in the United States: a Nationwide cross-sectional study. BMC Emerg Med 2022; 22:16. [PMID: 35090395 PMCID: PMC8795967 DOI: 10.1186/s12873-021-00564-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/24/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To understand the characteristics and clinical presentation of patients with Congestive Heart Failure (CHF) visiting the emergency department (ED), and to examine the factors associated with clinical outcomes and medical resource utilization amongst the studied population.
Methods
We analyzed the 2014–2016 ED visit data collected by the National Hospital Ambulatory Medical Care Survey Emergency Department Subfile. We described patients’ characteristics and clinical outcomes after ED visits with CHF vs. without CHF. Logistic regression models were used to estimate the association between these characteristics and CHF.
Results
ED visits with CHF visits represented 3.9% of annual ED visits (3,647,113 out of 92,899,685). ED patients with CHF were mostly non-Hispanic White (69.9%). Compared with other ED patients, those with CHF were older, including 71.2% that were were older than 60. ED patients with CHF were more likely to be admitted to the hospital (aOR: 2.56; 95% CI: 2.28–2.87) and intensive care unit (ICU) (aOR: 2.19; 95% CI: 1.77–2.71).
Conclusions
This study describes the demographic, socioeconic, and clinical characteristics of patients who present to the ED with CHF through analysis of a comprehensive national survey. These patients require a higher level of emergency care due to their higher chance of admittance to the hospital and ICU.
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Shah A, Mentz RJ, Sun JL, Rao VN, Alhanti B, Blumer V, Starling R, Butler J, Greene SJ. Emergency Department Visits Versus Hospital Readmissions Among Patients Hospitalized for Heart Failure. J Card Fail 2022; 28:916-923. [PMID: 34987009 DOI: 10.1016/j.cardfail.2021.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 11/20/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Worsening heart failure (HF) often requires hospitalization but in some cases may be managed in the outpatient or emergency department (ED) settings. The predictors and clinical significance of ED visits without admission vs hospitalization are unclear. METHODS The ASCEND-HF trial included 2661 US patients hospitalized for HF with reduced or preserved ejection fraction. Clinical characteristics were compared between patients with a subsequent all-cause ED visit (with ED discharge) within 30 days vs all-cause readmission within 30 days. Factors associated with each type of care were assessed in multivariable models. Multivariable models landmarked at 30 days evaluated associations between each type of care and subsequent 150-day mortality. RESULTS Through 30-day follow-up, 193 patients (7%) had ED discharge, 459 (17%) had readmission, and 2009 (76%) had neither urgent visit. Patients with ED discharge vs readmission were similar with respect to age, sex, systolic blood pressure, ejection fraction, and coronary artery disease, whereas ED discharge patients had a modestly lower creatinine (P < .01). Among patients with either event within 30 days, a higher creatinine and prior HF hospitalization were associated with a higher likelihood of readmission, as compared with ED discharge (P < .02). Landmarked at 30 days, rates of death during the subsequent 150 days were 21.0% for patients who were readmitted and 11.4% for patients discharged from the ED. Compared with patients who were readmitted, ED discharge was independently associated with lower 150-day mortality (adjusted hazard ratio 0.58, 95% confidence interval 0.36-0.92, P = .02). CONCLUSIONS In this cohort of US patients hospitalized for HF, worse renal function and prior HF hospitalization were associated with a higher likelihood of early postdischarge readmission, as compared with ED discharge. Although subsequent mortality was high after discharge from the ED, this risk of mortality was significantly lower than patients who were readmitted to the hospital.
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Affiliation(s)
- Anand Shah
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Durham, North Carolina
| | - Vishal N Rao
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina
| | - Vanessa Blumer
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Randall Starling
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, NC.
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Abstract
BACKGROUND Pain is a common but understudied symptom among patients with heart failure (HF) transported by emergency medical services (EMS). The aims were to determine explanatory factors of a primary complaint of pain and pain severity, and characterize pain among patients with HF transported by EMS. METHODS Data from electronic health records of patients with HF transported by EMS within a midwestern United States county from 2009 to 2017 were analyzed. Descriptive statistics, χ 2 , analysis of variance, and logistic and multiple linear regression analyses were used. RESULTS The sample (N = 4663) was predominantly women (58.1%) with self-reported race as Black (57.7%). The mean age was 64.2 ± 14.3 years. Pain was the primary complaint in 22.2% of the sample, with an average pain score of 6.8 ± 3.1 out of 10. The most common pain complaint was chest pain (68.1%). Factors associated with a primary pain complaint were younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.96-0.97), history of myocardial infarction (OR, 1.96; 95% CI, 1.55-2.49), and absence of shortness of breath (OR, 0.67; 95% CI, 0.58-0.77). Factors associated with higher pain severity were younger age ( b = -0.05, SE = 0.013), being a woman ( b = 1.17, SE = 0.357), and White race ( b = -1.11, SE = 0.349). CONCLUSIONS Clinical and demographic factors need consideration in understanding pain in HF during EMS transport. Additional research is needed to examine these factors to improve pain management and reduce transports due to pain.
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10
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Son YJ, Kim DY, Won MH. Sex Differences in the Association between Atrial Fibrillation and 90-Day Adverse Outcomes among Older Adults with Heart Failure: A Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:2237. [PMID: 33668276 PMCID: PMC7967669 DOI: 10.3390/ijerph18052237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 12/04/2022]
Abstract
Sex differences in the prognostic impact of coexisting atrial fibrillation (AF) in older patients with heart failure (HF) have not been well-studied. This study, therefore, compared sex differences in the association between AF and its 90-day adverse outcomes (hospital readmissions and emergency room (ER) visits) among older adults with HF. Of the 250 older adult patients, the prevalence rates of coexisting AF between male and female HF patients were 46.0% and 31.0%, respectively. In both male and female older patients, patients with AF have a significantly higher readmission rate (male 46.0%, and female 34.3%) than those without AF (male 6.8%, and female 12.8%). However, there are no significant differences in the association between AF and ER visits in both male and female older HF patients. The multivariate logistic analysis showed that coexisting AF significantly increased the risk of 90-day hospital readmission in both male and female older patients. In addition, older age in males and longer periods of time after an HF diagnosis in females were associated with an increased risk of hospital readmission. Consequently, prospective cohort studies are needed to identify the impact of coexisting AF on short- and long-term outcomes in older adult HF patients by sex.
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Affiliation(s)
- Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, Seoul 06974, Korea;
| | - Da-Young Kim
- Department of Nursing, Graduate School, Chung-Ang University, Seoul 06974, Korea;
| | - Mi Hwa Won
- Department of Nursing, Wonkwang University, Iksan 54538, Korea
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Chiu Y, Racine-Hemmings F, Dufour I, Vanasse A, Chouinard MC, Bisson M, Hudon C. Statistical tools used for analyses of frequent users of emergency department: a scoping review. BMJ Open 2019; 9:e027750. [PMID: 31129592 PMCID: PMC6537981 DOI: 10.1136/bmjopen-2018-027750] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Frequent users represent a small proportion of emergency department users, but they account for a disproportionately large number of visits. Their use of emergency departments is often considered suboptimal. It would be more efficient to identify and treat those patients earlier in their health problem trajectory. It is therefore essential to describe their characteristics and to predict their emergency department use. In order to do so, adequate statistical tools are needed. The objective of this study was to determine the statistical tools used in identifying variables associated with frequent use or predicting the risk of becoming a frequent user. METHODS We performed a scoping review following an established 5-stage methodological framework. We searched PubMed, Scopus and CINAHL databases in February 2019 using search strategies defined with the help of an information specialist. Out of 4534 potential abstracts, we selected 114 articles based on defined criteria and presented in a content analysis. RESULTS We identified four classes of statistical tools. Regression models were found to be the most common practice, followed by hypothesis testing. The logistic regression was found to be the most used statistical tool, followed by χ2 test and t-test of associations between variables. Other tools were marginally used. CONCLUSIONS This scoping review lists common statistical tools used for analysing frequent users in emergency departments. It highlights the fact that some are well established while others are much less so. More research is needed to apply appropriate techniques to health data or to diversify statistical point of views.
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Affiliation(s)
- Yohann Chiu
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - François Racine-Hemmings
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Isabelle Dufour
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alain Vanasse
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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12
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Lo AX, Donnelly JP, Durant RW, Collins SP, Levitan EB, Storrow AB, Bittner V. A National Study of U.S. Emergency Departments: Racial Disparities in Hospitalizations for Heart Failure. Am J Prev Med 2018; 55:S31-S39. [PMID: 30670199 PMCID: PMC11328969 DOI: 10.1016/j.amepre.2018.05.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/11/2018] [Accepted: 05/16/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Racial disparities in heart failure hospitalizations are well documented. The majority of heart failure hospitalizations originate from emergency departments, but emergency department hospitalization patterns for heart failure and the factors that influence hospitalization are poorly understood. This gap in knowledge was examined using a nationally representative sample of emergency department visits for heart failure. METHODS National Hospital Ambulatory Medicare Care Survey data on 2001-2010 emergency department visits were analyzed in 2015-2017 to examine age-related racial differences in hospitalization patterns for heart failure, using multivariable modified Poisson regression models. RESULTS More than 12million adult visits for heart failure to U.S. emergency departments occurred from 2001 to 2010, with 23% of visits by blacks. Overall, 71% of visits resulted in hospitalization (57% to floor beds and 14% to intensive care units). Among floor admissions for higher clinical acuity visits, whites were more likely than blacks to be hospitalized. Whites with higher clinical acuity were more likely to be hospitalized than those with lower clinical acuity (71% vs 63%, p=0.005). This expected pattern was not observed in blacks, particularly those aged ≥65years, who were hospitalized in 71% of lower clinical acuity visits, but only 61% of higher acuity visits. Among adults aged ≥65years, there was a significant interaction between clinical acuity Xrace with regard to hospitalization (p=0.037). CONCLUSIONS These results suggest age and racial disparities in hospitalization rates for emergency department patients with heart failure. The reasons for these disparities in hospitalization are unclear. Further studies on emergency department hospitalization decisions, and the impact of emergency department clinical factors, may help clarify this finding. SUPPLEMENT INFORMATION This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.
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Affiliation(s)
- Alexander X Lo
- Department of Emergency Medicine and Center for Healthcare Studies, Northwestern University, Chicago, Illinois.
| | - John P Donnelly
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Raegan W Durant
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Duero Posada JG, Moayedi Y, Zhou L, McDonald M, Ross HJ, Lee DS, Bhatia RS. Clustered Emergency Room Visits Following an Acute Heart Failure Admission: A Population-Based Study. J Am Heart Assoc 2018; 7:e007569. [PMID: 29588312 PMCID: PMC5907582 DOI: 10.1161/jaha.117.007569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/13/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND While it is well known that heart failure patients presenting to the emergency room (ER) have high short-term mortality after discharge, the outcomes of patients with heart failure with repeated ER visits within a short time are not known. In this study, we aimed to determine whether clustering is associated with an increased risk of death. METHODS AND RESULTS This is a retrospective, population-based cohort study with an accrual window between 2003 and 2014 and maximal follow-up up to and including March 31, 2015. Data were obtained from administrative databases from Ontario, Canada. Clustering was defined a priori as 3 or more ER visits within a 6-month period. The main outcome of interest was time to death conditional on 6-month survival. A total of 72 810 patients with an index hospitalization for acute heart failure were evaluated. ER clustering was observed in 15.1% of the population. Increased burden of comorbidities, primary rural residence, and lack of primary care provider were identified as factors associated with ER clustering. Age- and sex-adjusted mortality for clustered patients was higher than for nonclustered (hazard ratio [HR] 1.51; 95% confidence interval, 1.47-1.55, P<0.0001). Adjusted mortality risk was also higher for patients with clustered ER visits (HR 1.42; 95% confidence interval 1.38-1.46; P<0.0001). CONCLUSIONS Clustering, as defined by 3 or more ER visits for any reason within 6 months of index heart failure hospitalization reflects a novel risk factor associated with increased mortality. Future research into the strategies to better manage complex patients with heart failure with recurrent ER visits are warranted.
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Affiliation(s)
- Juan G Duero Posada
- Department of Medicine, University of Toronto, ON, Canada
- Division of Cardiology, University of Toronto, ON, Canada
| | - Yasbanoo Moayedi
- Department of Medicine, University of Toronto, ON, Canada
- Division of Cardiology, University of Toronto, ON, Canada
| | - Limei Zhou
- Institute for Clinical Evaluative Sciences, ON, Canada
| | - Michael McDonald
- Department of Medicine, University of Toronto, ON, Canada
- Division of Cardiology, University of Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, ON, Canada
| | - Heather J Ross
- Department of Medicine, University of Toronto, ON, Canada
- Division of Cardiology, University of Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, ON, Canada
| | - Douglas S Lee
- Department of Medicine, University of Toronto, ON, Canada
- Division of Cardiology, University of Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, ON, Canada
| | - R Sacha Bhatia
- Department of Medicine, University of Toronto, ON, Canada
- Division of Cardiology, University of Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, ON, Canada
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Hirayama A, Goto T, Shimada YJ, Faridi MK, Camargo CA, Hasegawa K. Association of Obesity With Severity of Heart Failure Exacerbation: A Population-Based Study. J Am Heart Assoc 2018; 7:JAHA.117.008243. [PMID: 29545263 PMCID: PMC5907573 DOI: 10.1161/jaha.117.008243] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Obesity and heart failure (HF) are important public health problems in the United States. Although studies have reported the association between obesity and higher chronic morbidity of HF, little is known about the relations of obesity with severity of HF exacerbation and in‐hospital mortality; therefore, we aimed to investigate the associations of obesity with severity of HF exacerbation and in‐hospital mortality. Methods and Results This retrospective cohort study of adults hospitalized for HF exacerbation used population‐based data sets (the State Inpatient Databases) of 7 US states from 2012 to 2013. The outcomes were acute severity measures—use of positive pressure ventilation and hospital length of stay—and in‐hospital mortality. We determined the associations between obesity and these outcomes, including adjustment for sociodemographic factors and comorbidities. We identified 219 465 patients hospitalized for HF exacerbation. Of those, 37 539 (17.1%) were obese. Obese patients had a significantly higher risk of positive pressure ventilation use compared with nonobese patients (13.6% versus 8.8%), with a corresponding adjusted odds ratio of 1.61 (95% confidence interval, 1.55–1.68; P<0.001). Likewise, obese patients were more likely to have hospital length of stay of ≥4 days compared with nonobese patients (62.5% versus 56.7%), with an adjusted odds ratio of 1.40 (95% confidence interval, 1.37–1.44; P<0.001). In contrast, obese patients had significantly lower in‐hospital mortality compared with nonobese patients (1.7% versus 3.3%), with an adjusted odds ratio of 0.87 (95% confidence interval, 0.80–0.95; P=0.002). Conclusions Based on large population‐based data sets of patients with HF exacerbation, obesity was associated with higher acute severity measures but lower in‐hospital mortality.
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Affiliation(s)
- Atsushi Hirayama
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Yuichi J Shimada
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
| | | | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.,Harvard T.H. Chan School of Public Health, Boston, MA.,Harvard Medical School, Boston, MA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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Garramone A, Cangemi R, Bresciani E, Carnevale R, Bartimoccia S, Fante E, Corinti M, Brunori M, Violi F, Bertazzoni G, Pignatelli P. Early decrease of oxidative stress by non-invasive ventilation in patients with acute respiratory failure. Intern Emerg Med 2018; 13:183-190. [PMID: 28914417 DOI: 10.1007/s11739-017-1750-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/05/2017] [Indexed: 01/07/2023]
Abstract
Oxidative stress plays an important role in chronic respiratory diseases where the use of non-invasive ventilation seems to reduce the oxidative damage. Data on acute respiratory failure are still lacking. The aim of the study is to investigate the interplay between oxidative stress and acute respiratory failure, and the role of non-invasive ventilation in this setting. We enrolled 60 patients suffering from acute respiratory failure (PaO2/FiO2 ratio <300): 30 consecutive patients treated with non-invasive ventilation and 30 consecutive patients treated with conventional oxygen therapy. Serum levels of soluble Nox2-derived peptide (sNOX2-dp), a marker of NADPH-oxidase activation, and 8-iso-PGF2α and H2O2, markers of oxidative stress, were evaluated at baseline and after 3 h of treatment. At baseline, higher values of sNOX2-dp, 8-iso-PGF2α and H2O2 are associated with lower values of PaO2/FiO2 ratio (p < 0.001). After 3 h, serum levels of sNOX2-dp, H2O2, and 8-iso-PGF2α significantly decrease in patients treated with non-invasive ventilation, but not in patients treated with conventional oxygen therapy. Delta changes of oxidative stress parameters correlate inversely with the delta changes of PaO2/FiO2 (R = -0.623, p < 0.001 for sNOX2-dp; R = -0.428, p < 0.001 for H2O2; R = -0.548, p < 0.001 for 8-iso-PGF2α). In the acute respiratory failure setting, treatment with non-invasive ventilation reduces the levels of oxidative stress in the first hours. This reduction is associated with an improvement of PaO2/FiO2 ratio as well as in a reduction of NADPH-oxidase activity.
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Affiliation(s)
- Alessia Garramone
- UOC Emergency Medicine, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Roberto Cangemi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Emanuela Bresciani
- UOC Emergency Medicine, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Roberto Carnevale
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Simona Bartimoccia
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Elisa Fante
- Department of Emergency, M.G. Vannini Hospital, Rome, Italy
| | - Marco Corinti
- UOC Emergency Medicine, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Marco Brunori
- Respiratory Pathophysiology and Rehabilitation Unit, Policlinico Umberto I, Rome, Italy
| | - Francesco Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Giuliano Bertazzoni
- UOC Emergency Medicine, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Pasquale Pignatelli
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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17
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Predictors of Frequent Readmissions in Patients With Heart Failure. Heart Lung Circ 2017; 28:277-283. [PMID: 29191505 DOI: 10.1016/j.hlc.2017.10.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 10/03/2017] [Accepted: 10/31/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with heart failure (HF) have a high incidence of hospital readmissions. However risk models that explore predictors of a single readmission may be less useful at identifying the patients with frequent readmissions who contribute to a disproportionately large proportion of morbidity and health care costs. METHODS A total of 6252 patients enrolled in the Management of Cardiac Failure Program (MACARF) in Northern Sydney Area Hospitals between 1998 and 2015 were randomly divided into derivation and validation cohorts to create and test a risk model for predictors of ≥2 readmissions or death within 1year of initial hospitalisation for HF. RESULTS Multivariate predictors of frequent (≥2) readmissions or death were a history of ischaemic heart disease and chronic kidney disease, being unmarried, having anaemia, low serum albumin, elevated creatinine, prolonged hospital stay (>7 days), and not receiving beta blockers on discharge. Event rates increased with a higher risk score (p<0.001) and the prediction was similar in the validation and derivation cohorts (p=0.588). The C-statistic was 0.65. CONCLUSIONS Our risk score may assist in focussing health care resources and interventions by identifying the subset of HF patients at increased risk for a disproportionately high burden of disease.
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18
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Shimada YJ, Tsugawa Y, Camargo CA, Brown DFM, Hasegawa K. Effect of Bariatric Surgery on Emergency Department Visits and Hospitalizations for Atrial Fibrillation. Am J Cardiol 2017; 120:947-952. [PMID: 28734462 PMCID: PMC11061550 DOI: 10.1016/j.amjcard.2017.06.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 05/23/2017] [Accepted: 06/13/2017] [Indexed: 01/24/2023]
Abstract
Atrial fibrillation (AF) and obesity are major health problems in the United States. However, little is known about whether bariatric surgery affects AF-related morbidities. This study investigated whether bariatric surgery is associated with short-term and long-term changes in the risk of emergency department (ED) visits or hospitalizations for AF. We performed a self-controlled case series study of obese adults with AF who underwent bariatric surgery by using population-based ED and inpatient databases in California, Florida, and Nebraska from 2005 to 2011. The primary outcome was ED visit or hospitalization for AF. We used conditional logistic regression to compare each patient's risk of the outcome event during sequential 12-month periods, using presurgery months 13 to 24 as a reference period. Our sample consisted of 523 obese adults with AF who underwent bariatric surgery. The median age was 57 years (interquartile range 48 to 64 years), 59% were female, and 84% were non-Hispanic white. During the reference period, 15.9% (95% confidence interval [CI] 12.7% to 19.0%) of patients had an ED visit or hospitalization for AF. The risk remained similar in the subsequent 12-month presurgery period (adjusted OR [aOR] 1.29 [95% CI, 0.94 to 1.76] p = 0.11). In contrast, the risk significantly increased within 12 months after bariatric surgery (aOR 1.53 [95% CI 1.13 to 2.07] p = 0.006). The risk remained elevated during 13-24 months after bariatric surgery (aOR 1.41 [95% CI, 1.03 to 1.91] p = 0.03). In conclusion, this population-based study demonstrated that bariatric surgery was associated with an increased risk of AF episodes requiring an ED visit or hospitalization for at least 2 years after surgery among obese patients with AF.
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Affiliation(s)
- Yuichi J Shimada
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Yusuke Tsugawa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David F M Brown
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Fabbri A, Marchesini G, Carbone G, Cosentini R, Ferrari A, Chiesa M, Bertini A, Rea F. Acute Heart Failure in the Emergency Department: the SAFE-SIMEU Epidemiological Study. J Emerg Med 2017; 53:178-185. [PMID: 28501384 DOI: 10.1016/j.jemermed.2017.03.030] [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: 12/16/2015] [Revised: 10/18/2016] [Accepted: 03/27/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Patients with acute heart failure (AHF) have high rates of attendance to emergency departments (EDs), with significant health care costs. OBJECTIVES We aimed to describe the clinical characteristics of patients attending Italian EDs for AHF and their diagnostic and therapeutic work-up. METHODS We carried out a retrospective analysis on 2683 cases observed in six Italian EDs for AHF (January 2011 to June 2012). RESULTS The median age of patients was 84 years (interquartile range 12), with females accounting for 55.8% of cases (95% confidence interval [CI] 53.5-57.6%). A first episode of AHF was recorded in 55.3% (95% CI 55.4-57.2%). Respiratory disease was the main precipitating factor (approximately 30% of cases), and multiple comorbidities were recorded in > 50% of cases (history of acute coronary syndrome, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, valvular heart disease). The treatment was based on oxygen (69.7%; 67.9-71.5%), diuretics (69.2%; 67.9-71.5%), nitroglycerin (19.7%; 18.3-21.4%), and noninvasive ventilation (15.2%; 13.8-16.6%). Death occurred within 6 h in 2.5% of cases (2.0-3.1%), 6.4% (5.5-7.3%) were referred to the care of their general practitioners within a few hours from ED attendance or after short-term (< 24 h) observation 13.9% (12.6-15.2%); 60.4% (58.5-62.2%) were admitted to the hospital, and 16.8% (15.4-18.3%) were cared for in intensive care units according to disease severity. CONCLUSIONS Our study reporting the "real-world" clinical activity indicates that subjects attending the Italian EDs for AHF are rather different from those reported in international registries. Subjects are older, with a higher proportion of females, and high prevalence of cardiac and noncardiac comorbidities.
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Affiliation(s)
- Andrea Fabbri
- Department of Emergency Medicine, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Giulio Marchesini
- Department of Medical and Surgical Sciences, Clinical Dietetics, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Giorgio Carbone
- Department of Emergency Medicine, Gradenigo Hospital, Torino, Torino, Italy
| | - Roberto Cosentini
- Department of Emergency Medicine, Osp. Maggiore Policlinico, fondazione Cà Granda, Milano, Italy
| | - Annamaria Ferrari
- Department of Emergency Medicine, Ospedale S. Maria Nuova, Reggio Emilia, Italy
| | - Mauro Chiesa
- Department of Emergency Medicine, Ospedale S. Antonio, Azienda Ospedaliera, Padova, Italy
| | - Alessio Bertini
- Department of Emergency Medicine, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Federico Rea
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milano, Italy
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Evans CS, Platts-Mills TF, Fernandez AR, Grover JM, Cabanas JG, Patel MD, Vilke GM, Brice JH. Repeated Emergency Medical Services Use by Older Adults: Analysis of a Comprehensive Statewide Database. Ann Emerg Med 2017; 70:506-515.e3. [PMID: 28559037 DOI: 10.1016/j.annemergmed.2017.03.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/16/2017] [Accepted: 03/22/2017] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE The objective of this study is to characterize repeated emergency medical services (EMS) transports among older adults across a large and socioeconomically diverse region. METHODS Using the North Carolina Prehospital Medical Information System, we analyzed the frequency of repeated EMS transports within 30 days of an index EMS transport among adults aged 65 years and older from 2010 to 2015. We used multivariable logistic regressions to determine characteristics associated with repeated EMS transport. RESULTS During the 6-year period, EMS performed 1,711,669 transports for 689,664 unique older adults in North Carolina. Of these, 303,099 transports (17.7%) were followed by another transport of the same patient within 30 days. The key characteristics associated with an increased adjusted odds ratio of repeated transport within 30 days include transport from an institutionalized setting (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.38 to 1.47), blacks compared with whites (OR 1.29; 95% CI 1.24 to 1.33), a dispatch complaint of psychiatric problems (OR 1.38; 95% CI 1.25 to 1.52), back pain (OR 1.35; 95% CI 1.26 to 1.45), breathing problems (OR 1.21; 95% CI 1.15 to 1.30), and diabetic problems (OR 1.14; 95% CI 1.06 to 1.22). Falls accounted for 15.6% of all transports and had a modest association with repeated transports (OR 1.07; 95% CI 1.00 to 1.14). CONCLUSION More than 1 in 6 EMS transports of older adults in North Carolina are followed by a repeated transport of the same patient within 30 days. Patient characteristics and chief complaints may identify increased risk for repeated transport and suggest the potential for targeted interventions to improve outcomes and manage EMS use.
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Affiliation(s)
- Christopher S Evans
- Department of Emergency Medicine and School of Medicine, University of California-San Diego, San Diego, CA; Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.
| | | | - Antonio R Fernandez
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC; EMS Performance Improvement Center, University of North Carolina, Chapel Hill, NC
| | - Joseph M Grover
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Jose G Cabanas
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC; Wake County Department of Emergency Medical Services, Wake County, NC
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Gary M Vilke
- Wake County Department of Emergency Medical Services, Wake County, NC
| | - Jane H Brice
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC
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Zsilinszka R, Mentz RJ, DeVore AD, Eapen ZJ, Pang PS, Hernandez AF. Acute Heart Failure: Alternatives to Hospitalization. JACC-HEART FAILURE 2017; 5:329-336. [PMID: 28285117 DOI: 10.1016/j.jchf.2016.12.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 11/11/2016] [Accepted: 12/15/2016] [Indexed: 01/17/2023]
Abstract
Acute heart failure (HF) is a major public health problem with substantial associated economic costs. Because most patients who present to hospitals are admitted irrespective of their level of risk, novel approaches to manage acute HF are needed, such as the use of same-day access clinics for outpatient diuresis and observation units from the emergency department. Current published data lacks a comprehensive overview of the present state of acute HF management in various clinical settings. This review summarizes the strengths and limitations of acute HF care in the outpatient and emergency department settings. Finally, a variety of innovative technologies that have the potential to improve acute HF management are discussed.
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Affiliation(s)
| | - Robert J Mentz
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D DeVore
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
| | - Zubin J Eapen
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
| | - Peter S Pang
- Department of Emergency Medicine and the Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adrian F Hernandez
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina.
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22
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Molina G, Neville BA, Lipsitz SR, Gibbons L, Childers AK, Gawande AA, Berry WR, Haynes AB. Postoperative acute care use after freestanding ambulatory surgery. J Surg Res 2016; 205:331-340. [DOI: 10.1016/j.jss.2016.06.084] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/09/2016] [Accepted: 06/26/2016] [Indexed: 10/21/2022]
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23
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Shimada YJ, Tsugawa Y, Brown DFM, Hasegawa K. Bariatric Surgery and Emergency Department Visits and Hospitalizations for Heart Failure Exacerbation: Population-Based, Self-Controlled Series. J Am Coll Cardiol 2016; 67:895-903. [PMID: 26916477 DOI: 10.1016/j.jacc.2015.12.016] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/01/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The United States is battling obesity and heart failure (HF) epidemics. Although studies have suggested relationships between obesity and HF morbidity, little is known regarding the effects of substantial weight reduction in obese patients with HF. OBJECTIVES This study investigated whether bariatric surgery is associated with a decreased rate of HF exacerbation. METHODS We performed a self-controlled case series study of obese patients with HF who underwent bariatric surgery, using the population-based emergency department (ED) and inpatient sample in California, Florida, and Nebraska. Primary outcome was ED visit or hospitalization for HF exacerbation from 2005 to 2011. We used conditional logistic regression to compare the outcome event rate during sequential 12-month periods, using pre-surgery months 13 to 24 as the reference period. RESULTS We identified 524 patients with HF who underwent bariatric surgery. During the reference period, 16.2% of patients had an ED visit or hospitalization for HF exacerbation. The rate remained unchanged in the subsequent 12-month pre-surgery period (15.3%; p = 0.67). In the first 12-month period after bariatric surgery, we observed a nonsignificantly reduced rate (12.0%; p = 0.052). However, the rate was significantly lower in the subsequent 13 to 24 months after bariatric surgery (9.9%; adjusted odds ratio: 0.57; p = 0.003). By contrast, there was no significant reduction in the rate of HF exacerbation among obese patients who underwent nonbariatric surgery (i.e., cholecystectomy, hysterectomy). CONCLUSIONS Our findings indicate that bariatric surgery is associated with a decline in the rate of HF exacerbation requiring ED evaluation or hospitalization among obese patients with HF.
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Affiliation(s)
- Yuichi J Shimada
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Yusuke Tsugawa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David F M Brown
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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24
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Goto T, Tsugawa Y, Mansbach JM, Camargo CA, Hasegawa K. Trends in Infectious Disease Hospitalizations in US Children, 2000 to 2012. Pediatr Infect Dis J 2016; 35:e158-63. [PMID: 26967815 PMCID: PMC4912127 DOI: 10.1097/inf.0000000000001134] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although infectious diseases (IDs) remain a major public health problem in US children, there have been no recent efforts to examine comprehensively the change in epidemiology of ID hospitalizations. METHODS A serial cross-sectional analysis using the Kids' Inpatient Database 2000, 2003, 2006, 2009, and 2012. We identified children ≤19 years of age with a primary diagnosis of IDs. Outcomes were national rate of ID hospitalizations, in-hospital mortality, length-of-stay and hospitalization-related direct costs. Negative binomial and multivariable logistic models were constructed to test the change in hospitalization rate and in-hospital mortality, respectively. RESULTS We identified 3,691,672 weighted hospitalizations for IDs, accounting for 24.5% of all pediatric hospitalizations. From 2000 to 2012, the rate of overall ID hospitalizations decreased from 91.0 to 75.8 per 10,000 US children (P < 0.001). The most frequently listed ID subgroup was lower respiratory infections (42.8% of all ID hospitalizations in 2012). Although the hospitalization rate for most ID subgroups decreased, the hospitalization rate for skin infections significantly increased (67.6% increase; P < 0.001). The multivariable model demonstrated a significant decline in in-hospital mortality (odds ratio for comparison of 2012 with 2000, 0.63; 95% confidence interval, 0.51-0.79). From 2000 to 2012, there was no significant change in the median length-of-stay (2 days in 2000 to 2 days in 2012; Ptrend = 0.33). The median direct cost for ID hospitalization increased from $3452 in 2003 to $3784 in 2012 (P = 0.007), with the nationwide direct cost of $4.4 billion in 2012. CONCLUSIONS We found a statistically significant decline in overall ID hospitalization rate among US children from 2000 to 2012, whereas skin infections statistically significantly increased. In addition, the median direct cost per ID hospitalization increased by 10% during the study period.
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Affiliation(s)
- Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Yusuke Tsugawa
- Harvard Interfaculty Initiative in Health Policy, Harvard University, Boston, MA
| | - Jonathan M. Mansbach
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Fabbri A, Marchesini G, Carbone G, Cosentini R, Ferrari A, Chiesa M, Bertini A, Rea F. Acute heart failure in the emergency department: a follow-up study. Intern Emerg Med 2016; 11:115-22. [PMID: 26506831 DOI: 10.1007/s11739-015-1336-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022]
Abstract
Acute heart failure (AHF) is a major public health issue due to high incidence and poor prognosis. Only a few studies are available on the long-term prognosis and on outcome predictors in the unselected population attending the emergency department (ED) for AHF. We carried out a 1-year follow-up analysis of 1234 consecutive patients from selected Italian EDs from January 2011 to June 2012 for an episode of AHF. Their prognosis and outcome-associated factors were tested by Cox proportional hazard model. Patients' mean age was 84, with 66.0% over 80 years and 56.2% females. Comorbidities were present in over 50% of cases, principally a history of acute coronary syndrome, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, valvular heart disease. Death occurred within 6 h in 24 cases (1.9%). At 30-day follow-up, death was registered in 123 cases (10.0%): 110 cases (89.4%) died of cardiovascular events and 13 (10.6%) of non-cardiovascular causes (cancer, gastrointestinal hemorrhages, sepsis, trauma). At 1-year follow-up, all-cause death was recorded in 50.1% (over 3 out of 4 cases for cardiovascular origin). Six variables (older age, diabetes, systolic arterial pressure <110 mm/Hg, high NT pro-BNP, high troponin levels and impaired cognitive status) were selected as outcome predictors, but with limited discriminant capacity (AUC = 0.649; SE 0.015). Recurrence of AHF was registered in 31.0%. The study identifies a cluster of variables associated with 1-year mortality in AHF, but their predictive capacity is low. Old age and the presence of comorbidities, in particular diabetes are likely to play a major role in dictating the prognosis.
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Affiliation(s)
- Andrea Fabbri
- Department of Emergency Medicine, Presidio Ospedaliero Morgagni-Pierantonio, AUSL della Romagna - Forlì, Via Forlanini 34, 47121, Forlì, Italy.
| | - Giulio Marchesini
- Department of Medical and Surgical Sciences, Clinical Dietetics, University of Bologna, S. Orsola-Malpighi Hospital, via Massarenti 9, 40138, Bologna, Italy
| | - Giorgio Carbone
- Department of Emergency Medicine, Gradenigo Hospital, Corso Regina Margherita 8/10, 10100, Torino, Italy
| | - Roberto Cosentini
- Department of Emergency Medicine, Osp. Maggiore Policlinico, fondazione Cà Granda, via F. Sforza 35, 20122, Milan, Italy
| | - Annamaria Ferrari
- Department of Emergency Medicine, Ospedale S. Maria Nuova, via Risorgimento 80, 4100, Reggio Emilia, Italy
| | - Mauro Chiesa
- Department of Emergency Medicine, Ospedale S. Antonio, Azienda Ospedaliera, via Facciolati 71, 36124, Padua, Italy
| | - Alessio Bertini
- Department of Emergency Medicine, Azienda Ospedaliera Universitaria Pisana, via Roma 67, 56126, Pisa, Italy
| | - Federico Rea
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, via Bicocca degli Arcimboldi 8, 20126, Milan, Italy
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Goto T, Tsugawa Y, Camargo CA, Hasegawa K. Sex differences in the risk of hospitalization among patients presenting to US emergency departments with asthma exacerbation, 2010-2012. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:149-51.e2. [DOI: 10.1016/j.jaip.2015.11.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 11/01/2015] [Accepted: 11/16/2015] [Indexed: 11/28/2022]
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27
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Goto T, Yoshida K, Tsugawa Y, Camargo CA, Hasegawa K. Infectious Disease-Related Emergency Department Visits of Elderly Adults in the United States, 2011-2012. J Am Geriatr Soc 2015; 64:31-6. [PMID: 26696501 DOI: 10.1111/jgs.13836] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the frequency of infectious disease (ID)-related emergency department (ED) visits of elderly adults in the United States. DESIGN Cross-sectional analysis. SETTING Nationwide emergency department sample in 2011-12. PARTICIPANTS Individuals in the ED aged 65 and older with a primary diagnosis of an ID. MEASUREMENTS ID-related ED visits, hospitalizations, hospital-based mortality. RESULTS During 2012, a weighted estimate of 3,123,909 ED visits for IDs was calculated in elderly U.S. adults. This accounted for 13.5% (3.1 million visits) of all ED visits of elderly adults; this burden was higher than that for myocardial infarction and congestive heart failure combined. The rate of ID-related ED visits was 7,231 per 100,000 elderly adults. The most-common diagnoses were lower respiratory infections (26.2%; 95% confidence interval (CI)=25.7-26.6%), urinary tract infections (25.3%, 95% CI=25.0-25.7%), and septicemia (18.9%, 95% CI=18.3-19.6%). Of all ID-related ED visits, 1,786,657 (57.2%, 95% CI=56.6-57.7%) resulted in hospitalization. The leading cause of hospitalization was septicemia, accounting for 32.2% (95% CI=31.1-33.3%) of all ID-related hospitalizations through EDs, followed by lower respiratory infections (27.8%, 95% CI=27.2-28.4%). Overall, 123,894 individuals (4.0%, 95% CI=3.8-4.1%) died during their ED visit or hospitalization. Of these, septicemia was the leading cause of mortality (74.7%, 95% CI=73.8-75.6%), followed by lower respiratory infections (15.2%, 95% CI=14.6-15.9%). Analysis of the 2011 data gave similar results for the burden of ID-related ED visits, hospitalizations, and mortality. CONCLUSION Using a nationally representative sample, it was found that the public health burden of IDs in elderly U.S. adults was substantial, as measured by ED visits, subsequent hospitalizations, and hospital-based mortality.
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Affiliation(s)
- Tadahiro Goto
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan.,Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kazuki Yoshida
- Department of Epidemiology, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Yusuke Tsugawa
- Harvard Interfaculty Initiative in Health Policy, Harvard University, Boston, Massachusetts
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Epidemiology, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Thinking Outside the Box: Treating Acute Heart Failure Outside the Hospital to Improve Care and Reduce Admissions. J Card Fail 2015; 21:667-73. [DOI: 10.1016/j.cardfail.2015.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 05/12/2015] [Accepted: 05/15/2015] [Indexed: 01/16/2023]
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Mosier JM, Hypes C, Joshi R, Whitmore S, Parthasarathy S, Cairns CB. Ventilator Strategies and Rescue Therapies for Management of Acute Respiratory Failure in the Emergency Department. Ann Emerg Med 2015; 66:529-41. [PMID: 26014437 DOI: 10.1016/j.annemergmed.2015.04.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/08/2015] [Accepted: 04/20/2015] [Indexed: 01/19/2023]
Abstract
Acute respiratory failure is commonly encountered in the emergency department (ED), and early treatment can have effects on long-term outcome. Noninvasive ventilation is commonly used for patients with respiratory failure and has been demonstrated to improve outcomes in acute exacerbations of chronic obstructive lung disease and congestive heart failure, but should be used carefully, if at all, in the management of asthma, pneumonia, and acute respiratory distress syndrome. Lung-protective tidal volumes should be used for all patients receiving mechanical ventilation, and FiO2 should be reduced after intubation to achieve a goal of less than 60%. For refractory hypoxemia, new rescue therapies have emerged to help improve the oxygenation, and in some cases mortality, and should be considered in ED patients when necessary, as deferring until ICU admission may be deleterious. This review article summarizes the pathophysiology of acute respiratory failure, management options, and rescue therapies including airway pressure release ventilation, continuous neuromuscular blockade, inhaled nitric oxide, and extracorporeal membrane oxygenation.
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Affiliation(s)
- Jarrod M Mosier
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine, University of Arizona, Tucson, AZ.
| | - Cameron Hypes
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Raj Joshi
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Sage Whitmore
- Division of Emergency Critical Care, Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Sairam Parthasarathy
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ
| | - Charles B Cairns
- Department of Emergency Medicine, University of Arizona, Tucson, AZ
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30
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McNaughton CD, Cawthon C, Kripalani S, Liu D, Storrow AB, Roumie CL. Health literacy and mortality: a cohort study of patients hospitalized for acute heart failure. J Am Heart Assoc 2015; 4:jah3939. [PMID: 25926328 PMCID: PMC4599411 DOI: 10.1161/jaha.115.001799] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background More than 30% of patients hospitalized for heart failure are rehospitalized or die within 90 days of discharge. Lower health literacy is associated with mortality among outpatients with chronic heart failure; little is known about this relationship after hospitalization for acute heart failure. Methods and Results Patients hospitalized for acute heart failure and discharged home between November 2010 and June 2013 were followed through December 31, 2013. Nurses administered the Brief Health Literacy Screen at admission; low health literacy was defined as Brief Health Literacy Screen ≤9. The primary outcome was all-cause mortality. Secondary outcomes were time to first rehospitalization and, separately, time to first emergency department visit within 90 days of discharge. Cox proportional hazards models determined their relationships with health literacy, adjusting for age, gender, race, insurance, education, comorbidity, and hospital length of stay. For the 1379 patients, average age was 63.1 years, 566 (41.0%) were female, and 324 (23.5%) had low health literacy. Median follow-up was 20.7 months (interquartile range 12.8 to 29.6 months), and 403 (29.2%) patients died. Adjusted hazard ratio for death among patients with low health literacy was 1.34 (95% CI 1.04, 1.73, P=0.02) compared to Brief Health Literacy Screen >9. Within 90 days of discharge, there were 415 (30.1%) rehospitalizations and 201 (14.6%) emergency department visits, with no evident association with health literacy. Conclusions Lower health literacy was associated with increased risk of death after hospitalization for acute heart failure. There was no evident relationship between health literacy and 90-day rehospitalization or emergency department visits.
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Affiliation(s)
- Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN (C.D.M.N., A.B.S.)
| | - Courtney Cawthon
- Department of Medicine, Vanderbilt University, Nashville, TN (C.C., S.K., C.L.R.)
| | - Sunil Kripalani
- Department of Medicine, Vanderbilt University, Nashville, TN (C.C., S.K., C.L.R.)
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University, Nashville, TN (D.L.)
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN (C.D.M.N., A.B.S.)
| | - Christianne L Roumie
- Department of Medicine, Vanderbilt University, Nashville, TN (C.C., S.K., C.L.R.) Veterans Health Administration, Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN (C.L.R.)
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