Resource utilisation, charges and mortality following hospital inpatient admission for congestive heart failure among the elderly in the US

Effects of high-quality nursing care on psychological outcomes in patients with chronic heart failure

BACKGROUND

This study will assess the effects of high quality nursing care (HQNC) on psychological outcomes (PCO) in patients with chronic heart failure (CHF).

METHODS

We will carry out a through search in 7 databases: PUBMED, EMBASE, Cochrane Library, Web of Science, Chinese Biomedical Literature Database, WANGFANG, and China National Knowledge Infrastructure. Eligibility criteria will be randomized controlled trials on assessing effects of HQNC on PCO in patients with CHF. Cochrane risk of bias evaluation will be utilized for methodological quality.

RESULTS

This proposed study will summarize a rational synthesis of current evidence for HQNC on PCO in patients with CHF.

CONCLUSION

The results of this study will provide convinced evidence for judging the effects of HQNC on PCO in patients with CHF.

Systematic review of economic burden of heart failure

The aim of this study is to perform a systematic review of the costing methodological approaches adopted by published cost-of-illness (COI) studies. A systematic review was performed to identify cost-of-illness studies of heart failure published between January 2003 and September 2015 via computerized databases such as Pubmed, Wiley Online, Science Direct, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Costs reported in the original studies were converted to 2014 international dollars (Int$). Thirty five out of 4972 studies met the inclusion criteria. Nineteen out of the 35 studies reported the costs as annual cost per patient, ranging from Int$ 908.00 to Int$ 84,434.00, while nine studies reported costs as per hospitalization, ranging from Int$ 3780.00 to Int$ 34,233.00. Cost of heart failure increased as condition of heart failure worsened from New York Heart Association (NYHA) class I to NYHA class IV. Hospitalization cost was found to be the main cost driver to the total health care cost. The annual cost of heart failure ranges from Int$ 908 to Int$ 40,971 per patient. The reported cost estimates were inconsistent across the COI studies, mainly due to the variation in term of methodological approaches such as disease definition, epidemiological approach of study, study perspective, cost disaggregation, estimation of resource utilization, valuation of unit cost components, and data sources used. Such variation will affect the reliability, consistency, validity, and relevance of the cost estimates across studies.

Gender differences in self-care maintenance and its associations among patients with chronic heart failure

Objectives

To identify the gender differences in self-care maintenance and its associations among chronic heart failure patients using the Information-Motivation-Behavioral Skills model.

Methods

Two hundred and ten patients (54.0% female) with chronic heart failure participated in this cross-sectional study. Self-care, knowledge of heart failure, social support and illness perception were measured using the Self-Care of Heart Failure Index, the questionnaire of heart failure knowledge, the Perceived Social Support Scale, and the Revised Illness Perception Questionnaire, respectively.

Results

Mean scores for self-care maintenance were 51.4 ± 14.8 in men and 55.6 ± 14.1 in women (t = -2.066, P < 0.05). Associated factors of self-care maintenance were social support and self-care confidence in men and the knowledge of heart failure, self-care management and self-care confidence in women. The relationship between social support and self-care maintenance was meditated by self-care confidence in men, whereas the relationship between knowledge of heart failure and self-care maintenance was meditated by self-care management and self-care confidence in women.

Conclusions

Self-care maintenance were inadequate in both genders with chronic heart failure. Interventions for enhancing social support and self-care confidence in men patients, and strengthening knowledge of heart failure, self-care management and self-care confidence in women patients, may facilitate self-care maintenance.

Clustered Emergency Room Visits Following an Acute Heart Failure Admission: A Population-Based Study

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.

Medical resource use and expenditure in patients with chronic heart failure: a population-based analysis of 88 195 patients

AIMS

Heart failure (HF) is one of the diseases with greater healthcare expenditure. However, little is known about the cost of HF at a population level. Hence, our aim was to study the population-level distribution and predictors of healthcare expenditure in patients with HF.

METHODS AND RESULTS

This was a population-based longitudinal study including all prevalent HF cases in Catalonia (Spain) on 31 December 2012 (n = 88 195). We evaluated 1-year healthcare resource use and expenditure using the Health Department (CatSalut) surveillance system that collects detailed information on healthcare usage for the entire population. Mean age was 77.4 (12) years; 55% were women. One-year mortality rate was 14%. All-cause emergency department visits and unplanned hospitalizations were required at least once in 53.4% and 30.8% of patients, respectively. During 2013, a total of €536.2 million were spent in the care of HF patients (7.1% of the total healthcare budget). The main source of expenditure was hospitalization (39% of the total) whereas outpatient care represented 20% of the total expenditure. In the general population, outpatient care and hospitalization were the main expenses. In multivariate analysis, younger age, higher presence of co-morbidities, and a recent HF or all-cause hospitalization were independently associated with higher healthcare expenditure.

CONCLUSIONS

In Catalonia, a large portion of the annual healthcare budget is devoted to HF patients. Unplanned hospitalization represents the main source of healthcare-related expenditure. The knowledge of how expenditure is distributed in a non-selected HF population might allow health providers to plan the distribution of resources in patients with HF.

Comparison of management and outcomes of ED patients with acute decompensated heart failure between the Canadian and United States' settings

Introduction The objective of this study was to compare the emergency department (ED) management and rate of admission of acute decompensated heart failure (ADHF) between two hospitals in Canada and the United States and to compare the outcomes of these patients.

METHODS

This was a health records review of adults presenting with ADHF to two EDs in Canada and the United States between January 1 and April 30, 2010. Outcome measures were admission to the hospital, myocardial infarction (MI), and death or relapse rates to the ED. Data were analysed using descriptive, univariate and multivariate analyses.

RESULTS

In total, 394 cases were reviewed and 73 were excluded. Comparing 156 Canadian to 165 U.S. patients, respectively, mean age was 76.0 and 75.8 years; male sex was 54.5% and 52.1%. Canadian and U.S. ED treatments were noninvasive ventilation 7.7% v. 12.8% (p=0.13); IV diuretics 77.6% v. 36.0% (p<0.001); IV nitrates 4.5% v. 6.7% (p=0.39). There were significant differences in rate of admission (50.6% v. 95.2%, p<0.001) and length of stay in ED (6.7 v. 3.0 hours, p<0.001). Proportion of Canadian and U.S. patients who died within 30 days of the ED visit was 5.1% v. 9.7% (p=0.12); relapsed to the ED within 30 days was 20.8% v. 17.5% (p=0.5); and had MI within 30 days was 2.0% v. 1.9% (p=1.0).

CONCLUSIONS

The U.S. and Canadian centres saw ADHF patients with similar characteristics. Although the U.S. site had almost double the admission rate, the outcomes were similar between the sites, which question the necessity of routine admission for patients with ADHF.

Factors associated with variations in hospital expenditures for acute heart failure in the United States

BACKGROUND

Relatively little contemporary data are available that describe differences in acute heart failure (AHF) hospitalization expenditures as a function of patient and hospital characteristics, especially from a population-based investigation. This study aimed to evaluate factors associated with variations in hospital expenditures for AHF in the United States.

METHODS

A cross-sectional analysis using discharge data from the 2011 Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, was conducted. Discharges with primary International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes for AHF in adults were included. Costs were estimated by converting Nationwide Inpatient Sample charge data using the Healthcare Cost and Utilization Project Cost-to-Charge Ratio File. Discharges with highest (≥80th percentile) versus lowest (≤20th percentile) costs were compared for patient characteristics, hospital characteristics, utilization of procedures, and outcomes.

RESULTS

Of the estimated 1 million AHF hospital discharges, the mean cost estimates were $10,775 per episode. Younger age, higher percentage of obesity, atrial fibrillation, pulmonary disease, fluid/electrolyte disturbances, renal insufficiency, and greater number of cardiac/noncardiac procedures were observed in stays with highest versus lowest costs. Highest-cost discharges were more likely to be observed in urban and teaching hospitals. Highest-cost AHF discharges also had 5 times longer length of stay, were 9 times more costly, and had higher in-hospital mortality (5.6% vs 3.5%) compared with discharges with lowest costs (all P < .001).

CONCLUSIONS

Acute heart failure hospitalizations are costly. Expenditures vary markedly among AHF hospitalizations in the United States, with substantial differences in patient and hospital characteristics, procedures, and in-hospital outcomes among discharges with highest compared with lowest costs.

The use of comorbidities among adults experiencing care transitions: a systematic review and evolutionary analysis of empirical literature

OBJECTIVE

To systematically review how comorbidities are employed in the empirical literature for adults coping with multiple chronic conditions during common episodes of acute illness that resulted in transition across health care setting.

METHODS

Evolutionary concept analysis inductively identifies current consensus regarding the usage of a concept and results in exploring attributes and clarification of the concept. Sixty studies from 1965 to 2009 identified from MEDLINE, CINAHL, PsychINFO, and ISI Web of Science databases were analysed.

RESULTS

Comorbidities were used heterogeneously among reviewed studies with most controlling for their presence (n=33) and lacking robust measurement (n=37). The designation of index or principal condition was equally heterogeneous with approximately half (n=26) representing the main disease or diagnosis of interest to the researcher. In this study comorbidities were associated with personal, disease or system level antecedents and consequences. A conceptual framework is proposed.

DISCUSSION

The impact of comorbidities on the care and outcomes of adults coping with multiple chronic conditions is limited by heterogeneous and ambiguous usage. While analytic techniques have become more sophisticated, continued lack of meaningful conceptualization and instrument use has limited maturation of this important concept for research, practice and policy purposes.

The challenge of heart failure discharge from the emergency department

Acute decompensated heart failure is a common reason for presentation to the emergency department and is associated with high rates of admission to hospital. Distinguishing between higher-risk patients needing hospitalization and lower-risk patients suitable for discharge home is important to optimize both cost-effectiveness and clinical outcomes. However, this can be challenging and few validated risk stratification tools currently exist to help clinicians. Some prognostic variables predict risks broadly in those who are admitted or discharged from the emergency department. Risk stratification methods such as the Emergency Heart Failure Mortality Risk Grade and Acute Heart Failure Index clinical decision support tools, which utilize many of these predictors, have been found to be accurate in identifying low-risk patients. The use of observation units may also be a cost-effective adjunctive strategy that can assist in determining disposition from the emergency department.