Recurrent heart failure hospitalizations increase the risk of mortality in heart failure patients with atrial fibrillation and type 2 diabetes mellitus in the United Kingdom: a retrospective analysis of Clinical Practice Research Datalink database

BACKGROUND

Heart failure (HF) is a global illness and is a leading cause of hospitalizations. Recurrent HF hospitalization (HFH) is associated with increased risk of cardiovascular (CV) and all-cause mortality, thereby burdening the health system. Type 2 diabetes mellitus (T2DM) and atrial fibrillation (AF) are two important comorbidities in patients living with HF. This study aims to assess the association between recurrent HFHs with CV and all-cause mortality in patients living with HF and having AF and/or T2DM.

METHODS

This study was conducted using primary care data from the Clinical Practice Research Datalink database with linkage to hospital data and mortality data. Adults living with HF and with at least 1 HFH were identified from January 2010 to December 2014. Patients were grouped based on the number of recurrent HFHs. During follow-up, all-cause mortality or CV mortality for the HF population with AF and T2DM was recorded.

RESULTS

Overall, 32.9% of 2344 T2DM patients and 28.2% of 4585 AF patients had at least 1 recurrent HFH. The patients were relatively elderly and were predominantly male. The mean number of all-cause hospitalizations in HF patients having T2DM and AF, with ≥ 1 recurrent HFH were significantly higher than patients without recurrent HFH. The annualized mortality rates in CV mortality as the primary cause and for all-cause mortality and increased with recurrent HFHs, in T2DM and AF patients. The risk of CV mortality as primary cause and all cause morality were 5.39 and 3.19 times higher in T2DM patients with 3 recurrent HFHs versus no recurrent HFH. Similarly, the risk of CV mortality as primary cause and all cause morality was 5.98 and 4.3 times higher in AF patients with 3 recurrent HFHs versus those with no recurrent HFH.

CONCLUSIONS

Recurrent HFHs are strongly associated with CV mortality and all-cause mortality in HF patients with TD2M or AF. The hospitalization rate highlights the need for treatment and disease management, which will improve the course of the disease and help patients stay out of hospital.

Recurrent heart failure hospitalizations are associated with increased cardiovascular mortality in patients with heart failure in Clinical Practice Research Datalink

Aims

Heart failure (HF) is a leading cause of hospitalization and is associated with high morbidity and mortality post‐diagnosis. Here, we examined the impact of recurrent HF hospitalization (HFH) on cardiovascular (CV) and all‐cause mortality among HF patients.

Methods and Results

Adult HF patients identified in the Clinical Practice Research Datalink with a first (index) hospitalization due to HF recorded in the Hospital Episode Statistics data set from January 2010 to December 2014 were included. Patients were followed up until death or end of study (December 2017). CV mortality as primary and as any reported cause and all‐cause mortality were evaluated. An extended Cox regression model was used for reporting adjusted relative CV mortality rates for time‐dependent recurrent HFHs. Overall, 8603 HF patients with an index hospitalization were included, providing 15 964 patient‐years of follow‐up. Patients were relatively old (median age: 80 years) and were mostly male (54.6%), with main co‐morbidities being hypertension and atrial fibrillation. Recurrent HFHs occurred one, two, three, and more than four times in 1561 (18.2%), 518 (6.02%), 206 (2.4%), and 153 (1.8%) patients, respectively. The median time to mortality was 215 (38–664) days for 50.8% of patients who died for any cause during the study period and 139 (27–531) days for 31.3% who died with CV reasons as primary cause. Compared with those of patients without recurrent HFHs, the adjusted hazard ratios (95% CI) for CV mortality as primary cause were 2.65 (2.35–2.99), 3.69 (3.06–4.43), 5.82 (4.48–7.58), and 5.95 (4.40–8.05) for those with one, two, three, and more than four recurrent HFHs.

Conclusions

There is a strong association between recurrent HFH and CV mortality, with the risk increasing progressively with each recurrent HFH.

3267Impact of recurrent heart failure hospitalizations on cardiovascular mortality in subpopulations with atrial fibrillation and Type 2 diabetes mellitus in a UK database

Background

Previous studies have suggested that recurrent heart failure hospitalizations (HFh) are a predictor of cardiovascular (CV) and all-cause mortality. Patients with atrial fibrillation (AF) or type 2 diabetes mellitus (T2DM) may be at increased risk.

Purpose

This real-world study examined the impact of recurrent HFh on CV mortality in subgroups of patients with (i) AF or (ii) T2DM in the UK.

Methods

Adult HF patients identified in the CPRD database with a first (index) hospitalization due to HF recorded in the HES dataset from 01/01/2010 to 31/12/2014 and with a claim for AF or T2DM (not mutually exclusive) within the year prior to the index hospitalization were included. Patients were followed until death, transfer out or end of study period (31/12/2017). CV death as primary cause and death due to any cause were evaluated. An extended Cox regression model was used for reporting adjusted relative CV mortality rates for time dependent recurrent HFh.

Results

4585 (53.30%) HF patients with AF and 2344 (27.25%) HF patients with T2DM were included, providing 7846 and 4269 patient-years follow-up, respectively. Patients were relatively old (median [IQR] age of 81 [74–87] and 78 [70–84]) and majority were male (54.2% and 59.1%, respectively). All-cause and CV mortality rates are provided in the table. Compared with those without recurrent HFh, the adjusted hazard ratios (95% CI) for CV death for the AF group were 2.6 (2.3–3.1), 3.2 (2.5–4.1), 5.8 (4.1–8.1) and 6.9 (4.6–10.5) for 1, 2, 3 and ≥4 recurrent HFh, and for the T2DM group were 2.2 (1.7–2.8), 3.3 (2.3–4.7), 5.1 (3.3–8.1) and 3.9 (2.3–6.6), respectively.

All-cause and CV mortality rates 0 Recurrent HFh 1 Recurrent HFh 2 Recurrent HFh 3 Recurrent HFh 4+ Recurrent HFh All patients AF n=3294 (71.8%) n=817 (17.8%) n=282 (6.2%) n=116 (2.5%) n=76 (1.2%) n=4585 (100.0%) Follow-up time (days) from respective recurrent HF hospitalization (median [IQR]) 345 [57–906] 118 [27–522] 80 [19–367] 54 [19–240] 126 [50–379] 254 [42–793] All-cause death (n (%)) 1755 (53.3%) 483 (59.1%) 159 (56.4%) 80 (69.0%) 46 (60.5%) 2523 (55.0%) CV death- primary cause (n (%)) 1059 (32.2%) 325 (39.8%) 109 (38.7%) 56 (48.3%) 34 (44.7%) 1583 (34.5%) T2DM n=1573 (67.1%) n=456 (19.5%) n=170 (7.3%) n=85 (3.6%) n=60 (2.6%) n=2344 (100.0%) Follow-up time (days) from respective recurrent HF hospitalization (median [IQR]) 360 [63–933] 198 [43–545] 68 [17–292] 106 [26–251] 160 [68–389] 267 [49–771] All-cause death (n (%)) 824 (52.4%) 248 (54.4%) 99 (58.2%) 51 (60.0%) 40 (66.7%) 1262 (53.8%) CV death – primary cause (n (%)) 501 (31.9%) 159 (34.9%) 69 (40.6%) 36 (42.4%) 26 (43.3%) 791 (33.8%)

Conclusion

Recurrent HFh are a strong predictor of CV death in the HF population with AF or with T2DM. The risk of CV and all-cause death increases with recurrent HFh in these subpopulations, highlighting the relevance of reducing hospitalizations in the management of HF patients with such comorbid conditions.

Treatment Initiation Patterns, Modifications, and Medication Adherence Among Newly Diagnosed Heart Failure Patients: A Retrospective Claims Database Analysis

BACKGROUND

Heart failure (HF) is a debilitating disease associated with high mortality and frequent hospitalizations. American College of Cardiology Foundation and American Heart Association (ACCF/AHA) guidelines recommend the following drug classes for HF treatment: angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor II blocker (ARB) for patients intolerant to ACEI, beta blocker (BB), and aldosterone antagonist (AA).

OBJECTIVE

To examine, in a real-word setting, the treatment initiation pattern among newly diagnosed HF patients in the United States, subsequent treatment modifications, hospitalizations and the impact of hospitalizations on therapy changes, and treatment adherence and persistence.

METHODS

Using medical and pharmacy claims data from the Truven Health MarketScan database, this retrospective cohort study included adult patients with ≥ 2 medical claims corresponding to an HF diagnosis (ICD-9-CM codes 428.x, 402.11, 402.91, 404.01, 404.11, 404.91, 404.03, 404.13, and 404.93) between April 2009 and March 2012. The date of the first claim was defined as the index date. Patients with continuous medical and pharmacy eligibility for a minimum of 12 months pre- and post-index were included in the analysis. Patients with an HF diagnosis in the 12 months before the index date were excluded. Index treatment (within 30 days post-index), subsequent treatment modification (class addition/removal) during the study period, hospitalization, and change in treatment after hospitalization (within 15 days after hospital discharge) were determined. Adherence was evaluated using the proportion of days covered (PDC) method, and persistence was defined as the proportion of patients remaining on index treatment after a defined period of time (12 months).

RESULTS

A total of 235,758 patients meeting the sample selection criteria were included in the analysis and were followed for a median of 28 months after the index date. Approximately 42% of patients were not prescribed any HF-specific treatment within 30 days post-index. Among those treated, prescriptions for ACEIs were filled by 46.42% of patients, ARBs by 17.07%, BBs by 75.62%, and AAs by 9.83%. Based on HF therapy class, monotherapy was prescribed to 51% of patients, bi-therapy to 40%, and triple therapy to 9%. More than 80% of patients experienced treatment modification during the median 28 months of follow-up. A total of 174,563 (74.0%) patients had at least 1 all-cause hospitalization (mean 1.11 [SD = 0.98]) per year, with a mean length of stay (LOS) of 7.19 [SD = 8.69] days. Within 12 months post-index, 85.7% of these patients experienced an all-cause hospitalization, with 29.6% having HF-related hospitalization (mean 0.18 [0.36]) and mean LOS of 5.85 [5.45] days. More than 60% of patients continued on the same therapy after all-cause or HF hospitalization. More patients on multiple therapies remained on the same treatment (73%-89%) compared with those treated with monotherapy (60%-73%) after the first HF hospitalization. Among patients untreated before hospitalization, 9.8% and 17% received treatment after all-cause and HF hospitalization, respectively. During the entire study period (median 28 months), 29% of patients did not have a prescription fill for HF-specific treatments. The median PDC was > 0.65, and considering a gap of 30 days between ends of supply from 1 medication fill to the subsequent fill, persistence ranged from 41% (AA) to 52% (BB).

CONCLUSIONS

Findings of this claims database analysis among 235,758 HF patients suggest that more than one third of newly diagnosed HF patients do not receive HF-specific medication within 30 days following initial diagnosis. Despite ACCF/AHA recommendations of initiating treatment with a combination of 2 HF drug classes, only 40% of patients had a prescription fill for bi-therapy. Hospitalization did not have a major impact on HF therapy prescribing patterns. To our knowledge, this is the first study to establish the impact of hospitalization on HF-specific treatment among newly diagnosed patients. Adherence and persistence were moderate across all HF therapies of interest. This analysis reveals the need for further research to better understand the reasons for the demonstrated delay in HF treatment initiation and limited use of guideline-directed medical therapy after initial diagnosis.

DISCLOSURES

This study was funded by Novartis Pharma AG, Basel, Switzerland. Deschaseaux, McSharry, Hudson, Agrawal, and Turner are permanent employees of Novartis. Concept and study design were contributed by Deschaseaux, Hudson, and Turner, along with McSharry. McSharry took the lead in data collection, along with Deschaseaux, Hudson, and Turner. Data interpretation was performed by Hudson, along with the other authors. The manuscript was written by Agrawal, along with Deschaseaux and Turner, and revised by Deschaseaux and Turner, along with the other authors.

Quality of life: but in whose judgement?

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The evolving role of the clinical nurse specialist

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