Prognostic Impact of Cardiovascular versus Noncardiovascular Hospitalizations in Heart Failure with Preserved Ejection Fraction: Insights from TOPCAT

BACKGROUND

Patients with heart failure (HF) with preserved ejection fraction (HFpEF) are commonly admitted to the hospital for both cardiovascular (CV) and noncardiovascular (non-CV) reasons. The prognostic implications of non-CV hospitalizations in this population are not well understood. In this study, we aimed to examine the prognostic implications of hospitalizations due to CV and non-CV reasons in a HFpEF population.

METHODS AND RESULTS

The Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial (TOPCAT) randomized 3,445 stable outpatients with chronic HF with left ventricular ejection fraction >=45% and either prior hospitalization for HF or elevated natriuretic peptides to treatment with spironolactone or placebo. Hospitalizations for any cause were reported by investigators during study follow-up and characterized according to prespecified category causes. This analysis focused on the subset of TOPCAT participants enrolled in the Americas (N=1,767), in which 2,973 hospitalizations were observed in 1,062 subjects (60%) over a mean follow-up of 3.3 years of study follow-up, of which 1,474 (49%) were ascribed to CV causes. Among 1,056 first hospitalizations, 478 (45%) were for CV reasons and 578 (55%) for non-CV reasons. Mortality rates were lowest for participants not hospitalized during the trial (3.2 per 100 patient-years (PY)), but similarly elevated following first hospitalization for CV and non-CV reasons (11.0 per 100 PY vs. 12.6 per 100 PY, respectively, p=0.24). Among those hospitalized for CV reasons, mortality rates were similar following hospitalization for HF and non-CV related reasons (15.2 per 100 PY vs. 12.6 per 100 PY, p=0.23). Recurrent hospitalization, whether due to CV or non-CV causes, was associated with heightened risk for subsequent mortality, with similar death rates following hospitalization twice for CV reasons (18.5 per 100 PY), twice for non-CV reasons (21.6 per 100 PY), or once each for CV and non-CV reasons (18.4 per 100 PY).

CONCLUSION

Among patients with HFpEF, hospitalization for any cause is associated with heightened risk for post-discharge mortality, with even higher risk associated with recurrent hospitalization. Given the high burden of non-CV hospitalizations in this population, targeted management of comorbid medical illness may be critical to reducing morbidity and mortality.

Reducing Hospital Admissions for Patients with Heart Failure by Implementing the Chronic Care Management Framework: A Cost, Quality and Satisfaction Improvement Project

OBJECTIVE

To reduce the rate of hospital admissions, and increase the perception of coordinated care for patients with heart failure and associated co-morbidities through improvement of interdisciplinary communication.

BACKGROUND

Heart failure patients with associated multi-morbidities and multiple provider visits are often left to navigate the health system independently. Limited provider to provider communication contributes to care fragmentation, unnecessary utilization and decreased satisfaction.

METHODS

A nurse led complex care management improvement project imbedded care plans and formal and informal collaborative care conferences to improve interprofessional communication across the care continuum.

RESULTS

Hospital admissions decreased by 62% and length of stay decreased by 73% (n = 47, p < .001). Using paired t-test, satisfaction questions improved post intervention, and one was statistically significant (p < 0.05).

CONCLUSION

Improved communication strategies decreased hospital admissions and length of stay in one large Pacific Northwest health system. Days subject to readmission penalties decreased by 98% with a variance in pre-post charges of $615,000.

IMPLICATION FOR NURSES

Nurses and nurse leaders play a significant role in achieving the Triple Aim and can be instrumental in developing small multidisciplinary teams targeting improved coordination across settings and sectors.

Multi-morbidities are Not a Driving Factor for an Increase of COPD-Related 30-Day Readmission Risk

Background and Objective

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. COPD is expensive to treat, whereas the quality of care is difficult to evaluate due to the high prevalence of multi-morbidity among COPD patients. In the US, the Hospital Readmissions Reduction Program (HRRP) was initiated by the Centers for Medicare and Medicaid Services to penalize hospitals for excessive 30-day readmission rates for six diseases, including COPD. This study examines the difference in 30-day readmission risk between COPD patients with and without comorbidities.

Methods

In this retrospective cohort study, we used Cox regression to estimate the hazard ratio of 30-day readmission rates for COPD patients who had no comorbidity and those who had one, two or three, or four or more comorbidities. We controlled for individual, hospital and geographic factors. Data came from three sources: Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), Area Health Resources Files (AHRF) and the American Hospital Association’s (AHA's) annual survey database for the year of 2013.

Results

COPD patients with comorbidities were less likely to be readmitted within 30 days relative to patients without comorbidities (aHR from 0.84 to 0.87, p < 0.05). In a stratified analysis, female patients with one comorbidity had a lower risk of 30-day readmission compared to female patients without comorbidity (aHR = 0.80, p < 0.05). Patients with public insurance who had comorbidities were less likely to be readmitted within 30 days in comparison with those who had no comorbidity (aHR from 0.79 to 0.84, p < 0.05).

Conclusion

COPD patients with comorbidities had a lower risk of 30-day readmission compared with patients without comorbidity. Future research could use a different study design to identify the effectiveness of the HRRP.

Aging Trajectories in Different Body Systems Share Common Environmental Etiology: The Healthy Aging Twin Study (HATS)

Little is known about the extent to which aging trajectories of different body systems share common sources of variance. We here present a large twin study investigating the trajectories of change in five systems: cardiovascular, respiratory, skeletal, morphometric, and metabolic. Longitudinal clinical data were collected on 3,508 female twins in the TwinsUK registry (complete pairs:740 monozygotic (MZ), 986 dizygotic (DZ), mean age at entry 48.9 ± 10.4, range 18-75 years; mean follow-up 10.2 ± 2.8 years, range 4-17.8 years). Panel data on multiple age-related variables were used to estimate biological ages for each individual at each time point, in linear mixed effects models. A weighted average approach was used to combine variables within predefined body system groups. Aging trajectories for each system in each individual were then constructed using linear modeling. Multivariate structural equation modeling of these aging trajectories showed low genetic effects (heritability), ranging from 2% in metabolic aging to 22% in cardiovascular aging. However, we found a significant effect of shared environmental factors on the variations in aging trajectories in cardiovascular (54%), skeletal (34%), morphometric (53%), and metabolic systems (53%). The remainder was due to environmental factors unique to each individual plus error. Multivariate Cholesky decomposition showed that among aging trajectories for various body systems there were significant and substantial correlations between the unique environmental latent factors as well as shared environmental factors. However, there was no evidence for a single common factor for aging. This study, the first of its kind in aging, suggests that diverse organ systems share non-genetic sources of variance for aging trajectories. Confirmatory studies are needed using population-based twin cohorts and alternative methods of handling missing data.