Abstract 103: Clinical Process and Outcome Improvements Based on Within Site Communication: Insights from the Patient Navigator Acute Myocardial Infarction and Heart Failure Program

Background: Team communication about hospital quality efforts in acute myocardial infarction and heart failure (AMI-HF) may affect compliance with hospital transitional care metrics. Methods: At 2 years, hospitals (n=35) participating in the Patient Navigator Program completed surveys on 5 types of communication (sharing meeting minutes, regular team meetings or conference calls with team leaders, a shared checklist, and electronic medical record (EMR)-directed communication) supporting program implementation. Results were assessed for association with 3 outcomes (30-day unadjusted AMI-HF readmission and in-hospital risk adjusted AMI death) and 14 processes: left ventricular systolic dysfunction evaluation, prescription of renin-angiotensin system and beta-blocker medications; identifying HF cases pre-discharge; medication reconciliation documentation on admission, discharge and both times [AMI-HF); planned follow-up in 7 days [HF]; documentation of self-care education and when to call healthcare providers [AMI-HF] and documentation of medication instructions, timing, and changes [AMI-HF]). In STEMI and NSTEMI, performance composites, overall defect free care and referral to cardiac rehabilitation were assessed. Univariate analyses were completed. Results: There were no differences in process or outcome metrics for sharing meeting minutes, regular team meetings or conference calls with leaders or using a shared checklist. EMR-directed communication was associated with a greater likelihood of discharge medication reconciliation (100% vs 68.4%, p=.027) and prescribed medication documentation, 100% vs 66.7%, p=.024). Sites that used 2-5 vs 0-1 communication types were more likely to identify patients with HF pre-discharge (100% vs 60%, p=.018), perform discharge medication reconciliation (100% vs 66.7%, p=.021), complete education documentation (93.3% vs 58.8%, p=.041) and medication instruction documentation (100% vs 64.7%, p=.019); but they were less likely to improve STEMI performance composite scores (37.5% vs 76.5%, p=.036). Conclusion: Team communication via EMR and using 2+ communication methods promoted some process metric improvements. Some communication methods may have had low use and process and outcome metrics that were unchanged may have been underpowered to detect differences

948-46 Preserved Cardiac Baroreflex Control of Renal Cortical Blood Flow in Advanced Heart Failure Patients: A Positron Emission Tomography Study

Cardiac baroreflex (CBR) control of forearm blood flow (FBF) is blunted or reversed in humans with heart failure (HF). but little is known about CBR control of renal cortical blood flow (RCBF) in HF due to technical limitations. Positron emission tomography (PET) 0–15 water is a new, precise method to measure RCBF quantitatively. We compared CBR control of RCBF and FBF (venous plethysmography) in 8 patients with HF (mean age, 47±3 y, ejection fraction 0.25±0.02) and 10 normal humans (mean age 35±5 y) during CBR unloading with phlebotomy (450ml). In 5 normals, cold pressor test was used as a strong, non-baroreflex mediated stimulus to vasoconstriction.ResultsPhlebotomy decreased central venous pressure (p <0.001), but did not change mean arterial pressure or heart rate in HF patients or controls. The major findings of the study are: 1) At rest, RCBF is markedly diminished in HF vs normals (2.4±0.1 vs 4.3±0.2ml/min/g, p < 0.001). 2) In normal humans during phlebotomy, FBF decreased substantially (basal vs phlebotomy: 3.3±0.4 vs 2.6±0.3 ml/min/100 ml, p=0.021, and RCBF decreased slightly, but significantly (basal vs phlebotomy: 4.3±0.2 vs 4.0±0.3 ml/min/g, p=0.01). 3) The small magnitude of reflex renal vasoconstriction is not explained by the inability of the renal circulation to vasoconstrict since the cold pressor stimulus induced substantial decreases in RCBF in normals (basal vs cold pressor: 4.4±0.1 vs 3.7±0.1 ml/min/g, p=0.003). 4) In humans with heart failure during phlebotomy, FBF did not change (basal vs phlebotomy: 2.6±0.3 vs 2.7±0.2 ml/min/100 ml, p=NS), but RCBF decreased slightly but significantly (basal vs phlebotomy: 2.4±0.1 vs 2.1±0.1 ml/min/g, p=0.01). Thus, in patients with heart failure, there is an abnormality in cardiopulmonary baroreflex control of the forearm circulation, but not the renal circulationConclusionThis study 1) shows the power of PET to study physiologic and pathophysiologic reflex control of the renal circulation in humans, and 2) describes the novel finding of selective dysfunction of cardiac baroreflex control of the forearm circulation, but its preservation of the renal circulation, in patients with heart failur

Differences in health care use and outcomes by the timing of in-hospital worsening heart failure

BACKGROUND: Patients hospitalized with acute heart failure may experience worsening symptoms requiring escalation of therapy. In-hospital worsening heart failure is associated with worse in-hospital and postdischarge outcomes, but associations between the timing of worsening heart failure and outcomes are unknown. METHODS: Using data from a large clinical registry linked to Medicare claims, we examined characteristics, outcomes, and costs of patients hospitalized for acute heart failure. We defined in-hospital worsening heart failure by the use of inotropes or intravenous vasodilators or initiation of mechanical circulatory support, hemodialysis, or ventilation. The study groups were early worsening heart failure (n = 1,990), late worsening heart failure (n = 4,223), complicated presentation (n = 15,361), and uncomplicated hospital course (n = 41,334). RESULTS: Among 62,908 patients, those with late in-hospital worsening heart failure had higher in-hospital and postdischarge mortality than patients with early worsening heart failure or complicated presentation. Those with early or late worsening heart failure had more frequent all-cause and heart failure readmissions at 30 days and 1 year, with resultant higher costs, compared with patients with an uncomplicated hospital course. CONCLUSION: Although late worsening heart failure was associated with the highest mortality, both early and late worsening heart failures were associated with more frequent readmissions and higher health care costs compared to uncomplicated hospital course. Prevention of worsening heart failure may be an important focus in the care of hospitalized patients with acute heart failure

Improving survival for patients with advanced heart failure: A study of 737 consecutive patients

Objectives.This study sought to determine whether survival and risk of sudden death have improved for patients with advanced heart failure referred for consideration for heart transplantation as advances in medical therapy were systematically implemented over an 8-year period.Background.Recent survival trials in patients with mild to moderate heart failure and patients after a myocardial infarction have shown that angiotensin-converting enzyme inhibitors are beneficial, type I antiarrhythmic drugs can be detrimental, and amiodarone may be beneficial in some groups. The impact of advances in therapy may be enhanced or blunted when applied to severe heart failure.Methods.One-year mortality and sudden death were determined in relation to time, baseline variables and therapeutics for 737 consecutive patients referred for heart transplantation and discharged home on medical therapy from 1986 to 1988, 1989 to 1990 and 1991 to 1993. Medical care was directed by a single team of physicians with policies established by consensus. From 1986 to 1990, the hydralazine/isosorbide dinitrate combination or angiotensin-converting enzyme inhibitors were the initial vasodilators, and class I antiarrhythmic drugs were allowed. After 1990, captopril was the initial vasodilator, given to 86% of patients compared with 46% of patients before 1989. After mid-1989, class I agents were routinely withdrawn, and amiodarone was used for frequent ventricular ectopic beats or atrial fibrillation (53% of patients after 1990 vs. 10% before 1989).Results.The total 1-year mortality rate decreased from 33% before 1989 to 16% after 1990 (p = 0.0001), and sudden death decreased from 20% to 8% (p = 0.0006). Adjusted for clinical and hemodynamic variables in multivariate proportional hazards models, total mortality and sudden death were lower after 1990.Conclusions.The large reduction in mortality, particularly in sudden death, from advanced heart failure since 1990 may reflect an enhanced impact of therapeutic advances shown in large randomized trials when they are incorporated into a comprehensive approach in this population. This improved survival supports the growing practice of maintaining potential heart transplant candidates on optimal medical therapy until clinical decompensation mandates transplantation

Primary Prevention Implantable Cardioverter-Defibrillators and Survival in Older Women

ObjectivesThe purpose of this study was to assess the benefit of primary prevention implantable cardioverter defibrillators (ICDs) in women.BackgroundClinical trials of primary prevention ICDs enrolled a limited number of women.MethodsUsing a propensity score method, we matched 490 women ≥65 years of age who received an ICD during a hospitalization for heart failure in the National Cardiovascular Data Registry ICD Registry from January 1, 2006, through December 31, 2007, to 490 ICD-eligible women without an ICD hospitalized for heart failure in the Get With The Guidelines for Heart Failure database from January 1, 2006, through December 31, 2009. The primary endpoint was all-cause mortality obtained from the Medicare Claims Database. An identical analysis was conducted in men.ResultsMedian follow-up for patients with an ICD was 4.6 years versus 3.2 years for patients with no ICD. Compared with women with no ICD, those with an ICD were younger and less frequently white. In the matched cohorts, the survival of women with an ICD was significantly longer than that of women without an ICD (adjusted hazard ratio: 0.79, 95% confidence interval: 0.66 to 0.95; p = 0.013). Similarly, men with an ICD had longer survival than men without an ICD (adjusted hazard ratio: 0.73, 95% confidence interval: 0.65 to 0.83; p < 0.0001). There was no interaction between sex and the presence of an ICD with respect to survival (p = 0.44).ConclusionsAmong older women with left ventricular dysfunction, a primary prevention ICD was associated with a significant survival benefit that was nearly identical to that seen in men. These findings support the use of primary prevention ICDs in eligible patients regardless of sex

Optimizing fluid management in patients with acute decompensated heart failure (ADHF): the emerging role of combined measurement of body hydration status and brain natriuretic peptide (BNP) levels

The study tests the hypothesis that in patients admitted with acutely decompensated heart failure (ADHF), achievement of adequate body hydration status with intensive medical therapy, modulated by combined bioelectrical vectorial impedance analysis (BIVA) and B-type natriuretic peptide (BNP) measurement, may contribute to optimize the timing of patient’s discharge and to improve clinical outcomes. Three hundred patients admitted for ADHF underwent serial BIVA and BNP measurement. Therapy was titrated to reach a BNP value of <250 pg/ml, whenever possible. Patients were categorized as early responders (rapid BNP fall below 250 pg/ml); late responders (slow BNP fall below 250 pg/ml, after aggressive therapy); and non-responders (BNP persistently >250 pg/ml). Worsening of renal function (WRF) was evaluated during hospitalization. Death and rehospitalization were monitored with a 6-month follow-up. BNP value on discharge of ≤250 pg/ml led to a 25% event rate within 6 months (Group A: 17.4%; Group B: 21%, Chi2; n.s.), whereas a value >250 pg/ml (Group C) was associated with a far higher percentage (37%). At discharge, body hydration was 73.8 ± 3.2% in the total population and 73.2 ± 2.1, 73.5 ± 2.8, 74.1 ± 3.6% in the three groups, respectively. WRF was observed in 22.3% of the total. WRF occurred in 22% in Group A, 32% in Group B, and 20% in Group C (P = n.s.). Our study confirms the hypothesis that combined BNP/BIVA sequential measurements help to achieve adequate fluid balance status in patients with ADHF and can be used to drive a “tailored therapy,” allowing clinicians to identify high-risk patients and possibly to reduce the incidence of complications secondary to fluid management strategies

Exploring the equity of GP practice prescribing rates for selected coronary heart disease drugs: a multiple regression analysis with proxies of healthcare need

Background There is a small, but growing body of literature highlighting inequities in GP practice prescribing rates for many drug therapies. The aim of this paper is to further explore the equity of prescribing for five major CHD drug groups and to explain the amount of variation in GP practice prescribing rates that can be explained by a range of healthcare needs indicators (HCNIs). Methods The study involved a cross-sectional secondary analysis in four primary care trusts (PCTs 1–4) in the North West of England, including 132 GP practices. Prescribing rates (average daily quantities per registered patient aged over 35 years) and HCNIs were developed for all GP practices. Analysis was undertaken using multiple linear regression. Results Between 22–25% of the variation in prescribing rates for statins, beta-blockers and bendrofluazide was explained in the multiple regression models. Slightly more variation was explained for ACE inhibitors (31.6%) and considerably more for aspirin (51.2%). Prescribing rates were positively associated with CHD hospital diagnoses and procedures for all drug groups other than ACE inhibitors. The proportion of patients aged 55–74 years was positively related to all prescribing rates other than aspirin, where they were positively related to the proportion of patients aged >75 years. However, prescribing rates for statins and ACE inhibitors were negatively associated with the proportion of patients aged >75 years in addition to the proportion of patients from minority ethnic groups. Prescribing rates for aspirin, bendrofluazide and all CHD drugs combined were negatively associated with deprivation. Conclusion Although around 25–50% of the variation in prescribing rates was explained by HCNIs, this varied markedly between PCTs and drug groups. Prescribing rates were generally characterised by both positive and negative associations with HCNIs, suggesting possible inequities in prescribing rates on the basis of ethnicity, deprivation and the proportion of patients aged over 75 years (for statins and ACE inhibitors, but not for aspirin)

What’s Next for Acute Heart Failure Research?

Each year over one million patients with acute heart failure (AHF) present to a United States emergency department (ED). The vast majority are hospitalized for further management. The length of stay and high postdischarge event rate in this cohort have changed little over the past decade. Therapeutic trials have failed to yield substantive improvement in postdischarge outcomes; subsequently, AHF care has changed little in the past 40 years. Prior research studies have been fragmented as either “inpatient” or “ED-based.” Recognizing the challenges in identification and enrollment of ED patients with AHF, and the lack of robust evidence to guide management, an AHF clinical trials network was developed. This network has demonstrated, through organized collaboration between cardiology and emergency medicine, that many of the hurdles in AHF research can be overcome. The development of a network that supports the collaboration of acute care and HF researchers, combined with the availability of federally funded infrastructure, will facilitate more efficient conduct of both explanatory and pragmatic trials in AHF. Yet many important questions remain, and in this document our group of emergency medicine and cardiology investigators have identified four high-priority research areas