Outcomes in heart failure patients with preserved ejection fraction Mortality, readmission, and functional decline

AbstractObjectivesWe evaluated the six-month clinical trajectory of patients hospitalized for heart failure (HF) with preserved ejection fraction (EF), as the natural history of this condition has not been well established. We compared mortality, hospital readmission, and changes in functional status in patients with preserved versus depressed EF.BackgroundAlthough the poor prognosis of HF with depressed EF has been extensively documented, there are only limited and conflicting data concerning clinical outcomes for patients with preserved EF.MethodsWe prospectively evaluated 413 patients hospitalized for HF to determine whether EF ≥40% was an independent predictor of mortality, readmission, and the combined outcome of functional decline or death.ResultsAfter six months, 13% of patients with preserved EF died, compared with 21% of patients with depressed EF (p = 0.02). However, the rates of functional decline were similar among those with preserved and depressed EF (30% vs. 23%, respectively; p = 0.14). After adjusting for demographic and clinical covariates, preserved EF was associated with a lower risk of death (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.26 to 0.90; p = 0.02), but there was no difference in the risk of readmission (HR 1.01, 95% CI 0.72 to 1.43; p = 0.96) or the odds of functional decline or death (OR 1.01, 95% CI 0.59 to 1.72; p = 0.97).ConclusionsHeart failure with preserved EF confers a considerable burden on patients, with the risk of readmission, disability, and symptoms subsequent to hospital discharge, comparable to that of HF patients with depressed EF

Randomized trial of an education and support intervention to preventreadmission of patients with heart failure

AbstractObjectivesWe determined the effect of a targeted education and support intervention on the rate of readmission or death and hospital costs in patients with heart failure (HF).BackgroundDisease management programs for patients with HF including medical components may reduce readmissions by 40% or more, but the value of an intervention focused on education and support is not known.MethodsWe conducted a prospective, randomized trial of a formal education and support intervention on one-year readmission or mortality and costs of care for patients hospitalized with HF.ResultsAmong the 88 patients (44 intervention and 44 control) in the study, 25 patients (56.8%) in the intervention group and 36 patients (81.8%) in the control group had at least one readmission or died during one-year follow-up (relative risk = 0.69, 95% confidence interval [CI]: 0.52, 0.92; p = 0.01). The intervention was associated with a 39% decrease in the total number of readmissions (intervention group: 49 readmissions; control group: 80 readmissions, p = 0.06). After adjusting for clinical and demographic characteristics, the intervention group had a significantly lower risk of readmission compared with the control group (hazard ratio = 0.56, 95% CI: 0.32, 0.96; p = 0.03) and hospital readmission costs of $7,515 less per patient.ConclusionsA formal education and support intervention substantially reduced adverse clinical outcomes and costs for patients with HF

Trends in left ventricular assist device use and outcomes among Medicare beneficiaries, 2004–2011

Objective: To characterise the trends in the left ventricular assist device (LVAD) implantation rates and outcomes between 2004 and 2011 in the Medicare population. Since the approval of the HeartMate II in 2008, the use of LVADs has steadily climbed. Given the increase in LVAD use, issues around discharge disposition, post-implant hospitalisations and costs require further understanding. Methods: We examined LVAD implantation rates and short-term and long-term outcomes among Medicare fee-for-service beneficiaries hospitalised for LVAD implantation. We also conducted analyses among survivors 1-year post-discharge to examine rehospitalisation rates. Lastly, we reported Centers for Medicare & Medicaid Services (CMS) payments for both index hospitalisation and rehospitalisations 1 year post-discharge. Results: A total of 2152 LVAD implantations were performed with numbers increasing from 107 in 2004 to 612 in 2011. The 30-day mortality rate decreased from 52% to 9%, and 1-year mortality rate decreased from 69% to 31%. We observed no change in overall length of stay, but post-procedure length of stay increased. We also found an increase in home discharge dispositions from 26% to 53%. Between 2004 and 2010, the rehospitalisation rate increased and the number of hospital days decreased. The adjusted CMS payment for the index hospitalisation increased from $188 789 to$225 697 over time but decreased for rehospitalisation from $60 647 to$53 630. Conclusions: LVAD implantations increased over time. We found decreasing 30-day and 1-year mortality rates and increasing home discharge disposition. The proportion of patients rehospitalised among 1-year survivors remained high with increasing index hospitalisation cost, but decreasing post-implantation costs over time

Prevalence, Correlates, and Inter-hospital Variation of Early Outpatient Follow-up After Acute Myocardial Infarction

Computational Infrastructure and Informatics Poster SessionBackground: Early outpatient follow-up (EFU) after acute myocardial infarction (AMI) is strongly endorsed in guidelines and has been emphasized nationally as a means to improve transitions of care, medication adherence and outcomes. Currently, little is known about associations between patient characteristics and EFU or the variability in EFU across different hospitals. Methods: We compared patients with and without EFU within 1-month of discharge in the 24-center TRIUMPH registry of AMI patients. We excluded patients who died or did not complete 1-month follow-up. Since the 1-month follow-up interview occurred 4 weeks from enrollment at the time of hospital admission, we also excluded patients with long hospital stays (≥ 7 days) since these patients had less outpatient exposure time for follow-up. We used multivariable Poisson regression to identify the independent association between patient characteristics and site with EFU. Results: Of 2484 patients, 76% had EFU within 1 month of discharge. There was marked variation in the rate of EFU between hospitals (54% to 100%; Figure). Site differences remained significant after adjustment for patient characteristics. The independent patient-level correlates of achieved EFU were health insurance (RR 1.15, 95% CI 1.06-1.25) and African American race (RR 1.08, 95% CI 1.02-1.15). Other sociodemographic characteristics, co-morbidities, clinical factors, and discharge documentation of follow-up arrangements were not indpendent predictors of EFU. Conclusion: Almost 1 in 4 patients enrolled in TRIUMPH did not receive EFU after AMI. The rate of EFU varies substantially across hospitals and is related to insurance status. The lack of association between EFU and discharge documentation of follow-up arrangements suggests achieved follow-up may be a superior quality indicator. Further characterization of the approach for providing EFU is warranted

Decision making in advanced heart failure: A scientific statement from the american heart association

Shared decision making for advanced heart failure has become both more challenging and more crucial as duration of disease and treatment options have increased. High-quality decisions are chosen from medically reasonable options and are aligned with values, goals, and preferences of an informed patient. The top 10 things to know about decision making in advanced heart failure care are listed in Table 1