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

Predictors and consequences of nonadherence to antihypertensive medication

Context: Nonadherence to antihypertensive therapy attributes to uncontrolled blood pressure. This may worsen the severity of hypertension and ultimately increase health care costs. This underlines the importance of identifying predictors and consequences of nonadherence to antihypertensive therapy. Objectives: (I) To empirically determine the length of gap between antihypertensive prescription refills that predicts long term prescription discontinuation. This gap can be used to define antihypertensive medication nonadherence. (II) To examine predictors of nonadherence and (III) To evaluate the role of nonadherence on rates of hospitalization and emergency room visits. Design, settings and subjects: For Objectives I and II, retrospective cohort designs were employed on 51,615 subjects enrolled in a large United States pharmacy benefit manager during Jan 1st 2003 and May 31st 2006. Subjects were included if they had [greater than or equal to] 2 prescriptions of antihypertensive medication, were new users and were [greater than or equal to] 30 years. For Objective III, a cross-sectional design was employed on 9,945 subjects aged 30-64 years continuously enrolled in New Jersey Medicaid between Jan 1999 and Dec 2001. For Objective I, Receiver Operating Characteristics (ROC) analysis was performed using maximum gap in anti hypertensive therapy as a predictor of long term treatment discontinuation. For Objective II, time to nonadherence was analyzed with the use of Cox Proportional Hazard Regression model. For Objective III, Log-Linear Regression analysis was utilized to estimate the risk of health care utilization associated with nonadherence Results: For Objective I, ROC analysis generated a C-statistic of 0.87. The cut-off value for maximum gap between refills that optimized sensitivity (0.81) and specificity (0.79) was 75 days. For Objective II, region of the country in which the subjects resided and subjects living in a census block with high percentage of African American population and low levels of income were found to be significant predictors of nonadherence. Subjects who were treated by cardiologists and younger physicians also had improved adherence. Objective III showed that subjects who were nonadherent to antihypertensive therapy had significantly higher rates of hospitalizations as well as emergency visits. Conclusion: Timely corrective interventions to improve adherence will have significant impact on the cost-effectiveness in the treatment of hypertension.Ph.D.Includes bibliographical references

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

BackgroundRelatively 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.MethodsA 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.ResultsOf 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).ConclusionsAcute 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

High-sensitivity C-reactive protein elevation in patients with prior myocardial infarction in the United States

ImportanceThe extent to which levels of high-sensitivity C-reactive protein (hs-CRP), a known marker of increased cardiovascular risk, are elevated and are associated with standard cardiovascular risk factors in patients with a history of myocardial infarction (MI) is unknown.ObjectivesTo determine the pattern and determinants of the distribution of hs-CRP in those with a prior MI in the United States using a nationally representative sample.Design and participantsAdults with hs-CRP data in the National Health and Nutrition Examination Surveys from 1999-2010.ResultsAmong 1296 individuals in our cohort, the median age was 65 years and the median hs-CRP level was 2.69 mg/L, measured an average of 7.1 years after the MI. Among these patients, 22% had hs-CRP levels of <1 mg/L, 61% had ≥2 mg/L, and 48% had ≥3 mg/L. Increasing hs-CRP was associated in a multivariable model with increasing body mass index (partial R2 [pR2] 0.113, P < .001), increasing non-high-density lipoprotein [HDL] (pR2 0.030, P < .001), increasing age (pR2 0.008, P = .017), and decreasing HDL (pR2 0.005, P = .046). Adjusted mean hs-CRP was also higher in women (3.6 vs 2.7 mg/L; P < .001), in people with hypertension (3.5 vs. 2.8, P = .030), and among smokers (4.2 vs 2.3 mg/L; P < .001), and lower in people with hyperlipidemia (2.8 vs. 3.5, P = .007). Standard cardiovascular risk factors accounted for only 22% of the variability in hs-CRP levels.Conclusions and relevanceAmong patients with prior MI, elevated hs-CRP is prevalent several years after the MI, and standard cardiovascular risk factors explain only a small proportion of hs-CRP variability. In light of emerging evidence on the importance of inflammation in the pathogenesis of cardiovascular disease, the high prevalence of elevated hs-CRP in patients with prior MI in the United States may have public health implications

Long-Term Mortality of Older Patients With Acute Myocardial Infarction Treated in US Clinical Practice.

BackgroundThere is limited information about the long-term survival of older patients after myocardial infarction (MI).Methods and resultsCRUSADE (Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines) was a registry of MI patients treated at 568 US hospitals from 2001 to 2006. We linked MI patients aged ≥65 years in CRUSADE to their Medicare data to ascertain long-term mortality (defined as 8 years post index event). Long-term unadjusted Kaplan-Meier mortality curves were examined among patients stratified by revascularization status. A landmark analysis conditioned on surviving the first year post-MI was conducted. We used multivariable Cox regression to compare mortality risks between ST-segment-elevation myocardial infarction and non-ST-segment-elevation myocardial infarction patients. Among 22 295 MI patients ≥ age 65 years (median age 77 years), we observed high rates of evidence-based medication use at discharge: aspirin 95%, β-blockers 94%, and statins 81%. Despite this, mortality rates were high: 24% at 1 year, 51% at 5 years, and 65% at 8 years. Eight-year mortality remained high among patients who underwent percutaneous coronary intervention (49%), coronary artery bypass graft (46%), and among patients who survived the first year post-MI (59%). Median survival was 4.8 years (25th, 75th percentiles 1.1, 8.5); among patients aged 65-74 years it was 8.2 years (3.3, 8.9) while for patients aged ≥75 years it was 3.1 years (0.6, 7.6). Eight-year mortality was lower among ST-segment-elevation myocardial infarction than non-ST-segment-elevation myocardial infarction patients (53% versus 67%); this difference was not significant after adjustment (hazard ratio 0.94, 95% confidence interval, 0.88-1.00).ConclusionsLong-term mortality remains high among patients with MI in routine clinical practice, even among revascularized patients and those who survived the first year