30-day Heart Failure Readmission Research Articles

Adapting evidence-informed peri-discharge complex interventions in reducing 30-day hospital readmissions for heart failure and COPD

ObjectiveTo select and refine evidence-informed peri-discharge complex interventions(abbrev. Interventions) for reducing 30-day hospital readmissions among Heart Failure(HF) and COPD patients in Hong Kong public healthcare system context using GRADE Evidence to Decision(EtD) framework. MethodsTwo 18-participant panels were recruited to carry out a two-step process for both conditions. In Step 1, participants were invited to prioritize Interventions and suggest important combinations of Interventions. In Step 2, based on the priority lists, participants were invited to conduct a two-round Delphi study for generating consensus-based Interventions for reducing 30-day hospital readmissions. GRADE EtD framework was used to guide the decision-making process, taking into consideration of benefits, harms, values and preferences, equity, acceptability, and feasibility. ResultsFive out of ten Interventions reached positive consensus for HF, while six reached positive consensus for COPD. Case management, discharge planning, patient education, self-management, and telephone follow-up were common components, and were considered as core elements for reducing 30-day hospital readmissions among HF and COPD patients in Hong Kong. Preliminary implementation issues mainly included governance and leadership, financing, health workforce development, service access and readiness, as well as empowerment of patients and caregivers. ConclusionsThis study successfully applied the GRADE EtD framework for starting the adaptation process of complex interventions and established a list of local stakeholders-endorsed Interventions for reducing 30-day hospital readmissions for HF and COPD in Hong Kong. Before implementing and maintaining these endorsed Interventions at scale in local context, further research to improve intervention-context fit as well as piloting and evaluation is necessary.

Evaluation Of Post-acute Follow-up On 30-day Heart Failure Readmission Rate In Patients With And Without Dialysis-dependent End Stage Renal Disease

Evaluation Of Post-acute Follow-up On 30-day Heart Failure Readmission Rate In Patients With And Without Dialysis-dependent End Stage Renal Disease

Quality of Care and Outcomes Among Patients Hospitalized for Heart Failure in Rural vs Urban US Hospitals

Prior studies have suggested patients with heart failure (HF) from rural areas have worse clinical outcomes. Contemporary differences between rural and urban hospitals in quality of care and clinical outcomes for patients hospitalized for HF remain poorly understood. To assess quality of care and clinical outcomes for US patients hospitalized for HF at rural vs urban hospitals. This retrospective cohort study analyzed 774 419 patients hospitalized for HF across 569 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry between January 1, 2014, and September 30, 2021. Postdischarge outcomes were assessed in a subset of 161 996 patients linked to Medicare claims. Data were analyzed from August 2022 to January 2023. GWTG-HF quality measures, in-hospital mortality, length of stay, and 30-day mortality and readmission outcomes. This study included 19 832 patients (2.6%) and 754 587 patients (97.4%) hospitalized at 49 rural hospitals (8.6%) and 520 urban hospitals (91.4%), respectively. Of 774 419 included patients, 366 161 (47.3%) were female, and the median (IQR) age was 73 (62-83) years. Compared with patients at urban hospitals, patients at rural hospitals were older (median [IQR] age, 74 [64-84] years vs 73 [61-83] years; standardized difference, 10.63) and more likely to be non-Hispanic White (14 572 [73.5%] vs 498 950 [66.1%]; standardized difference, 34.47). In adjusted models, patients at rural hospitals were less likely to be prescribed cardiac resynchronization therapy (adjusted risk difference [aRD], -13.5%; adjusted odds ratio [aOR], 0.44; 95% CI, 0.22-0.92), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (aRD, -3.7%; aOR, 0.71; 95% CI, 0.53-0.96), and an angiotensin receptor-neprilysin inhibitor (aRD, -5.0%; aOR, 0.68; 95% CI, 0.47-0.98) at discharge. In-hospital mortality was similar between rural and urban hospitals (460 of 19 832 [2.3%] vs 20 529 of 754 587 [2.7%]; aOR, 0.86; 95% CI, 0.70-1.07). Patients at rural hospitals were less likely to have a length of stay of 4 or more days (aOR, 0.75; 95% CI, 0.67-0.85). Among Medicare beneficiaries, there were no significant differences between rural and urban hospitals in 30-day HF readmission (adjusted hazard ratio [aHR], 1.03; 95% CI, 0.90-1.19), all-cause readmission (aHR, 0.97; 95% CI, 0.91-1.04), and all-cause mortality (aHR, 1.05; 95% CI, 0.91-1.21). In this large contemporary cohort of US patients hospitalized for HF, care at rural hospitals was independently associated with lower use of some guideline-recommended therapies at discharge and shorter length of stay. In-hospital mortality and 30-day postdischarge outcomes were similar at rural and urban hospitals.

Proportion, Precipitators and Prognostic Marker of 30-Day Heart Failure Readmission at MOI Teaching and Referral Hospital, Eldoret, Kenya

Background: Heart failure (HF) affects 26 million people globally. It is associated with a high 30-day readmission rate due to multiple cardiovascular and non-cardiovascular precipitants. Readmissions are associated with high mortality, which may be predicted by pre-discharge N-terminal pro brain natriuretic peptide (NT-proBNP). There is no data on HF readmission rates, its precipitators and use of NT-proBNP as a prognostic marker at Moi Teaching and Referral Hospital (MTRH) in Western Kenya. Objective: To determine the 30-day proportion of HF readmission, the precipitators of HF and the association between NT-proBNP and 30 days’ readmission. Methods:This was a six-month prospective cohort study where we carried out a census and recruited adult participants admitted with HF at Moi Teaching and Referral Hospital. At discharge from hospital, an interviewer administered questionnaire was administered and blood samples for NT-proBNP drawn. Upon readmission, precipitators for HF were identified and compliance to therapy assessed using European heart failure Self Care Behavioral Scale. Continuous variables were summarized using median and IQR, categorical variables using frequencies and percentages. Associations were determined using Chi square, Fishers exact and Wilcoxon rank test. A p-value of <0.05 was considered statistically significant. Results: From April to November 2018, 94 participants were recruited into the study; with median age 48 years (IQR 31,70), 58 (62%) were female, 35 (38%) consumed alcohol and 25(25%) smoked. Hypertension was the commonest comorbidity 20 (21%) while cardiomyopathy was the underlying etiology for HF in 58 (63%). HF with reduced Ejection Fraction (HFrEF) was present in 76% of the participants while 24% had HF with preserved Ejection Fraction (HFpEF). Sixty percent of the participants had NT-proBNP levels of >4137 pg/ml, which implied poor prognosis. Of 17 readmitted patients, 12 participants (12.8%) were readmitted within 30 days at MTRH. Six (6.4%) participants were lost to follow up. Median time to readmission was 14 days, (IQR 7, 26). Pneumonia (55%) was the commonest precipitator of HF readmissions, followed by arrhythmias (atrial fibrillation) in 5 (42%), anemia 4 (33%), noncompliance 4 (33%), acute kidney injury 2 (16.6%) and no identified precipitator 1 (8.3%). There was no association between NT-proBNP and readmission (p =0.584) or NT-pro BNP and survival (p=0.773). Readmission was associated with a high mortality (p=0.008) with 50% of readmitted participants dying during the readmission period. The total mortality of both readmitted and non-readmitted participants was 16% at the end of the 6 months’ study period. Conclusions:In this cohort of participants with HF the proportion of 30 days readmission was high. Infections, mainly pneumonia was the commonest precipitator of readmission. Discharge NT-proBNP did not predict likelihood of 30 days’ readmission. Mortality was higher among participants readmitted within 30 days. Recommendations: Measures like pneumoccal vaccinations should be implemented to prevent pneumonia. Early appointments to cardiac clinic (less than 2 weeks post discharge) should be given to screen for precipitators and reduce HF readmissions. A follow up study to assess % change in NT pro BNP in relation to 30 days readmission.

Abstract 14128: Impact of Sarcoidosis in Patients Undergoing Aortic Valve Replacement: Insight From National Readmission Database 2016-2019

Introduction: Limited data exist on the in-hospital and readmission outcomes in sarcoidosis patients after surgical or transcatheter aortic valve replacement (SAVR/TAVR). Hypothesis: Sarcoidosis can lead to cardiac conduction abnormalities and cardiomyopathy which can lead to poor outcomes after aortic valve intervention (AVI). We hypothesize that SAVR/TAVR in sarcoidosis patients has the worst outcomes. Methods: The NRD was queried for all sarcoidosis patients who underwent SAVR/TAVR from 2016-2019. Our outcomes of interest were in-hospital mortality, in-hospital complications, and 30-day readmissions for heart failure and pacemaker implantation. Clinical outcomes were modeled using logistic regression for binary outcomes and linear regression for continuous outcomes. Results: We identified a total of 507,441 SAVR/TAVR hospitalizations of which 1429 were of sarcoidosis patients. Patients with sarcoidosis were younger (mean age 70.1 years vs 72.4 years) and had more women (48.3% vs 38.2%, p<0.001). In-hospital mortality occurred in 35 (2.5%) patients with sarcoidosis and in 13,367 (2.6%) patients without sarcoidosis. After SAVR/TAVR, the risk of in-hospital mortality in sarcoidosis patients was similar to patients without sarcoidosis (OR: 0.86, 95% CI 0.50 - 1.48, p = 0.58). Risks of stroke, cardiogenic shock, pacemaker implantation, paravalvular leak, AKI requiring dialysis, hemorrhage requiring transfusion, cardiorespiratory complications, need for cardiothoracic procedures, 30-day heart failure and pacemaker implantation readmissions were also similar in patients with and without sarcoidosis. Conclusions: Sarcoidosis is not associated with an increased risk of in-hospital mortality, in-hospital complications and 30-day readmissions for heart failure and pacemaker implantation. Thus, AVI is possibly not futile in sarcoidosis patients and future studies are necessary to understand the benefits of AVI in these patients.

Abstract 14287: Development of an Innovated Heart Failure Hospitalist Program Drives Best Practice and Exceptional Outcomes From 2018-2021

Introduction: Heart Failure (HF) is an important health care issue given its high prevalence, mortality, and cost of care. Despite numerous evidence-based strategies in the literature aiming at reducing HF readmissions, patients with HF remain at high risk for subsequent hospitalization with 20 to 25% readmitted within 30 days. Hypothesis: The UPMC Hospitalist and Cardiology leadership recognized the need to foster consistent inpatient hospitalist providers, which was lacking in the current model. The concept of a dedicated Heart Failure Hospitalist service line emerged. Methods: Patients with both primary HF: UPMC Hospitalist, Cardiologist, teaching service N= 4192 (70%); CHF hospitalist Team N=1785 (30%). Heart failure order set usage, length of stay, all-cause 30-day readmission rates, readmission with HF, cost per case were assessed between these two groups from 2018-2021. Results: All-cause 30-day HF readmission rates at UPMC (Harrisburg, West Shore, Community General Hospitals) for all providers is 21% from 2018-2021, matching the national average. HF Hospitalist team (only at Harrisburg Hospital) has consistently lower readmission rates: 9% (2018), 8.34% (2019), 8.6% (2020), 6.95% (2021). HF hospitalist length of stay was also consistently lower, by 0.5 to 0.9 days. Potential cost savings to UPMC hospitals is $1.5 million dollars since start of HF Hospitalist service line. Conclusions: Heart failure is a major health care issue. The HF Hospitalist service line was created to support an environment of patient-centered care by providing continuity of care for HF admissions and HF patients admitted for non-HF medical issues. The HF Hospitalists provide quality care with frequent daily rounding, optimization of HF medications, providing education to the patient and family to improve treatment plan adherence, as well as engaging in early discussion of palliative and hospice transition. At this community-based healthcare system, HF Hospitalist outcomes include decreasing length of stay; decreased 30 day all-cause readmission to an impressive 8.2%, and reduced 30 day HF readmissions 4.12%. This was done while reducing healthcare costs during the 4yrs of the HF Hospitalist service line at UPMC.

Clinical outcomes and 30-day readmissions for heart failure with reduced ejection fraction with cardiorenal syndrome: A National Cohort Study

BackgroundLiterature regarding outcomes of cardiorenal syndrome (CRS) among heart failure with reduced ejection fraction (HFrEF) is limited. ObjectiveTo study the clinical outcomes and 30-day readmission rates of CRS patients with HFrEF. MethodsData from the Nationwide Readmissions Database (NRD) that constitutes 49.1% of the stratified sample of all hospitals in the United States (US), representing >95% of the national population, was analyzed for the CRS with HFrEF visits from 2018 to 2019. CRS was defined by the ICD-10 codes. ResultsOut of the 1,530,749 index CRS-related hospitalizations (mean age:64.37 ± 13.30 years; 38.6%females) 73,126 (6.0%) CKD I-II, 883,119 (72.6%) CKD III-IV, and 258,835 (21.3%) CKD V-and-more related encounters were recorded. Mortality was higher among CKD stage V-and-more in comparison to other subgroups(7.6%vs5.73%;p < 0.001). AKI with underlying CKD was more common among stage III-IV compared to other subgroups (55.9%vs43.7%;p < 0.001). Respiratory failure, the second major complication, was more common among stage V-and-more compared to other subgroups (32.5%vs30%;p < 0.001). The overall CRS-related 30-day readmission rate was 22.7%, with CKD V-and-more accounting for highest rates(29.89%), followed by CKD stage III-IV(20.05%) and CKD I-II(12.99%). The primary etiology for 30-day readmission was cardiovascular among all subgroups (54.2%, 54.6%, and 41.80%, which corresponds to CKD I-II, CKD III-IV and CKD V-and-more, respectively). ConclusionCRS among HFrEF accounts for substantial healthcare burden with high 30-day readmission rates. Higher all-cause mortality and 30-day readmissions were associated with worse renal disease. This would suggest that more vigilance is needed by physicians for discharge planning among this patient population.

A Predictive Model of Early Readmission for Patients with Heart Failure

Background: Readmission within 30 days of discharge for heart failure (HF) has become a challenging public health issue. Predicting the risk of 30-day readmission may assist clinicians in making individualized treatment plans for HF patients. Methods: A total of 2254 patients were enrolled in this study. The risk predictors associated with 30-day readmission were selected using the least absolute shrinkage and the selection operator regression model. The performance of the nomogram was evaluated using the receiver operating characteristic (ROC) curve, Hosmer–Lemeshow (HL) test, and decision curve analysis (DCA). Results: The 30-day all-cause readmission rate was 7.1%. Thirteen clinical parameters were identified as the risk predictors, including age, cystatin C, albumin, red cell distribution width coefficient variation, neutrophils, N-terminal pro-B-type natriuretic peptide, high-sensitivity cardiac troponin T, myoglobin, sex, dyslipidaemia, left ventricular ejection fraction, left ventricular end-diastolic dimension, and atrial fibrillation. The nomogram showed good discrimination, with an area under the ROC curve of 0.653 (95% confidence interval: 0.608–0.698) and good calibration results (HL test p = 0.328). The DCA showed that the nomogram would have good clinical utility. Conclusions: This predictive model based on clinical data makes it simple for clinicians to assess the 30-day HF readmission risk.

Improved 30-day Heart Failure Readmissions Following Implementation of an Advanced Cardiovascular Education (ACE) Academy.

Journal of Nursing Care Quality: October/December 2022 - Volume 37 - Issue 4 - p E80 doi: 10.1097/NCQ.0000000000000658

The role of a multidisciplinary heart failure clinic in optimization of guideline-directed medical therapy: HF-optimize

BackgroundGuideline-directed medical therapy (GDMT) reduces mortality and hospitalizations in adults with heart failure with reduced ejection fraction (HFrEF); however, few are receiving GDMT. National registries show as few as 1% of patients are receiving appropriate GDMT. Development of heart failure clinics achieving optimal GDMT are crucial to improve outcomes for HFrEF patients. ObjectiveWe developed a multidisciplinary HF-Optimize clinic aimed at improving GDMT use along with providing education, resources, and comorbidity screening for adults with HFrEF. MethodsWe targeted patients with newly diagnosed HFrEF and/or recent or multiple admissions for 6 visits over 12 weeks. We measured medication use, ejection fraction, 6-minute walk test distance, and health-related quality of life (EuroQol Visual Analog Scale) at visits 1 and 6. ResultsOne-hundred ten patients completed all visits. Patients were a mean age of 58 (±14) years, 37% were female, and 42% were of non-White race. From visit 1 to visit 6, utilization of GDMT increased from 35.5% to 85.5% (p < 0.001) and significant improvements in ejection fraction (25.9% to 35.5%, p < 0.001), 6-minute walk distance (1032 feet to 1121.7 feet, p = 0.001), and quality of life (63.8/100 vs 70.8/100, p = 0.002). Only 2 patients (1.8%) that completed HF-Optimize had a 30-day heart failure readmission. ConclusionOur multidisciplinary HF-Optimize clinic improved medication usage and clinical outcomes. Further studies are needed to validate outcomes of multidisciplinary GDMT clinics.

Abstract P324: Clinical Outcomes And 30-day Readmissions For Heart Failure With Preserved Ejection Fraction And Cardiorenal Syndrome: A Multicenter Database Analysis.

Background: Literature regarding cardiorenal syndrome (CRS) outcomes among heart failure with preserved ejection fraction (HFpEF) is limited. Objective: This study sought to characterize CRS patients' clinical outcomes and 30-day readmission rates with HFpEF. Methods: Data was collected from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP) Nationwide Readmissions Database (NRD) from January 1, 2018, to November 30, 2019. We used the International Classification of Diseases, 10 th revision (ICD-10) diagnostic codes to identify encounters with CRS related to HFpEF. Results: Out of the 1,530,749 index HFpEF-CRS related hospitalizations (mean age 74.44±12.42years; 56.7%females), 1,295,302(82.1%) had CKD stage I-IV and 281,689(17.9%) had CKD stage V+. The CKD I-IV+ group had higher multi-organ complications including atrial fibrillation (AF) (33.7% vs 21.1%; p-value &lt;0.001), acute kidney injury (AKI) (53.2% vs 20.1%; p-value &lt;0.001), AKI requiring hemodialysis (53.2% vs 20.1%; p-value &lt;0.001), respiratory failure (36.2% vs 34%, p-value &lt;0.001), and ischemic stroke (2.21% vs 2%, p-value &lt;0.001). However, the all-cause mortality for CRS with CKD V+ was higher as compared to CRS with CKD I-IV (4.83% vs 4.39%; p &lt;0.001). HFpEF with CKD V+ had a significantly higher 30-day readmission rates compared to CKD I-IV subgroup (40.6% vs 15.8%; p-value &lt;0.001). The predominant etiologies associated with 30-day readmissions among CKD I-IV in comparison to CKD V+ include cardiopulmonary (54.2%vs48.8%), and infectious (10.7%vs11.3%) diseases. Conclusion: Among HFpEF-CRS hospital encounters, progression of CKD stages is associated with higher 30-day readmission rates and all-cause mortality. These factors are accountable for a substantially increased healthcare burden. These findings suggest that regardless of CKD stages, patients with CRS should be monitored vigilantly during hospital admissions to avoid life-threatening complications.

Nurse-Provided Lung and Inferior Vena Cava Assessment in Patients With Heart Failure

BackgroundResidual congestion detected using handheld ultrasound may be associated with increased risk of readmission and death after hospitalization for acute decompensated heart failure (ADHF). However, effective application necessitates routine use by nonexperts delivering clinical care. ObjectivesThe objective of this study was to determine the ability of heart failure (HF) nurses to deliver a predischarge lung and inferior vena cava (IVC) assessment (LUICA) to predict 90-day outcomes. MethodsIn this multisite, prospective, observational study, HF nurses scanned 240 patients with ADHF (median age: 77 years; 56% men) using a 9-zone LUICA protocol. Obtained images were reviewed by independent nurses who were blinded to clinical characteristics and outcomes. Based on a B-line cut-off of 10, patients were dichotomized as congested (n = 115) or not congested (n = 125). ResultsCongested patients were more likely to have previous cardiac operations, long-standing HF (>6 months), and renal impairment. At 90 days, HF readmission or mortality occurred in 42 congested patients (37%) compared with 18 noncongested patients (14%). Pulmonary congestion increased at 30-day (OR: 3.86; 95% CI: 1.65-8.99; P < 0.01) and 90-day (OR: 3.42; 95% CI: 1.82-6.4; P < 0.01) HF readmission or mortality risk and 90-day mortality (OR: 5.18; 95% CI: 1.44-18.69; P < 0.01). Pulmonary congestion increased the 90-day odds of HF readmission and/or death by 3.3- to 4.2-fold (P < 0.01), independent of demographics, HF characteristics, comorbidities, and event risk score. Over 90 days, days alive out of hospital were fewer (78.3 ± 21.4 days vs 85.5 ± 12.4 days; P < 0.01) in congested patients. ConclusionsLUICA can be a powerful tool for detection of predischarge residual congestion. HF nurses can obtain images and provide diagnostic reports that are predictive of ADHF outcomes.

Improved 30-Day Heart Failure Readmissions Following Implementation of an Advanced Cardiovascular Education (ACE) Academy.

Heart failure readmissions are common, though some are preventable through evidence-based management. Despite outperforming national benchmarks for 30-day readmissions, compliance with an evidence-based institutional heart failure management pathway was inconsistent. The purpose of this project was to reduce 30-day heart failure readmission rates through an educational intervention and an electronic health record (EHR) redesign. The cardiac services nursing leadership team conducted an education and documentation needs assessment to identify knowledge gaps and practical barriers to effective utilization of evidence-based interventions for heart failure management. This intervention included an Advanced Cardiovascular Education (ACE) Academy and an EHR workflow redesign for clinical and supportive nursing staff. The 30-day heart failure readmission rates reduced immediately following the intervention, and rates continued to decrease over a 3-year follow-up. Even among hospitals outperforming national benchmarks, 30-day heart failure readmissions can be reduced and sustained with enhanced education and EHR redesign.

Perceived symptoms as the primary indicators for 30-day heart failure readmission.

To identify 30-day rehospitalizations in patients discharged with heart failure (HF) based on clinical indications, physiologic measures and symptoms. Fifty-six patients with heart failure participated. After discharge to home, clinical indicators of dyspnea, fatigue, orthopnea, dyspnea with exertion, daily weight, edema, heart rate, blood pressure, mental condition, medication adherence, and overall well-being were reported by participants daily for up to 30 days. Joint modeling of longitudinal and time-to-event approach was applied to assess the association of readmission with longitudinal measurements. There was no association between demographic, physiological, or laboratory variables and re-hospitalization within 30 days post discharge. Perceptions of dyspnea (p = .012) and feeling unwell (p < .001) were associated with rehospitalization. Patients struggling to breath were 10.7 times more likely to be readmitted than those not struggling to breath. Perceived measures, particularly dyspnea and feeling unwell were more important factors than demographic, physiological, or laboratory parameters in predicting 30-day rehospitalizations in this racially diverse cohort. The symptomatic experience of heart failure is an important indicator of rehospitalization.

Symptomatic Indicators As Predictors For 30-day Heart Failure Readmissions

Introduction Heart failure (HF) remains a common, chronic, clinical syndrome associated with high rates of re-hospitalization. Although numerous studies have evaluated objective measurements of clinical and diagnostic characteristics of hospitalized patients with HF, there remains a paucity of reliable clinical indicators that predict patient re-hospitalization. Further research is critical to provide effective post-discharge monitoring and practice recommendations. The objective of this study was to examine patient-reported variables in a daily monitoring instrument to determine 30-day outcomes in patients discharged with HF. Hypothesis The primary hypothesis was that patient-recorded clinical indicators would identify clinical predictors for re-hospitalization within 30 days post discharge. Clinical indicators of dyspnea, fatigue, orthopnea, dyspnea with exertion, daily weight, edema, heart rate, blood pressure, mental condition, medication adherence, and overall well-being were reported by participants daily. Method This prospective study included 56 participants. Demographics and clinical characteristics data including frequency with percentage for categorical variables and mean with standard deviation for continuous variables were summarized. The variables were evaluated to determine key predictors for re-hospitalization within 30 days. The relationship between readmission and answers to the monitoring instrument over the 30 days after discharge were analyzed by joint modeling of longitudinal and readmission data. Longitudinal trajectory plots were constructed. Results Participants had a mean age of 67 years, 54% female, 63% black. Means: BMI 31, SBP 116 mmHg, NT-pro-BNP 8675 pg/mL, creatinine 1.47 mg/dL, HR 94, LVEF 33%. There was no association between demographic, physiological, or laboratory variables and re-hospitalization within 30 days post discharge. Perceptions of dyspnea and feeling unwell were associated with re-hospitalization. Patients who reported struggling to breath were 10 times more likely to be readmitted than those not struggling to breath, and patients who reported feeling well in general were less likely to be readmitted by a 55% margin. Conclusions Patient-reported outcomes, particularly patient perceived symptoms of dyspnea and feeling unwell were more predictive for re-hospitalization than the demographic, physiological, or laboratory parameters. The subjective, patient-reported symptomatic experience of HF is an important indicator of rehospitalization that deserves additional research and clinical attention. Heart failure (HF) remains a common, chronic, clinical syndrome associated with high rates of re-hospitalization. Although numerous studies have evaluated objective measurements of clinical and diagnostic characteristics of hospitalized patients with HF, there remains a paucity of reliable clinical indicators that predict patient re-hospitalization. Further research is critical to provide effective post-discharge monitoring and practice recommendations. The objective of this study was to examine patient-reported variables in a daily monitoring instrument to determine 30-day outcomes in patients discharged with HF. The primary hypothesis was that patient-recorded clinical indicators would identify clinical predictors for re-hospitalization within 30 days post discharge. Clinical indicators of dyspnea, fatigue, orthopnea, dyspnea with exertion, daily weight, edema, heart rate, blood pressure, mental condition, medication adherence, and overall well-being were reported by participants daily. This prospective study included 56 participants. Demographics and clinical characteristics data including frequency with percentage for categorical variables and mean with standard deviation for continuous variables were summarized. The variables were evaluated to determine key predictors for re-hospitalization within 30 days. The relationship between readmission and answers to the monitoring instrument over the 30 days after discharge were analyzed by joint modeling of longitudinal and readmission data. Longitudinal trajectory plots were constructed. Participants had a mean age of 67 years, 54% female, 63% black. Means: BMI 31, SBP 116 mmHg, NT-pro-BNP 8675 pg/mL, creatinine 1.47 mg/dL, HR 94, LVEF 33%. There was no association between demographic, physiological, or laboratory variables and re-hospitalization within 30 days post discharge. Perceptions of dyspnea and feeling unwell were associated with re-hospitalization. Patients who reported struggling to breath were 10 times more likely to be readmitted than those not struggling to breath, and patients who reported feeling well in general were less likely to be readmitted by a 55% margin. Patient-reported outcomes, particularly patient perceived symptoms of dyspnea and feeling unwell were more predictive for re-hospitalization than the demographic, physiological, or laboratory parameters. The subjective, patient-reported symptomatic experience of HF is an important indicator of rehospitalization that deserves additional research and clinical attention.

Acute myocardial infarction and acute heart failure among renal transplant recipients: a national readmissions database study.

The literature on the mortality and 30-day readmissions for acute heart failure and for acute myocardial infarction among renal-transplant recipients is limited. To study the in-hospital mortality, cardiovascular complications, and 30-day readmissions among renal transplant recipients (RTRs). Data from the national readmissions database sample, which constitutes 49.1% of all hospitals in the United States and represents more than 95% of the stratified national population, wasanalyzed for the years 2012-2018 using billing codes. A total of 588,668hospitalizations inrenal transplant recipients (mean age 57.7 ± 14.2years; 44.5% female) were recorded in the study years. A total of 15,788 (2.7%) patients had a diagnosis of acute heart failure; 11,320 (71.7%) had acute heart failure with preserved ejection fraction and 4468 (28.3%) had acute heart failure with reduced ejection fraction; 17,256 (3%) patients had myocardial infarction, 3496 (20%) had ST-Elevation myocardial infarction while 13,969 (80%) had non-ST-elevation myocardial infarction. Overall,11,675 (2%) renal-transplant patients died, of whom 757 (6.5%) had acute heart failure, 330 (2.8%) had acute reduced and 427 (3.7%) had acute preserved ejection fraction failure. Among 1652 (14.1%) patient deaths with myocardial infarction, 465 (4%) were ST-elevation- and 1187 (10.1%) were non-ST-Elevation-related. The absolute yearly mortalityrate due toacute heart failure increased over the years 2012-2018 (p-trend 0.0002, 0.001, 0.002, 0.05, respectively), while the mortality rate due to myocardial infarction withST-elevation decreased (p-trend 0.002). Cardiovascular complications are significantly associated with hospitalizations among RTRs. The absolute yearly mortality, and rate of heart failure (withreduced orpreserved ejection fraction) increasedover the study years, suggesting thatmore research is needed to improve the management ofthese patients.

Serum and Urine Osmolality as Predictors of Adequate Diuresis in Acute Decompensated Heart Failure: A Prospective Cohort Study

Background: Determination of adequacy of decongestion remains a significant challenge in the management of acute heart failure (AHF). Methods: This is a prospective single center cohort study of patients (>18 years old) admitted for AHF on intravenous diuretics, with BNP >100 pg/mL or echocardiographic findings of reduced ejection fraction or diastolic dysfunction, and at least 1 clinical sign of volume overload. Patients with eGFR ≤45 mL/min or on dialysis, and with exposure to contrast dye or nephrotoxins were excluded. Serum and spot urine osmolality were obtained in the early morning simultaneously daily for 5 days or until discharge. Receiver operating characteristic curves were used to analyze the optimal cutoffs for the osmolality values in the prediction of heart failure (HF) readmissions Results: Of the total 100 patients, 62% were male and 59% were Black American. The mean age was 64.41 ± 12.53 and 34% had preserved ejection fraction. Patients with 30-day readmission had higher serum osmolality (mOsm/kg) on admission (305 [299–310] vs. 298 [294–303]; p = 0.044) and had higher drop in serum osmolality between admission and discharge (−7.5 [−9.0, −1.25] vs. −1.0 [−4.0, 4.0]; p = 0.044). Serum osmolality on admission of >299 mOsm/kg (sensitivity: 83%, specificity: 61%) and drop in serum osmolality between admission and discharge of >2 mOsm/kg (sensitivity: 83%, specificity: 65%) was associated with 30-day HF readmissions. No patients discharged with urine osmolality more than 500 mOsm/kg had 30-day readmissions, but this was not statistically significant, p = 0.334. Conclusion: Measurement of serum osmolality and urine osmolality may have some utility in AHF, but interpretation should consider baseline values and dynamic changes to account for individual differences in sodium and water handling.

Decreasing 30-Day Heart Failure Readmission through Self-Care Education

Decreasing 30-Day Heart Failure Readmission through Self-Care Education

In-Hospital Weight Loss and Outcomes in Patients With Heart Failure

Acute decompensation of heart failure (HF) is often marked by fluid retention, and weight loss is a marker of successful diuresis. We examined the relationship between in-hospital weight loss and post-discharge outcomes in patients with HF. We conducted a propensity score-matched study of 8830 patients hospitalized for decompensated HF in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, in which 4415 patients in the weight-loss group and 4415 patients in the no-weight-loss group were balanced on 75 baseline characteristics. We defined weight loss as an admission-to-discharge weight loss of 1-30 kilograms, and we defined no weight loss as a weight gain or loss of < 1 kilogram. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with weight loss were estimated. Patients had a mean age of 78 years, 57% were women, and 11% were African American. The median weight loss in the weight-loss group was 3.6 (interquartile range, 2.0-6.0) kilograms. HRs and 95% CIs for 30-day all-cause mortality, all-cause readmission and HF readmission associated with weight loss were 0.75 (0.63-0.90), 0.90 (0.83-0.99) and 0.83 (0.72-0.96), respectively. Respective 60-day HRs (95% CIs) were 0.80 (0.70-0.92), 0.91 (0.85-0.98) and 0.88 (0.79-0.98). These associations were attenuated and lost significance during 6 months of follow-up. Among older patients hospitalized for decompensated HF, in-hospital weight loss was associated with a lower risk of mortality and hospital readmission. These findings suggest that in-hospital weight loss, a marker of successful diuresis and decongestion, is also a marker of improved clinical outcomes.

Abstract 10817: Association of Hospital Procedural Volumes with Outcomes of Left Ventricular Assist Devices

Introduction: Left Ventricular Assist Devices (LVADs) are effective and feasible options for stage D heart failure. The impact of procedural volumes on LVAD outcomes has been seldomly investigated. Methods: We investigated the Nationwide Readmission Database for the impact of different institutional LVAD volumes on clinical outcomes in 2018. Institutional procedural volumes were stratified into Low (1-7/year), medium (8-24/year) and high (&gt;25/year). Multivariant analysis and adjusted odds ratio was performed to examine association between LVAD hospital volumes and outcomes. Primary outcome was major adverse events (MAE) defined as a composite of mortality, myocardial infarction, stroke or TIA, bleeding requiring transfusion, acute kidney injury, vascular complications and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Results: A total of 2315 patients underwent LVAD placement, with a mean age of 57. No difference in age, sex or presence of chronic disease was noted among patient in different procedural volume tiers. There was statistically significant difference in MAE in medium-volume center when comparing to low volume centers. No difference in MAE was present in low and high-volume center. No significant difference was noted in 30-day all cause readmission, 30-day heart failure readmission or in individual components of MAE across different hospital procedural volumes. Conclusions: Medium-volume centers are associated with better composite clinical outcomes. Overall, no difference in mortality, stroke or myocardial infarction exists among different volume centers. Further clinical research is warranted to clarify the appropriate minimum LVAD procedural volumes required for accreditation.