30-day Heart Failure Readmission Research Articles

Abstract 17148: Association of Atrial Fibrillation With Short-Term Outcomes in Patients Hospitalized for Heart Failure With Preserved Ejection Fraction

Background: Atrial fibrillation (AF) is frequently present in patients with heart failure (HF) with preserved ejection fraction (HFpEF). The association of AF with short term outcomes in patients hospitalized for HFpEF is not well studied. Methods: We queried the United States Nationwide Readmissions Database year 2014 using appropriate ICD-9 codes to identify a weighted sample of adult patients hospitalized for HFpEF. Patients with concomitant diagnoses of HF with reduced ejection fraction (HFrEF) were excluded. The primary outcome was a composite of in-hospital death or a 30-day readmission for HF. Secondary outcomes studied were individual outcomes along with composites of in-hospital death or a 30-day readmission for any cause or cardiac etiologies. Survey specific adjusted multivariable logistic regression models were used to analyze the association of AF with outcomes. Results: Of 229,098 patients (mean age 76 years, 38% men) who were hospitalized for HFpEF during the study period, AF was present in 45.3% (N=103,852). Patients with AF were older (mean age 80 vs 72 years, p<.001) and more likely men (39% vs 37.5%, p<.001) compared to patients without AF. Primary outcome occurred in 9.5% patients with AF and in 8.0% patients without AF (p<0.001). After adjusting for patient demographics, comorbidities, complications, and hospital characteristics, AF was associated with 17% higher odds of the primary outcome (OR 1.17, 95% CI 1.11-1.23), 20% higher odds of in-hospital death (OR 1.20, 95% CI 1.07-1.34), and 17% higher odds of a 30-day readmission for HF (OR 1.17, 95% CI 1.10-1.25). Similar results were noted for other outcomes; TABLE . Conclusion: AF was associated with significantly worse short-term outcomes in patients hospitalized for HFpEF. Additional strategies are needed to improve outcomes in HFpEF patients with AF. Future prospective studies need to examine if AF ablation in HFpEF may improve outcomes as in HFrEF.

Transitions in Care From Acute Care Telemetry Unit to Home: An Evidence-Based Quality Improvement Project.

Transitions in Care From Acute Care Telemetry Unit to Home: An Evidence-Based Quality Improvement Project.

Effect of Pharmacist Clinic Visits on 30-Day Heart Failure Readmission Rates at a County Hospital.

Purpose: This study evaluated the comparative effectiveness of different pharmacist visit types on reducing readmission rates. Method: A single-center, retrospective cohort study was conducted from January 2015 to July 2017. Patients were 18 years or older with an index heart failure (HF) exacerbation admission. Upon hospital discharge, patients were seen in clinic by a clinical pharmacy specialist (CPS) with collaborative practice agreement (CPA) (High Intensity Bundle), medication therapy management (MTM) pharmacist without CPA (Low Intensity Bundle), or no pharmacist (Standard of Care [SOC]). The primary outcome was 30-day all-cause readmission rate. Secondary outcomes included rate of 30-day HF readmissions and average number of days until readmission in those who were readmitted. Results: Totally, 98 patients were included in the final analysis (35 High Intensity Bundle, 28 Low Intensity Bundle, and 35 SOC). The primary outcome of all-cause readmissions was lower in both the pharmacist groups compared with SOC (CPS 8.6% [3/35] vs SOC 25.7% [9/35], P = 0.046 and MTM 7.1% [2/28] vs SOC 25.7% [9/35], P = 0.057). Incremental differences were seen between visit types for the secondary outcome of 30-day HF readmissions (CPS 2.9% vs MTM 7.1% vs SOC 17.1%, P = 0.039). The average number of days until readmission was longer in the CPS versus the MTM and SOC (26.7 days vs 12.5 days vs 14.1 days, respectively). Conclusion: Post-hospital discharge pharmacist visits were associated with lower 30-day all-cause readmission. In particular, clinic visits with a Higher Intensity Bundle may be more effective in reducing HF readmissions. These exploratory findings warrant further investigation.

Home-Delivered Meals Postdischarge From Heart Failure Hospitalization.

Background In patients with heart failure (HF), malnutrition and dietary sodium excess are common and may worsen outcomes. No prior studies have provided low-sodium, nutritionally complete meals following HF hospitalization. Methods and Results The GOURMET-HF study (Geriatric Out-of-Hospital Randomized Meal Trial in Heart Failure) randomized patients discharged from HF hospitalization to 4 weeks of home-delivered sodium-restricted Dietary Approaches to Stop Hypertension meals (DASH/SRD; 1500 mg sodium/d) versus usual care. The primary outcome was the between-group change in the Kansas City Cardiomyopathy Questionnaire summary score from discharge to 4 weeks postdischarge. Additional outcomes included changes in the Kansas City Cardiomyopathy Questionnaire clinical summary score and cardiac biomarkers. All patients were followed 12 weeks for death/all-cause readmission and potential diet-related adverse events (symptomatic hypotension, hyperkalemia, acute kidney injury). Sixty-six patients were randomized 1:1 at discharge to DASH/SRD versus usual care (age, 71±8 years; 30% female; ejection fraction, 39±18%). The Kansas City Cardiomyopathy Questionnaire summary score increased similarly between groups (DASH/SRD 46±23-59±20 versus usual care 43±19-53±24; P=0.38), but the Kansas City Cardiomyopathy Questionnaire clinical summary score increase tended to be greater in DASH/SRD participants (47±22-65±19 versus 45±20-55±26; P=0.053). Potentially diet-related adverse events were uncommon; 30-day HF readmissions (11% versus 27%; P=0.06) and days rehospitalized within that timeframe (17 versus 55; P=0.055) trended lower in DASH/SRD participants. Conclusions Home-delivered DASH/SRD after HF hospitalization appeared safe in selected patients and had directionally favorable effects on HF clinical status and 30-day readmissions. Larger studies are warranted to clarify the effects of postdischarge nutritional support in patients with HF. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02148679.

Use of ReDS Technology to Treat Heart Failure in the Home Health Setting

Background Volume overload is a major determinant in the physical symptoms and quality of life in patients with heart failure (HF), as well as the predominant factor leading to HF admissions. Accurate assessment of a patient's volume status can be difficult. The Remote Dielectric Sensing (ReDS) Wearable System is an FDA-approved device developed by Sensible Medical Innovations that allows a health care provider to accurately, quickly and non-invasively measure lung fluid. In this study, we used the ReDS system to facilitate a nurse-led care transitions program to improve outcomes and reduce HF readmission rate in a rural hospital lacking an onsite HF program. Methods Randolph Hospital (RH) is a non-profit facility in central North Carolina with a 30-day HF readmission rate ≥ 25%. Medicare patients admitted for HF were enrolled into a nurse-led care transitions program. Patients received telephone follow up or home visit by a nurse within 3 days of discharge. Patients were instructed to call the care transitions nurse with any signs or symptoms of worsening HF during the follow-up period. If the patient complained of volume overload or increased dyspnea a nurse would travel to the patient's home to assess the patient and obtain a ReDS measurement. If the ReDS reading was consistent with volume overload (lung fluid > 35%), a specifically-designed diuretic protocol was initiated. Daily ReDS readings were performed and treatment protocol followed until the reading was below 35% or the protocol was stopped by the medical director. Renal function and electrolytes were monitored and replaced following pre-specified protocol. Results The Care Transitions Team has evaluated 61 patients thus far. There have been 32 elevated readings (ReDS > 35%) which triggered implementation of treatment using the diuretic-protocol. It took an average of 2.5 visits to titrate diuretics and obtain a reading Conclusions A nurse-led care transitions program employing ReDS technology and a specifically-designed diuretic protocol to manage HF patients post hospital discharge, was successful in reducing 30-day HF readmission and reduce overall resource utilization in a community hospital without a dedicated HF clinic.

The Subclinical Hypothyroid State might Predict 30 Day Readmission in Patients with an Acute Heart Failure Syndrome and Reduced Left Ventricular Ejection Fraction.

Introduction Thyroid hormone has an essential role on the functional capability of cardiac muscle with its gene modulation and induction of vasodilatory effects. There is a considerable evidence to suggest the role of thyroid hormone in acute coronary syndrome (ACS) patients but less is known about its prognostic role in heart failure (HF) patients. We aim to evaluate the association between the subclinical hypothyroid state and event rates including 30-day all-cause and HF readmission in patients with an index hospitalization for an acute HF syndrome (AHFS). Methods A retrospective chart review analysis of 1,020 patients, who were admitted to Bronx-Care Hospital Center with the diagnosis of an AHFS was conducted. We reviewed cases from January 1, 2012 to December 31, 2017. The subclinical hypothyroid state was defined as thyroid stimulating hormone (TSH) level>4.50 mIU/L with a normal thyroxine (T4) level. Subjects with preexisting thyroid disease or receiving thyroid replacement therapy were excluded. HF with preserved ejection fraction (HFpEF) was defined as left ventricular ejection fraction (LVEF)>40% and HF with reduced ejection fraction (HFrEF) was defined as having LVEF≤40%. Percentage of 30-day all-cause readmission and mortality was calculated in both cohorts of AHFS (HFpEF and HFrEF) with and without subclinical hypothyroidism. Results The mean age of our 1,020 AHFS population was 66 ± 15.1 years. Of 1,020 patients admitted with AHFS, 635 (63%) patients were found to have HFrEF and 385 with HFpEF(37%). There were 64 (6.27%) patients with AHFS found to have subclinical hypothyroidism. There were more males than females (52% versus 48%). The percentage of hospital readmission within 30 days was higher for patients with subclinical hypothyroidism compared to those without subclinical hypothyroidism in the HFrEF group (42.9% versus 27.2%, P = 0.029). Hospital readmission within 30 days for patients with subclinical hypothyroidism compared to those without subclinical hypothyroidism in HFpEF group did not differ (30% versus 22%, P = 0.675). Additionally, all-cause mortality was higher among patients with subclinical hypothyroidism compared to patients without subclinical hypothyroidism in the HFrEF group (20% versus 6.0%, P Conclusion Subclinical hypothyroidism during an index hospital admission for an AHFS was an independent predictor of readmission in 30 days in patients with HFrEF but not in patients with HFpEF. It is also related to an adverse outcome such as all-cause mortality. Further studies regarding the concept of tissue thyroid and the potential for a therapeutic target are warranted.

Who's Readmitted for Heart Failure and Why? Real-time Capture of Admissions through an Institutional Analytics Dashboard

Introduction Enhanced cognizance and timely reporting are crucial for hospitals engaging in readmissions reduction efforts to improve both process and outcomes among heart failure (HF) patients. Utilizing electronic medical record and claims data, we created an analytics dashboard to identify admissions and readmissions across multiple campuses of an academic medical center with over 3000 annual acute decompensated HF (ADHF) hospitalizations. We hypothesized that the addition of the dashboard to the established HF readmissions reduction program (HFRRP) would further reduce the 30-day all-cause readmission rate. Methods The dashboard captured HF admissions by medical record number 72 hours post discharge and generated a 24-hour look-back report that provided recent activity for patients that presented to the emergency department or were rehospitalized within 30 days. To track progress over time the dashboard displayed 3 years of data and could be filtered by hospital campus, unit and discharging provider. Monthly audits of readmitted patients identified through the dashboard were conducted to evaluate adherence to HFRRP interventions. Patients who routinely appeared on the look-back reports with multiple admissions for ADHF were interviewed to determine patient-specific gaps in care. Clinical teams received quarterly updates on the readmission rate. Results Construction of the dashboard facilitated quality improvement initiatives throughout the medical center. Increased transparency of HFRRP data, along with feedback to the clinical teams, stimulated interest in performance and outcomes. Targeted efforts determined by data analysis and reporting reduced the 30-day all-cause HF readmission rate from 25.2% in 2016 to 22.9% in 2017. Conclusion An informatics-based approach using an institutional dashboard further reduced the readmission rate of our existing HFRRP. Hospitals can incorporate real-time data derived from a dashboard to improve decision making and resource utilization for patients admitted with HF.

Six-Minute Walk Distance Under 135 Meters Predicts Early and Frequent 30-day Heart Failure Readmissions in Patients with Stage C and D Heart Failure

Introduction With a 30-day all cause readmission rate around 23%, individuals with heart failure (HF) are a medically high risk and costly patient population. Though predictive models have been developed for readmission based on descriptive variables, many of these tools are cumbersome and limited in prognosticative capacity. A few studies have examined the role of the six-minute walk test (6MWT) and found good predictive ability for both 30-day and 1-3-year readmission rates. The goal of this study was to further elucidate the prognostic ability of the 6MWT in stage C/D HF patients with NYHA class IIIb-VI symptoms. Methods We prospectively enrolled 97 patients who from our step-down units with a primary diagnosis of heart failure between October 2016 and March 2017. Every patient who was enrolled had a standardized 6MWT prior to discharge. Multivariate logistic regression analysis was constructed to determine relationships between 6MW distance and 30-day survival free of readmission. Results Baseline characteristics were compared between the 6-minute walk test distance groups using Wilcoxon rank-sum tests for continuous variables and Fisher's exact tests for categorical variables, and no significant differences were found between the patients. The 135-meter cut-point was selected as the threshold which maximizes the sum of sensitivity and specificity of a logistic regression model for 30-day readmission with 6-minute walk test distance as a continuous predictor. Approximately 25.7% of the patients walked less than 135 meters. Out of these about 32% were admitted within 30 days [p= .026]. Among the patients who walked > 135 meters, 11.1% were admitted within 30 days [p= 0.026]. Furthermore, patients who walked Conclusions 6MWT distance less than 135m was associated with not only increased risk of 30 day readmission but also correlated with increased frequency of admissions in patients admitted with stage C/D heart failure.

The effect of emphysema on readmission and survival among smokers with heart failure.

Heart Failure (HF) and chronic obstructive pulmonary disease (COPD) are morbid diseases that often coexist. In patients with coexisting disease, COPD is an independent risk factor for readmission and mortality. However, spirometry is often inaccurate in those with active heart failure. Therefore, we investigated the association between the presence of emphysema on computed tomography (CT) and readmission rates in smokers admitted with heart failure (HF). The cohort included a consecutive group of smokers discharged with HF from a tertiary center between January 1, 2014 and April 1, 2014 who also had a CT of the chest for dyspnea. The primary endpoint was any readmission for HF before April 1, 2016; secondary endpoints were 30-day readmission for HF, length of stay and all-cause mortality. Over the study period, there were 225 inpatient smokers with HF who had a concurrent chest CT (155 [69%] males, age 69±11 years, ejection fraction [EF] 46±18%, 107 [48%] LVEF of < 50%). Emphysema on CT was present in 103 (46%) and these were older, had a lower BMI, more pack-years, less diabetes and an increased afterload. During a follow-up of 2.1 years, there were 110 (49%) HF readmissions and 55 (24%) deaths. When separated by emphysema on CT, any readmission, 30-day readmission, length of stay and mortality were higher among HF patients with emphysema. In multivariable regression, emphysema by CT was associated with a two-fold higher (adjusted HR 2.11, 95% CI 1.41–3.15, p < 0.001) risk of readmission and a trend toward increased mortality (adjusted HR 1.70 95% CI 0.86–3.34, p = 0.12). In conclusion, emphysema by CT is a frequent finding in smokers hospitalized with HF and is associated with adverse outcomes in HF. This under recognized group of patients with both emphysema and heart failure may benefit from improved recognition and characterization of their co-morbid disease processes and optimization of therapies for their lung disease.

Bedside Ultrasound Assessment of Jugular Venous Compliance as a Potential Point-of-Care Method to Predict Acute Decompensated Heart Failure 30-Day Readmission.

BackgroundHeart failure is one of the most costly diagnosis‐related groups, largely because of hospital readmissions. Objective assessment of volume status to ensure optimization before hospital discharge could significantly reduce readmissions. We previously demonstrated an ultrasound method of quantifying percentage of cross‐sectional area (CSA) change of the right internal jugular vein with Valsalva that reliably estimates central venous pressure.Methods and ResultsPatients admitted with acute decompensated heart failure (ADHF) underwent ultrasound measurements of the right internal jugular vein at end‐expiration and during the strain phase of Valsalva to determine a percentage of CSA change. An initial subgroup of patients with right heart catheterization and accompanying ultrasound measurements of the right internal jugular vein identified a percentage of CSA change predictive of right atrial pressure (RAP) ≥12 mm Hg. Images of admitted ADHF patients were obtained at admission and discharge for final analysis. Simultaneous right heart catheterization and right internal jugular vein ultrasound measurements demonstrated that a <66% CSA change predicted RAP ≥12 mm Hg (positive predictive value: 87%; P<0.05, receiver operating characteristic curve). Elevated admission RAP by percentage of CSA change normalized by discharge (P<0.05), indicating that this test is significantly responsive to therapeutic interventions. Using the cutoff value of 66% CSA change, normal RAP at discharge had 91% predictive value for patients avoiding 30‐day readmission (P<0.05).ConclusionsThis bedside ultrasound technique strongly correlates to invasive RAP measurement in ADHF patients, identifies restoration of euvolemia, and is predictive of 30‐day ADHF readmission. This tool could help guide inpatient ADHF treatment and may lead to reduced readmissions.

ModelHeart: a resident-led implementation of metrics to reduce 30-day heart failure readmissions

Hospitals have been penalised for excessive 30-day readmissions via Medicare payment penalties. As such there has been keen interest in finding ways of reducing readmissions. The basis for the study...

Protease Inhibitors and Cardiovascular Outcomes in Patients With HIV and Heart Failure

BackgroundIncident heart failure (HF) is increased in persons with human immunodeficiency virus (PHIV). Protease inhibitors (PIs) are associated with adverse cardiac remodeling and vascular events; however, there are no data on the use of PIs in PHIV with HF. ObjectivesThis study sought to compare characteristics, cardiac structure, and outcomes in PHIV with HF who were receiving PI-based versus non-PI (NPI) therapy. MethodsThis was a retrospective single-center study of all 394 antiretroviral therapy–treated PHIV who were hospitalized with HF in 2011, stratified by PI and NPI. The primary outcome was cardiovascular (CV) mortality, and the secondary outcome was 30-day HF readmission rate. ResultsOf the 394 PHIV with HF (47% female, mean age 60 ± 9.5 years, CD4 count 292 ± 206 cells/mm3), 145 (37%) were prescribed a PI, whereas 249 (63%) were prescribed NPI regimens. All PI-based antiretroviral therapy contained boosted-dose ritonavir. PHIV who were receiving a PI had higher rates of hyperlipidemia, diabetes mellitus, and coronary artery disease (CAD); higher pulmonary artery systolic pressure (PASP); and lower left ventricular ejection fraction. In follow-up, PI use was associated with increased CV mortality (35% vs. 17%; p < 0.001) and 30-day HF readmission (68% vs. 34%; p < 0.001), effects seen in all HF types. Predictors of CV mortality included PI use, CAD, PASP, and immunosuppression. Overall, PIs were associated with a 2-fold increased risk of CV mortality. ConclusionsPI-based regimens in PHIV with HF are associated with dyslipidemia, diabetes, CAD, a lower left ventricular ejection fraction, and a higher PASP. In follow-up, PHIV with HF who are receiving a PI have increased CV mortality and 30-day HF readmission.

Early Readmission Risk Identification for Hospitalized Older Adults With Decompensated Heart Failure.

The current study evaluated risk factors of early hospital readmission in geriatric patients with acute heart failure (HF) and analyzed 2,279 consecutively hospitalized older adults with decompensated HF from November 2013 to October 2014 across 15 U.S. hospitals. The eTracker-HF was designed to make risk factors known to treating clinicians in electronic health records. Multilevel multivariate logistic regression was applied to examine the association between risk factors and all-cause and HF 30-day readmission rates. All-cause and HF 30-day readmission rates were 22.3% and 9.8%, respectively. Old age, non-White ethnicity, delirium, physical impairment, ejection fraction <40%, advanced chronic kidney disease, and previous myocardial infarction were associated with all-cause and HF readmission. Home health care use was inversely associated with early readmission. In addition to demographic and cardiovascular risk factors, geriatric syndromes were associated with early readmission. Discharge to home health care may reduce early readmission in these patients. [Res Gerontol Nurs. 2018; 11(4):190-197.].

Sleep Apnea and Heart Failure With a Reduced Ejection Fraction Among Persons Living With Human Immunodeficiency Virus.

Sleep apnea (SA) is common and has prognostic significance among broad groups of patients with heart failure (HF). There are no data characterizing the presence, associations, and prognostic significance of SA among persons living with human immunodeficiency virus (PLHIV) with HF. We conducted a single-center study of PLHIV with HF with reduced ejection fraction (HFrEF; left ventricular ejection fraction [LVEF] <50%) and analyzed the relationship of SA with 30-day HF hospital readmission rate. Our cohort included 1124 individuals admitted with HFrEF; 15% were PLHIV, and 92% were on antiretroviral therapy. SA was noted in 28% of PLHIV and 26% of uninfected controls. Compared to uninfected controls with HFrEF and SA, PLHIV with HFrEF and SA had a lower body mass index, lower LVEF, a higher pulmonary artery systolic pressure (PASP), were more likely to have obstructive rather than central SA (P < .05 for all). In a multivariable model, PASP, low CD4 count, high viral load (VL), and SA parameters (apnea-hypopnea index, CPAP use and duration) were predictors of 30-day HF readmission rate. Each 1-hour increase in CPAP use was associated with a 14% decreased risk of 30-day HF readmission among PLHIV. Compared to uninfected controls, PLHIV were more likely to have obstructive SA than central SA. Apnea severity, low CD4 count, high VL, and cocaine use were positively associated with 30-day HF hospital readmission rate, whereas CPAP use and increased duration of CPAP use conferred protection.

Developing and Testing a New Machine-Learning Method to Identify Patients with Heart Failure Who Are at Risk of 30-Day Readmission or Mortality

Background: Predicting readmissions or mortality following hospital discharge in patients with heart failure (HF) is a major challenge. Commonly used machine learning (ML) algorithms have reported suboptimal performances in predicting HF readmissions or mortality due to class imbalance in the outcome levels (e.g. low number of readmissions vs no readmission). Moreover, the area under the receiver operating characteristic curve (AUC), a commonly used indicator of model performance, is a crude indicator for data with class imbalances. Our main aim was to develop ML models to predict 30-day HF readmission or mortality and compare various measures of model performance. Methods: We identified all Western Australian patients 65 years or older admitted for HF in 2003–08 in the linked Hospital Morbidity Data Collection. In addition to common ML models to predict 30-day HF readmissions or mortality, we also developed multi-layer perceptron (MLP) with a synthetic minority oversampling technique, considered superior in data with class imbalances. We calculated the AUC, sensitivity, and specificity of the models. Results: Of the 10,735 patients with HF, 23.6% were readmitted or died within 30 days. We observed AUCs of 0.51, 0.50, and 0.51 for linear regression, least absolute shrinkage and selection operator, and random forest models, respectively. The MLP model had a higher AUC (0.58), with a sensitivity of 57% and a specificity of 56%. Conclusion: The MLP method may be a better ML technique for data with outcome class imbalances. In addition to AUC, other metrics such as sensitivity and specificity should also be considered for such data.

Abstract 21219: Predictors of Heart Failure Readmission in a High Risk Population

Introduction: High risk for readmission in heart failure (HF) patients is associated with Hispanic ethnicity, multi-morbidity, and hospitals serving low socioeconomic or heavily Hispanic regions or with limited cardiac services. Information for hospitals caring primarily for such high-risk patients is lacking. Objective: To explore and describe the characteristics of patients hospitalized for acute heart failure and identify factors associated with 30-day HF readmission in a heavily Hispanic, rural, low-income community hospital near the California-Mexico border. Methods: Retrospective chart review of all patients admitted for HF within a two-year period was used to gather patient characteristics, presentation, previous one-year emergency department (ED) and hospital visits, medical therapy, and discharge status. Univariate analyses with student t-tests, Wilcoxon rank, and chi-square analysis as appropriate were used to identify factors associated with 30-day readmission. Logistic regression was used to identify independent predictors. Results: A total of 215 patients experienced 288 HF hospitalizations. Patients were primarily Hispanic (72%), male (58%), and obese (56%) with a mean age of 69 years, preserved ejection fraction (52%), and four or more chronic comorbid conditions (80%). In the prior 6 months, most (53%) had an ED visit and 28% had been hospitalized. The sample had high rates of hypertension (89%), diabetes (59%), hyperlipidemia (47%), renal disease (34%), and mental health disorders (18%). Median length of stay was two days and two (.9%) patients died. In the 189 patients discharged alive and with 30-day data, 69% were classified as high risk for early readmission by a commonly used clinical risk assessment metric (LACE score). Ten (5.3%) patients were readmitted for HF within 30 days. Number of ED visits in the previous six months (OR 1.5, p=.009) and atrial fibrillation at discharge (OR 5.7, p=.039) were independent predictors of 30-day HF readmission. Conclusions: Prior ED use and atrial fibrillation predicted early HF readmission following hospital discharge. These data provide support for a clinically useful alternative to standardized risk assessment tools in heavily Hispanic, multi-morbid, low-income HF patients.

OPTIMAL USAGE OF SACUBITRIL/VALSARTAN FOR HEART FAILURE TREATMENT IN CANADA POTENTIALLY REDUCES HOSPITALIZATIONS AND EARLY DISCHARGE RE-ADMISSIONS

Despite multiple evidenced-based therapies, heart failure (HF) continues to be characterized by high hospitalization rates. Sacubitril/valsartan, a first-in-class angiotensin receptor neprilysin inhibitor treatment for HF with reduced ejection fraction (HFrEF) provided incremental cardiovascular and overall survival benefit in PARADIGM-HF in HF patients. The objective of this analysis was to quantify the number of potential hospitalizations and 30-day HF re-admissions avoided with optimal usage of sacubitril/valsartan in the treatment of HFrEF patients in Canada. Data from Statistics Canada was used to quantify the population above 18 years of age. A literature search was then conducted to determine the prevalence of HF in Canada, the proportion of these with NYHA class II and III, and finally the proportion of patients with HFrEF. The number needed to treat (NNT) to avoid one hospitalization or one 30-day HF re-admission, standardized to 12 months was derived from the PARADIGM-HF trial. The potential number of hospitalizations prevented as a result of optimal usage of sacubitril/valsartan as per current approved indication in Canada (patients with HFrEF, ejection fraction ≤ 40% and NYHA class II or III symptoms) was estimated along with multiple-way sensitivity analysis using the analysis-of-extremes method. The main outcomes were HF hospitalizations and 30-day HF re-admission. A Canadian HF prevalence of 2.31% was applied to determine the number of HF patients. Of those, 64% were classified as NYHA Class II and III with 56% considered as HFrEF. It was estimated that in Canada, approximately 242,200 patients are affected with HFrEF with NYHA class II and III. Based on a NNT of 80, optimal usage of sacubitril/valsartan therapy was estimated to prevent 3,016 hospitalizations per year (range, 1,930 – 4,331 per year). Based on a NNT of 61, optimal usage of sacubitril/valsartan therapy was estimated to prevent 3,984 30 day HF re-admissions per year (range, 2,546-5,744). Evidence-based treatment for HF is well-established and has resulted in important reductions of hospitalization but there is still a need for new guideline recommended therapies to further improve hospitalization rates for HFrEF patients. The findings from this analysis suggest that a substantial number of hospitalizations and 30 day HF re-admissions in Canada could potentially be avoided by optimal usage of sacubitril/valsartan therapy. This analysis supports the importance of rapidly implementing evidence-based therapy, in this case sacubitril/valsartan, into routine clinical practice to improve clinical outcomes for HFrEF patients in Canada.

Impact of Injectable Furosemide Hospital Shortage on Congestive Heart Failure Outcomes: A Time Series Analysis

BackgroundBeginning in February 2012, there was a shortage of injectable furosemide in the province of Ontario, Canada. The objective of this study was to assess the effects of the furosemide shortage on heart failure outcomes in Ontario, Canada. MethodsWe determined which hospitals experienced a shortage of injectable furosemide using an online survey. We then used health administrative data to identify all patients who presented to those hospitals with congestive heart failure. Using 40 months of data from before the shortage, we determined the proportion of patients with heart failure expected to die each month. We then used time series analysis to forecast the 30-day mortality rate during the shortage period and compared it with the observed rate. Secondary outcomes included length of hospital stay, transfer to an intensive care unit, mechanical ventilation during the hospital stay, and risk of 30-day readmission for heart failure. ResultsSurvey results were obtained for 82% of hospitals, 28 of which experienced a severe shortage of injectable furosemide in the year 2012. The 30-day mortality among patients presenting to these hospitals with congestive heart failure before the shortage period was 11.2%. We forecasted a mortality rate of 11.3% (95% confidence interval, 8.2-14.4) for the shortage period, which was not significantly different from the observed rate of 10.9%. Similarly, we found no significant effect of the shortage on secondary outcomes. ConclusionsA severe shortage of injectable furosemide did not increase the risk of adverse outcomes among patients who presented to the hospital with congestive heart failure.

P2462Prediction of 30-day heart failure readmission and death with early post-discharge ST2 and NT-proBNP

P2462Prediction of 30-day heart failure readmission and death with early post-discharge ST2 and NT-proBNP

Associations between nursing home performance and hospital 30-day readmissions for acute myocardial infarction, heart failure and pneumonia at the healthcare community level in the United States.

To evaluate community-specific nursing home performance with community-specific hospital 30-day readmissions for Medicare patients discharged with acute myocardial infarction, heart failure or pneumonia. Cross-sectional study using 2009-2012 hospital risk-standardised 30-day readmission data for Medicare fee-for-service patients hospitalised for all three conditions and nursing home performance data from the Centers for Medicare & Medicaid Services Five-Star Quality Rating System. Medicare-certified nursing homes and acute care hospitals. 12,542 nursing homes and 3,039 hospitals treating 30 or more Medicare fee-for-service patients for all three conditions across 2,032 hospital service areas in the United States. Community-specific hospital 30-day risk-standardised readmission rates. Community-specific nursing home performance measures: health inspection, staffing, Registered Nurses and quality performance; and an aggregated performance score. Mixed-effects models evaluated associations between nursing home performance and hospital 30-day risk-standardised readmission rates for all three conditions. The relationship between community-specific hospital risk-standardised readmission rates and community-specific overall nursing home performance was statistically significant for all three conditions. Increasing nursing home performance by one star resulted in decreases of 0.29% point (95% CI: 0.12-0.47), 0.78% point (95% CI: 0.60-0.95) and 0.46% point (95% CI: 0.33-0.59) of risk-standardised readmission rates for AMI, HF and pneumonia, respectively. Among the specific measures, higher performance in nursing home overall staffing and Registered Nurse staffing measures was statistically significantly associated with lower hospital readmission rates for all three conditions. Notable geographic variation in the community-specific nursing home performance was observed. Community-specific nursing home performance is associated with community-specific hospital 30-day readmission rates for Medicare fee-for-service patients for acute myocardial infarction, heart failure or pneumonia. Coordinated care between hospitals and nursing homes is essential to reduce readmissions. Nursing homes can improve performance and reduce readmissions by increasing registered nursing homes. Further, communities can work together to create cross-continuum care teams comprised of hospitals, nursing homes, patients and their families, and other community-based service providers to reduce unplanned readmissions.