30-day Heart Failure Readmission Research Articles

The subclinical hypothyroid state might predict 30-day readmission in patients admitted with acute heart failure syndrome and reduced left ventricular ejection fraction.

Introduction:Thyroid hormone (TH) has an essential role on the functional capability of cardiac muscle with its gene modulation and induction of vasodilatory effects. There is considerable evidence to suggest the role of TH in patients with acute coronary syndrome, but less is known about its prognostic role in heart failure (HF) patients. We aim to evaluate the association between subclinical hypothyroid state (SCHS) and event rates including 30-day all-cause and HF readmission in patients with an index hospitalization for acute HF syndrome (AHFS).Methodology:A retrospective chart review analysis of 2335 patients admitted with the diagnosis of AHFS between 1 January 2007 and 31 December 2017 was conducted. SCHS was defined as thyroid-stimulating hormone (TSH) level >4.50 mIU/L with a normal thyroxine (T4) level. Patients with pre-existing 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, 3-month and 6-month all-cause readmission and mortality rates were calculated in both cohorts of AHFS (HFpEF and HFrEF) with and without SCHS.Results:The mean age of the 2335 AHFS population was 65 (±14.8) years. Of the 2335 patients admitted with AHFS, 1228 (52.6%) patients were found to have HFrEF and 1107 (47.4%) with HFpEF. There were 170 (7.3%) patients with AHFS found to have SCHS. There were more males than females (54% versus 46%). The percentage of hospital readmission within 30 days was higher for patients with SCHS compared with those without SCHS in the HFrEF group (42% versus 30%, p = 0.001). Hospital readmission within 30 days for patients with SCHS compared with those without SCHS in the HFpEF group did not differ (36.5% versus 31%, p = 0.47). Additionally, all-cause mortality was higher among patients with SCHS compared with patients without SCHS in the HFrEF group (18.7% versus 7.0%, p < 0.001). All-cause mortality was found similar in both arms of the HFpEF group (9.5% versus 7.7%, p = 0.73).Conclusion:During an index hospital admission for AHFS, SCHS was an independent predictor of readmission in 30 days in patients with HFrEF but not in patients with HFpEF. Additionally, it was related to adverse outcome such as all-cause mortality in HFrEF patients but not in HFpEF patients. Further studies regarding the concept of tissue thyroid and the potential for a therapeutic target are warranted.

Association of Pulmonary Hypertension With Clinical Outcomes of Transcatheter Mitral Valve Repair

Pulmonary hypertension (pHTN) is associated with increased risk of mortality after mitral valve surgery for mitral regurgitation. However, its association with clinical outcomes in patients undergoing transcatheter mitral valve repair (TMVr) with a commercially available system (MitraClip) is unknown. To assess the association of pHTN with readmissions for heart failure and 1-year all-cause mortality after TMVr. This retrospective cohort study analyzed 4071 patients who underwent TMVr with the MitraClip system from November 4, 2013, through March 31, 2017, across 232 US sites in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy registry. Patients were stratified into the following 4 groups based on invasive mean pulmonary arterial pressure (mPAP): 1103 with no pHTN (mPAP, <25 mm Hg [group 1]); 1399 with mild pHTN (mPAP, 25-34 mm Hg [group 2]); 1011 with moderate pHTN (mPAP, 35-44 mm Hg [group 3]); and 558 with severe pHTN (mPAP, ≥45 mm Hg [group 4]). Data were analyzed from November 4, 2013, through March 31, 2017. Patients were stratified into groups before TMVr, and clinical outcomes were assessed at 1 year after intervention. Primary end point was a composite of 1-year mortality and readmissions for heart failure. Secondary end points were 30-day and 1-year mortality and readmissions for heart failure. Linkage to Centers for Medicare & Medicaid Services administrative claims was performed to assess 1-year outcomes in 2381 patients. Among the 4071 patients included in the analysis, the median age was 81 years (interquartile range, 73-86 years); 1885 (46.3%) were women and 2186 (53.7%) were men. The composite rate of 1-year mortality and readmissions for heart failure was 33.6% (95% CI, 31.6%-35.7%), which was higher in those with pHTN (27.8% [95% CI, 24.2%-31.5%] in group 1, 32.4% [95% CI, 29.0%-35.8%] in group 2, 36.0% [95% CI, 31.8%-40.2%] in group 3, and 45.2% [95% CI, 39.1%-51.0%] in group 4; P < .001). Similarly, 1-year mortality (16.3% [95% CI, 13.4%-19.5%] in group 1, 19.8% [95% CI, 17.0%-22.8%] in group 2, 22.4% [95% CI, 18.8%-26.1%] in group 3, and 27.8% [95% CI, 22.6%-33.3%] in group 4; P < .001) increased across pHTN groups. The association of pHTN with mortality persisted despite multivariable adjustment (hazard ratio per 5-mm Hg mPAP increase, 1.05; 95% CI, 1.01-1.09; P = .02). These findings suggest that pHTN is associated with increased mortality and readmission for heart failure in patients undergoing TMVr using the MitraClip system for severe mitral regurgitation. Further efforts are needed to determine whether earlier intervention before pHTN develops will improve clinical outcomes.

The Impact of Transitions of Care Pharmacist Services and Identification of Risk Predictors in Heart Failure Readmission

Background: Heart failure (HF) is a prevalent and costly disease state for adult Americans, with 30-day readmissions rates for patients with HF utilized to limit hospital compensation. Objective: To determine the impact of the transitions of care (TOC) service at our institution on 30-day all-cause and HF readmissions and identify predictive risk factors for 30-day all-cause readmission. Methods: Retrospective chart review of patients aged 18 years and older admitted with HF and all subsequent readmissions between October 1, 2015, and September 30, 2017. A weighted logistic regression model was developed to determine risk factors for 30-day all-cause readmission. Results: There were no significant differences in all-cause or HF readmission rates analyzed by TOC service involvement. Significant risk predictors for 30-day all-cause readmission included discharge to a rehabilitation facility (odds ratio [OR] = 9.3) or home with home health (OR = 1.6) versus home with self-care. Comorbidities associated with an increased risk of 30-day all-cause readmission included diabetes, coronary artery disease, and aortic stenosis. Use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and spironolactone was associated with decreased risk of 30-day all-cause readmission. Conclusion: Identified predictors in the patient population with HF at our institution may be used to target patients at increased risk of all-cause readmission within 30 days.

Impact of Pharmacist Involvement in Heart Failure Transition of Care.

Background: Heart failure (HF) transition of care (TOC) programs may improve continuity of care and coordination and decrease hospital readmissions. Objective: This study evaluated the impact of pharmacy-led HF TOC on HF readmission rate. Methods: This was a single-center, pre-post quasi-experimental study. Pharmacy TOC comprised admission and discharge medication reconciliations and patient education. Patients were included if they had a primary HF diagnosis. Patients were excluded if they were admitted for a non-HF diagnosis, admitted for <24 hours, had a stage IV cancer or dementia diagnosis, or were transferred to hospice care. The primary outcome was HF 30-day readmission rate. Results: A total of 663 patients were included in the study: 330 in the control group and 333 in the intervention group. The average age for both groups was 67 ± 16 years; 48.1% were female; 56.9% were African American; and 51.4% of patients had an ejection fraction ≤40%. In the control group, 57 (17.3%) patients had a HF 30-day readmission compared with 35 (10.5%) patients in the intervention group. After adjusting for age, the intervention group continued to show a difference in readmission (odds ratio = 0.578; 95% CI = 0.367-0.911; P = 0.018). The most common interventions were medication addition (11%), dose titration (7.5%), medication discontinuation (6.6%), and duplication avoidance (2.7%). Conclusion and Relevance: Pharmacy-led HF TOC, as a component of a targeted hospital-based initiative, significantly decreased HF 30-day readmission rate. Results from this study warrant further research to explore which interventions in TOC are most effective.

Carvedilol Among Patients With Heart Failure With a Cocaine-Use Disorder

ObjectivesThis study sought to assess the safety of carvedilol therapy among heart failure (HF) patients with a cocaine-use disorder (CUD). BackgroundAlthough carvedilol therapy is recommended among certain patients with HF, the safety and efficacy of carvedilol among HF patients with a CUD is unknown. MethodsThis was a single-center study of hospitalized patients with HF. Cocaine use was self-reported or defined as having a positive urine toxicology. Patients were divided by carvedilol prescription. Subgroup analyses were performed by strata of ejection fraction (EF) ≤40%, 41% to 49%, or ≥50%. Major adverse cardiovascular events (MACE) were defined as cardiovascular mortality and 30-day HF readmission. ResultsFrom a cohort of 2,578 patients hospitalized with HF in 2011, 503 patients with a CUD were identified, among whom 404 (80%) were prescribed carvedilol, and 99 (20%) were not. Both groups had similar characteristics; however, those prescribed carvedilol had a lower LVEF, heart rate, and N-terminal pro–B-type natriuretic peptide concentrations at admission and on discharge, and more coronary artery disease. Over a median follow-up of 19 months, there were 169 MACEs. The MACE rates were similar between the carvedilol and the non-carvedilol groups (32% vs. 38%, respectively; p = 0.16) and between those with a preserved EF (30% vs. 33%, respectively; p = 0.48) and were lower in patients with a reduced EF taking carvedilol (34% vs. 58%, respectively; p = 0.02). In a multivariate model, carvedilol therapy was associated with lower MACE among patients with HF with a CUD (hazard ratio: 0.67; 95% confidence interval; 0.481 to 0.863). ConclusionsOur findings suggest that carvedilol therapy is safe for patients with HF with a CUD and may be effective among those with a reduced EF.

Correlation between hospital finances and quality and safety of patient care.

BackgroundHospitals under financial pressure may struggle to maintain quality and patient safety and have worse patient outcomes relative to well-resourced hospitals. Poor predictive validity may explain why previous studies on the association between finances and quality/safety have been equivocal. This manuscript employs principal component analysis to produce robust measures of both financial status and quality/safety of care, to assess our a priori hypothesis: hospital financial performance is associated with the provision of quality care, as measured by quality and safety processes, patient outcomes, and patient centered care.MethodsThis 2014 cross-sectional study investigated hospital financial condition and hospital quality and safety at acute care hospitals. The hospital financial data from the Centers for Medicare and Medicaid Services (CMS) cost report were used to develop a composite financial performance score using principal component analysis. Hospital quality and patient safety were measured with a composite quality/safety performance score derived from principal component analysis, utilizing a range of established quality and safety indicators including: risk-standardized inpatient mortality, 30-day mortality, 30-day readmissions for select conditions, patient safety indicators from inpatient admissions, process of care chart reviews, CMS value-based purchasing total performance score and patient experience of care surveys. The correlation between the composite financial performance score and the composite quality/safety performance score was calculated using linear regression adjusting for hospital characteristics.ResultsAmong the 108 New York State acute care facilities for which data were available, there is a clear relationship between hospital financial performance and hospital quality/safety performance score (standardized correlation coefficient 0.34, p<0.001). The composite financial performance score is also positively associated with the CMS Value Based Purchasing Total Performance Score (standardized correlation coefficient 0.277, p = 0.002); while it is negatively associated with 30 day readmission for all outcomes (standardized correlation coefficient -0.236, p = 0.013), 30-day readmission for congestive heart failure (standardized correlation coefficient -0.23, p = 0.018), 30 day readmission for pneumonia (standardized correlation coefficient -0.209, p = 0.033), and a decrease in 30-day mortality for acute myocardial infarction (standardized correlation coefficient -0.211, p = 0.027). Used alone, operating margin and total margin are poor predictors of quality and safety outcomes.ConclusionsStrong financial performance is associated with improved patient reported experience of care, the strongest component distinguishing quality and safety. These findings suggest that financially stable hospitals are better able to maintain highly reliable systems and provide ongoing resources for quality improvement.

A Pilot Study: Decreased Hospitalization in Elderly Heart Failure Patients While on Sacubitril-Valsartan Combination

Introduction Sacubitril-Valsartan combination (SVC) is new to the heart failure (HF) armamentarium. SVC, in addition to HF goal directed medical therapy (GDMT), is indicated to reduce the risk of cardiovascular (CV) death and HF hospitalizations in patients with reduced ejection fraction (HFrEF). PARADIGM-HF was stopped early due to overwhelming efficacy when compared to Enalapril. SVC dosed to the target 97/103 mg twice daily, reduced the primary composite outcomes of CV death or first HF hospitalization by 20%. HF guidelines recommend SVC as an option in patients with HFrEF. In PIONEER-HF, compared to Enalapril, SVC had a greater time-averaged reduction in NT-proBNP levels (25% vs. 47%, respectively) from baseline through weeks 4 and 8 after HF hospitalization. This combination was safe and well-tolerated in both studies. Hypothesis In PARADIGM-HF and PIONEER-HF the mean age was 62 years and the majority NYHA FC II to III. Results were difficult to extrapolate in patients &gt75 years with HFrEF. This group would be excluded from advanced therapies, i.e. cardiac transplant or durable mechanical circulatory support. HF GDMT optimization is the goal for this population. In clinical trials, SVC shows significant reduction in CV death and/or HF hospitalizations compared to Enalapril. We hypothesize that the clinical outcomes of patients &gt75 years with HFrEF receiving SVC would be favorable. Methods A retrospective chart review was conducted in a community hospital between January 2016 and December 2017. Subjects were identified via electronic health record. Inclusion criteria included age &gt 75 years, left ventricular ejection fraction &lt 40%, on maximally tolerated GDMT and SVC initiated during hospitalization. Subjects were excluded if SVC was not continued at discharge or lost to follow up. The clinical outcomes were CV death or first 30-day HF readmission, change in renal function or blood pressure. Descriptive statistics were used for data analysis. Results Inclusion criteria was met in 34 patients. Baseline characteristics: mean age 81 years, female 50%, mean weight 75 kg, BMI of 25, Caucasians 79% and mean ejection fraction 26%. Mean NT-ProBNP change from baseline was -68%. The first 30-day HF readmission was 14.7%. No patients were discharged on intravenous inotropes and no mortality reported. Conclusions SVC appears to lower first 30-day HF hospital readmissions in patients &gt 75 years old. It is well-tolerated among this population. Further, well-designed study was warranted.

Home for the Holidays Campaign to Reduce Seasonal Heart Failure Hospitalizations

Introduction Heart failure (HF) is a progressive syndrome and previous studies have shown that HF patients are more likely to be hospitalized during colder winter months. These seasonal variations coincide with holidays and can cause an additional emotional burden on patients, family members, and caregivers. Historically, 1 out of 4 HF patients at our institution experienced multiple hospitalizations during this period compared to 1 out of 5 in all other months. Therefore, we created a Home for the Holidays campaign to engage interdisciplinary care teams (IDT) and patients. We hypothesized that these efforts, in conjunction with existing hospital readmission reduction program interventions, would reduce the 30-day all-cause HF readmission rate. Methods A readmission rate goal of less than 15% was established for 23 nursing units across 3 hospital campuses within a large, urban academic health system. Units that achieved this goal received recognition and breakfast with senior executive health system leadership. A toolkit consisting of a low sodium holiday menu, education workbook and magnet advertising the post-discharge helpline were distributed in a tote bag to all patients identified with acute decompensated HF (ADHF). IDT members focused on self-care management and early symptom recognition with patients and caregivers, as well as timely follow-up appointments. Results Between 2014 and 2017 the average 30-day all-cause HF readmission rate for the month of December was 24.3%. In December 2018, 235 patients were admitted for ADHF, 37 patients were subsequently readmitted within 30 days and the readmission rate was 15.7%. The Home for the Holidays campaign contributed to a 35.4% rate reduction (p= 0.046) and 9 units achieved the institutional goal of less than 15%. Conclusions Implementation of the toolkit, along with enhanced counseling and post-discharge follow-up, successfully reduce HF hospital readmissions. Health systems can easily integrate a seasonal campaign to increase awareness and stimulate transitional care and educational activities to keep patients healthy and at home for the holidays.

The Effect of Nurse Navigation Program on 30-Day Heart Failure Readmissions

The Effect of Nurse Navigation Program on 30-Day Heart Failure Readmissions

Early Goal Directed Sepsis Management in Patients with Heart Failure and Concomitant Chronic Kidney Disease

Current guidelines recommend for the use of protocolized quantitative fluid resuscitation in patients with sepsis. Limited data is available regarding optimal fluid management in patients with sepsis and concomitant heart failure (HF) and/or chronic kidney disease (CKD). Methods: This is a single center retrospective cohort study of patients diagnosed with sepsis and concomitant HF and CKD (K-HF) between January of 2015 and December of 2018. The primary outcome includes all cause in-hospital mortality. Secondary outcomes include length of stay, requirement of intravenous diuretics, need for renal replacement therapy, and 30-day heart failure readmission rate. Results: This cohort of 1116 patients included 621/1116 (55.64%) men with a mean age of 76 ± 14 years (see Table I for baseline characteristics). A total of 383/1116 (34.31%) patients had K-HF and 733/1116 (65.68%) did not have K-HF. Patients with K-HF received an initial bolus intravenous fluid (IVF) administration of 1.63 liters vs. patients with non-K-HF and sepsis who received 1.77 liters (p=0.1766). Mortality was 121/383 (31.93%) for patients with K-HF vs. 199/733 (27.26%) for non-K-HF patients (p=0.1084). 30-day readmission was 56/383(15.73%) in patients with K-HF vs. 112/733 (16.62) in patients with non-K-HF. In patients with sepsis with K-HF 204 (53.54%) developed AKI vs. 327 (44.61%) in non-K-HF patients. Renal replacement therapy (RRT) was required in 90/383 (23.69%) in patients with K-HF vs 327/733(44.61%) in non-K-HF patients. Conclusion: EGDT in patients with sepsis and concomitant HF and CKD shows diverse morbidity, however, with similar mortality in this special population.

Etiological Role of Diet in 30-Day Readmissions for Heart Failure: Implications for Reducing Heart Failure-Associated Costs via Culinary Medicine.

Background. Reducing the under-30-day readmission for heart failure (HF) patients is a modifiable quality-of-care measure, yet the role of diet in HF readmissions and cost-effective HF care remain ill-defined. Methods. Medical chart review was conducted to determine cause(s) for HF treatment failure. Randomized controlled trial-backed machine learning models were employed to assess the relationship of culinary medicine education with HF 30-day readmission rate and cost. Results. Of 1031 HF admissions, 130 occurred within 30 days of discharge (12.61%.) Nearly two-thirds of individuals were male (64.02%), while the mean age and median length of stay were 64.33 ± 14.02 and 2, respectively. Medication noncompliance (34.62%) was the most common etiology for 30-day readmissions, followed by dietary noncompliance (16.92%), comorbidity (16.92%), a combination of dietary and medication noncompliance (10%), HF exacerbation (10%), iatrogenic (10%), and drug abuse (1.54%). Medication noncompliance contributed to the highest gross charge by readmission, costing a total of $1 802 096. Compared with traditional care, culinary medicine education for HF patients would prevent 93 HF readmissions and save $3.9 million in an estimated 4-year period. Conclusion. Though pharmacological treatment remains a focal point of HF management, diet-based approaches may improve tertiary HF prevention and reduce HF-associated health care expenditures.

Evaluation of 30-Day Hospital Readmission and Mortality Rates Using Regression-Discontinuity Framework

BackgroundThe Hospital Readmissions Reduction Program (HRRP) has been associated with reduced 30-day readmissions for acute myocardial infarction (AMI) and heart failure (HF). ObjectivesThe purpose of this study was to test whether this 30-day readmission reduction is a manifestation of practices that defer or avoid hospitalizations beyond the 30-day period. MethodsAt all U.S. hospitals under HRRP, the authors calculated daily readmission rates for elderly Medicare fee-for-service beneficiaries through day-60 post-discharge following a hospitalization for AMI and HF—the 2 target cardiovascular conditions—as well as pneumonia in July 2008 to June 2016. The authors applied a robust bias-corrected nonparametric regression approach to evaluate for discontinuities in rates around day 30. ResultsThe authors identified 3,256 eligible hospitals, with median readmission rates in the days 1 to 30 and 31 to 60 post-discharge of 19.6% (interquartile range [IQR]: 16.7% to 22.9%) and 7.8% (IQR: 6.5% to 9.4%) for AMI, 23.0% (IQR: 20.6% to 25.3%) and 11.4% (IQR: 10.2% to 12.6%) for HF, and 17.5% (IQR: 15.4% to 19.8%) and 8.3% (IQR: 7.3% to 9.3%) for pneumonia, respectively. Daily readmission rates decreased across most of the 60 post-discharge days, with no discontinuities in the local polynomial regression for readmission at the 30-day mark, with a >95% power to detect 0.1% difference for each outcome across post-discharge day 30. Similarly, there was no discontinuity in mortality at 30 days post-discharge, or for either outcome at hospitals that incurred readmission penalties. ConclusionsThere was no evidence that clinicians adopted strategies that specifically deferred admissions or affected mortality in the 30-day period after discharge. The findings are consistent with the institution of strategies that generally affected readmission risk after discharge.

Electronic health records systems and hospital clinical performance: a study of nationwide hospital data.

Electronic health records (EHRs) were expected to yield numerous benefits. However, early studies found mixed evidence of this. We sought to determine whether widespread adoption of modern EHRs in the US has improved clinical care. We studied hospitals reporting performance measures from 2008-2015 in the Centers for Medicare and Medicaid Services Hospital Compare database that also reported having an EHR in the American Hospital Association 2015 IT supplement. Using interrupted time-series analysis, we examined the association of EHR implementation, EHR vendor, and Meaningful Use status with 11 process measures and 30-day hospital readmission and mortality rates for heart failure, pneumonia, and acute myocardial infarction. A total of 1246 hospitals contributed 8222 hospital-years. Compared to hospitals without EHRs, hospitals with EHRs had significant improvements over time on 5 of 11 process measures. There were no substantial differences in readmission or mortality rates. Hospitals with CPSI EHR systems performed worse on several process and outcome measures. Otherwise, we found no substantial improvements in process measures or condition-specific outcomes by duration of EHR use, EHR vendor, or a hospital's Meaningful Use Stage 1 or Stage 2 status. In this national study of hospitals with modern EHRs, EHR use was associated with better process of care measure performance but did not improve condition-specific readmission or mortality rates regardless of duration of EHR use, vendor choice, or Meaningful Use status. Further research is required to understand why EHRs have yet to improve standard outcome measures and how to better realize the potential benefits of EHR systems.

Length of hospital stay and its impact on subsequent early readmission in patients with acute heart failure: a report from the WET-HF Registry.

Heart failure (HF) is characterized by frequent rehospitalization and prolonged hospital stay. Although length of stay has been used as a surrogate marker for hospital performance, its association with early rehospitalization remains unknown. We investigated their precise association using contemporary Japanese HF registry. We analyzed the 2785 acute HF patients who were registered in the West Tokyo Heart Failure registry and discharged or transferred to the recuperation facilities (mean age, 73.8 ± 13.5years; 60.8% were men). Median length of stay was 15days (interquartile range, 10-23days). One-hundred and fourteen patients (4.1%) were readmitted for worsening HF within 30days after discharge. Thirty-day risk-adjusted HF readmission after a shorter length of stay (1-12days; the lower tertile within the cohort) was higher than those after intermediate (13-19days; the middle tertile) [HR 1.71, 95% confidence interval (CI) 1.05-2.77]. Even after a longer length of stay, there tended to be a higher risk of 30-day HF readmission (HR 1.59, 95% CI 0.96-2.65). In conclusion, the Japanese acute HF patients had low rates of early-HF readmission after quite a long length of stay at urban tertiary care centers. Shorter length of stay was associated with increased rates of 30-day HF readmission, while longer length of stay also the same trended.Clinical Trial Registration: https://www.umin.ac.jp/icdr/index-j.html . Unique identifier: UMIN000001171.

Predictors of Heart Failure Readmission in a High-Risk Primarily Hispanic Population in a Rural Setting.

High risk for readmission in patients with heart failure (HF) is associated with Hispanic ethnicity, multimorbidity, smaller hospitals, and hospitals serving low-socioeconomic or heavily Hispanic regions and those with limited cardiac services. Information for hospitals caring primarily for such high-risk patients is lacking. The aim of this study was to identify factors associated with 30-day HF readmission after HF hospitalization in a rural, primarily Hispanic, low-socioeconomic, and underserved region. Electronic medical records for all HF admissions within a 2-year period to a 107-bed hospital near the California-Mexico border were reviewed. Logistic regression was used to identify independent predictors of readmission. A total of 189 unique patients had 30-day follow-up data. Patients were primarily Hispanic (71%), male (58%), and overweight or obese (82.5%) with 4 or more chronic conditions (83%) and a mean age of 68 years. The 30-day HF readmission rate was 5.3%. Early readmission was associated with history of HF, more previous emergency department (ED) and hospital visits, higher diastolic blood pressure and hypokalemia at presentation, shorter length of stay, and higher heart rate, diastolic blood pressure, and atrial fibrillation (AF) at discharge. Using logistic regression, previous 6-month ED visits (odds ratio, 1.5; P = .009) and AF at discharge (odds ratio, 5.7; P = .039) were identified as independent predictors of 30-day HF readmission. Previous ED use and AF at discharge predicted early HF readmission in a high-risk, primarily Hispanic, rural population in a low-socioeconomic region.

PCV82 FACTORS ASSOCIATED WITH UNPLANNED 30-DAY HEART FAILURE READMISSION RATES AMONG MEDICARE AND MEDICAID PATIENTS IN TEXAS

The study aimed to determine an association between unplanned 30-day Heart Failure (HF) readmission rates and factors outside of hospital’s control among Medicare and Medicaid patients in Texas. We used the Texas Hospital Inpatient Research Data File (RDF) to select Medicare and Medicaid patients discharged with a principal diagnosis of heart failure (HF) during the January 1st, through December 31st, 2014. We applied an endorsed measure by the National Quality Forum (NQF) to develop analytic sample. Multi-level logistic regression analyses examined patient-level and community-level characteristics. The unplanned 30-day HF readmission rates were 20.76% in Medicare (5,392 readmission/25,978 HF admission) vs. 30.63% in Medicaid (939 readmission/3066 HF admission). Controlled for other factors, Medicaid patients were 1.51 times more likely to be readmitted within 30 days than Medicare patients. (OR: 1.51 95% CI 1.38 - 1.65, p< 0.001). Patients lived in area with higher median household income were less likely to be readmitted (OR: 0.89, 95% CI 0.83 - 0.95, p < 0.001). The odds ratios were significantly lower in counties with higher density of health professionals (Primary care physician per 100K - OR: 0.89, 95%CI 0.80 - 0.99, p=0.025, Ratio general practitioner to specialist – OR: 0.89 95%CI 0.80 - 0.99, p=0.025, Hospital bed per 100K – OR: 0.90, 95%CI 0.83 - 0.99, p=0.032). Policy makers should consider a multidisciplinary strategy to help hospitals serving higher composition of patients with lower socioeconomic status or lower access to care to achieve higher performance.

Abstract 185: The Expanded Benefit of Neprilysin Inhibitor Therapy on 30 Day Readmissions: A Useful Tool at a Safety Net Hospital

Introduction: Heart failure (HF) related hospitalizations contribute to the ever-increasing financial burden of chronic disease. There are approximately 6.5 million individuals in the US with HF, with an estimated annual cost of $39 billion. Within the arsenal of strategies developed to curb this trend, pharmacological therapy has shown to be very effective. Whilst many drugs are favored for their ability to reduce mortality and morbidity, neprilysin-inhibitors (ARNI) have recently shown to reduce 30-day readmissions in patients with HF, presenting an expanded indication to favor its usage. Methods: A retrospective review of patients discharged from the Kings County Hospital Center from October 1 st 2017 to June 30 th 2018 with a diagnosis of heart failure was conducted. Inclusion required follow up in the Heart Health Clinic at Kings County Hospital and discharge therapy with a beta-blocker and either an ACE-I, ARB or ARNI. Patients were divided into 2 groups, those continued on an ACE-i/ARB versus those who were transitioned to an ARNI. The end outcome was a 30-day all-cause readmission for heart failure at any point after enrollment. Time to event was calculated using the date the drug was started. If the drug was started prior to being enrolled, we used the date that the patient was enrolled in the study. Demographic data was extracted via chart review and analyzed by descriptive statistics. A Kaplan-Meier survival analysis was done to compare the time-to-event between both study cohorts. Results: There were 101 patient discharges. There was no statistically significant age or gender difference between cohorts. The mean age in the ARNI group was 60.4 and in the ACE-i/ARB group was 64.7. A 30-day readmission occurred in 3 (10.7%) of the 28 patients in the intervention group, compared with 21 (28.8%) of the 73 patients with ACE-i/ARB therapy. The patients transitioned to ARNI therapy had a better event free survival with a 62.8% reduction in 30-day readmission events (log rank p=0.046). Conclusion: There is statistically significant reduction in 30-day all-cause readmission following the initiation of ARNI therapy in the treatment for HF. While this trend was shown in a prospective post-hoc analysis of the initial PARADIGM-HF trial, our study presents a unique patient benefit group. Kings County Hospital serves as a safety net hospital that has a large volume of uninsured, low socioeconomic status patients, with a large African American influence, and compounded social and environmental factors that make them highly prone to CHF readmissions. It underscores the need for clinically useful strategies to reduce the burden of CHF related readmissions especially for hospitals located in low socioeconomic areas at risk for penalties.

THE HOSPITAL READMISSIONS REDUCTION PROGRAM AND CHANGES IN THE CAUSES AND TIMING OF READMISSIONS AFTER HEART FAILURE HOSPITALIZATIONS

It has been unclear if declines in 30-day readmissions for heart failure (HF) under the Hospital Readmissions Reduction Program (HRRP) were associated with changes in the causes and timing of readmissions. A retrospective study of Medicare beneficiaries discharged after HF 1/1/2008 – 6/30/2015 at

Heart failure and adverse heart failure outcomes among persons living with HIV in a US tertiary medical center

Persons living with HIV (PLHIV) have an increased risk of heart failure (HF). However, little is known about outcomes among PLHIV with HF. The study aim was to compare HF outcomes among PLHIV with HF versus individuals without HIV with HF. Our cohort included 2,308 individuals admitted with decompensated HF. We compared baseline characteristics, 30-day HF readmission, and cardiovascular (CV) and all-cause mortality. Within PLHIV, we assessed outcomes stratified between CD4 count and viral load (VL), and tested the association between traditional and HIV-specific parameters with 30-day HF readmission. There were 374 (16%) PLHIV with HF. Among PLHIV, 92% were on antiretroviral therapy and 63% had a VL <200 copies/mL. Groups were similar with respect to age, sex, race/ethnicity, and CV risk factors. In follow-up, PLHIV had increased 30-day HF readmission (49% vs 32%) and CV (26% vs 13.5%) and all-cause mortality rates (38% vs 22%). Among PLHIV, cocaine use, HIV-specific parameters (CD4, VL), and coronary artery disease were predictors of 30-day HF readmission. Specifically, among PLHIV, those with detectable VL had higher 30-day HF readmission and CV mortality, whereas PLHIV with undetectable VL had a similar 30-day HF readmission rate and CV mortality to uninfected controls with HF. Similar outcomes were observed across strata of left ventricular ejection fraction and by CD4. PLHIV with a low CD4 count or detectable VL have an increased 30-day HF readmission rate as well as increased CV and all-cause mortality. In contrast, PLHIV with a higher CD4 count and undetectable VL have similar HF outcomes to uninfected controls.

Risk Factors Associated With 7- Versus 30-Day Readmission Among Patients With Heart Failure Using the Nationwide Readmission Database.

The 30-day all-cause readmission for heart failure (HF) is a standard measure to evaluate hospital performance. A recent study found that a shorter period after discharge may be more indicative of hospital quality. To compare risk factors for 7- versus 30-day readmission in patients with HF. This is a retrospective cohort using the 2014 Nationwide Readmissions Database. Patients 65 years and older with Medicare coverage discharged after HF admission. The 7- or 30-day all-cause readmissions were the outcomes of interest. HF-related readmissions were secondary outcomes. Covariates included patient characteristics, hospital characteristics, and admission-related information. Hierarchical logistic regression evaluated the association between covariates and readmissions. There were N=15,039 all-cause readmissions within 7 days after discharge and N=47,896 within 30 days. Surgical service was a risk factor for 30-day but not 7-day all-cause readmission (odds ratio=1.10, 95% confidence interval=1.05-1.16). Depression, rheumatoid arthritis, liver disease, drug abuse, lymphoma, and psychosis were associated with an increased risk of 30-day all-cause readmission but not 7-day. Longer lengths of stay also had a higher likelihood of all-cause readmission within 30 days compared with 7 days. In contrast, smaller hospital bed size was associated with an increased risk of 7-day all-cause readmission (odds ratio=1.06, confidence interval=1.01-1.12) but not 30-day. Sensitivity analysis with using a 3-day readmission interval showed similar results. Risk factors for hospital readmission are slightly different dependent on the measurement interval. In general, hospital-related factors were associated with shorter readmissions intervals while patient factors were more associated with longer intervals.