All-cause Admissions Research Articles

Clinical, echocardiographic and prognostic outcomes of patients with concordant and discordant high-gradient aortic stenosis in an Asian cohort.

Literature of patients with severe high-gradient aortic stenosis (HG AS) (mean pressure gradient [MPG] ≥ 40mmHg and aortic valve area [AVA] ≥ 1.0cm2) remains limited. This study seeks to compare the prognostic outcomes of patients with high-gradient concordant (HGCON-AS) and discordant AS (HGDIS-AS) in an Asian cohort. From 2010 to 2015, patients with moderate-to-severe AS with preserved left ventricular ejection fraction (LVEF ≥ 50%) were recruited and stratified into 3 groups based on index echocardiogram-(1) HGDIS-AS, (2) HGCON-AS and (3) moderate AS (MOD-AS). The primary study endpoints was all-cause mortality, with secondary endpoints of congestive heart failure (CHF) admissions and aortic valve replacement (AVR). Multivariable Cox regression was used and Kaplan-Meier curves were constructed to evaluate associations between HGDIS-AS, HGCON-AS and MOD-AS, and the study outcomes. A total of 467 patients were studied, comprising of 6.2% HGDIS-AS, 13.9% HGCON-AS and 79.9% MOD-AS patients. There was significantly higher AVR rates in the HGCON-AS group (58.5%), followed by HGDIS-AS (31.0%) and MOD-AS (4.6%), p < 0.001) groups. After adjusting for confounders, HGCON-AS was significantly associated with all-cause mortality (HR 3.082, 95% CI 1.479-6.420, p = 0.003) and CHF admissions (HR 12.728, 95% CI 2.922-55.440 p = 0.001) but not HGDIS-AS, with MOD-AS as the reference group. Both HGDIS-AS (HR 7.715, 95% CI 2.927-20.338; p < 0.001) and HGCON-AS (HR 21.960, 95% CI 10.833-44.515, p < 0.001) were independent predictors of AVR. After exclusion of reversible high-flow states, HGDIS-AS patients appear to have a more favourable prognostic profile compared to HGCON-AS patients. Large prospective interventional studies examining the prognostic differences between the two groups will be the next important step.

Development of frailty index using ICD-10 codes to predict mortality and rehospitalization of older adults: An update of the multimorbidity frailty index

ObjectiveThis study aims to develop an updated mFI (multimorbidity frailty index) using ICD-10-CM codes and to examine the association between frailty and all-cause mortality, unplanned hospitalization, and ICU admission by adopting the updated mFI in the contemporary ICD-10-CM era. MethodsFrom NHIRD, subjects aged 65–100 years with full National Health Insurance coverage in 2017 were included. We constructed the renewed mFI using ICD-10 CM codes (mFI-v10) by the cumulative deficit approach and categorized the study subjects according to the mFI-v10 quartiles: fit, mild frailty, moderate frailty, and severe frailty. Outcomes of interests (1-year mortality, unplanned hospitalization, and intensive care unit (ICU) admission) were assessed using Cox regression analyses, adjusted by sex and age. ResultsCompared with the fit group, those with severe frailty were associated with a 4-fold (adjusted HR 3.86, 95% CI 3.54–4.20) higher risk for death at one year. Subjects with moderate frailty or mild frailty were associated with a 2.4-fold (adjusted HR 2.35, 95% CI 2.18–2.55) or 1.6-fold (adjusted HR 1.57, 95% CI 1.47–1.69) higher risk for death at one year than the fit group. Similar risk trends can also be observed in unplanned hospitalization and intensive care unit (ICU) admission among the study population. ConclusionThe renewed multimorbidity frailty index constructed from ICD-10 codes is associated with an increased risk of 1-year of all-cause mortality, unplanned hospitalization, and ICU admission. It can provide updated information contributing to risk stratification using frailty index in the ICD-10 era.

Higher rates of all-cause mortality and resource utilization during episodes-of-care for diabetic foot ulceration

AimsOur primary objective was to determine whether all-cause rates of mortality and resource utilization were higher during periods of diabetic foot ulceration. In support of this objective, a secondary objective was to develop and validate an episode-of-care model for diabetic foot ulceration. MethodsWe evaluated data from the Medicare Limited Data Set between 2013 and 2019. We defined episodes-of-care by clustering diabetic foot ulcer related claims such that the longest time interval between consecutive claims in any cluster did not exceed a duration which was adjusted to match two aspects of foot ulcer episodes that are well-established in the literature: healing rate at 12 weeks, and reulceration rate following healing. We compared rates of outcomes during periods of ulceration to rates immediately following healing to estimate incidence ratios. ResultsThe episode-of-care model had a minimum mean relative error of 4.2% in the two validation criteria using a clustering duration of seven weeks. Compared to periods after healing, all-cause inpatient admissions were 2.8 times more likely during foot ulcer episodes and death was 1.5 times more likely. ConclusionsA newly-validated episode-of-care model for diabetic foot ulcers suggests an underappreciated association between foot ulcer episodes and all-cause resource utilization and mortality.

One-year readmission and mortality following ischaemic stroke by diabetes status, sex, and socioeconomic disadvantage: An analysis of 27,802 strokes from 2012 to 2017

ObjectiveWe estimated the 1-year incidence of readmission to hospital and 1-year all-cause mortality following ischaemic stroke (IS), by diabetes status, sex, and socioeconomic disadvantage. MethodsThis study included all individuals aged ≥30 years who were discharged from hospital following an IS between July 2012 and June 2017 in Victoria, Australia (n = 25,421). Individuals were followed from discharge until readmission (for all-causes, cardiovascular readmission, and readmission for IS) or death, censoring at 1-year of follow-up. ResultsThe 1-year cumulative incidence of all-cause readmission following an IS was 56.1% (95% CI: 55.5–56.7); 24% of first all-cause admission were attributed to cardiovascular disease. People with diabetes were at an excess risk of all-cause, cardiovascular, and IS readmission following an IS (adjusted sub-HRs: 1.13 [95% CI: 1.09–1.17], 1.14 [1.07–1.21], and 1.17 [1.06–1.29], for people with vs. without diabetes, respectively) and 1-year mortality (adjusted HR: 1.11 [1.03–1.19]). There was no significant difference between men and women in all-cause and cardiovascular readmission risk, while women were at higher risk of IS readmission (sub-HR: 1.10 [1.01–1.21] for women vs. men) and mortality (HR: 1.12 [1.05–1.20]). There was no relationship between socioeconomic disadvantage and risk of cardiovascular or IS readmission, while 1-year mortality risk did increase with increasing socioeconomic disadvantage (HR for most vs. least disadvantaged quintile: 1.15 [1.03–1.27]; ptrend = 0.006), and all-cause readmission risk decreased (sub-HR: 0.94 [0.90–0.99]; ptrend = 0.001). ConclusionsThere is a high risk of readmission following IS. Decreasing the readmission rate will require more complex interventions than solely improving post-discharge cardiovascular management.

The effect of introduction of routine immunization for rotavirus vaccine on paediatric admissions with diarrhoea and dehydration to Kenyan Hospitals: an interrupted time series study

Background: Dehydration secondary to diarrhoea is a major cause of hospitalization and mortality in children aged less than five years. Most diarrhoea cases in childhood are caused by rotavirus, and routine introduction of rotavirus vaccine is expected to reduce the incidence and severity of dehydration secondary to diarrhoea in vaccinated infants. Previously, studies have examined changes in admissions with stools positive for rotavirus but this study reports on all admissions with dehydration secondary to diarrhoea regardless of stool rotavirus results. We aimed to assess the changes in all-cause severe diarrhoea and dehydration (DAD) admissions following the vaccine’s introduction. Methods: We examined changes in admissions of all clinical cases of DAD before and after introduction of routine vaccination with rotavirus vaccine in July 2014 in Kenya. We use data from 13 public hospitals currently involved in a clinical network, the Clinical Information Network (CIN). Routinely collected data for children aged 2-36 months were examined. We used a segmented mixed effects model to assess changes in the burden of diarrhoea and dehydration after introduction of rotavirus vaccine. For sensitivity analysis, we examined trends for non-febrile admissions (surgical or burns). Results: There were 17,708 patients classified as having both diarrhoea and dehydration. Average monthly admissions due to DAD for each hospital before vaccine introduction (July 2014) was 35 (standard deviation: ±22) and 17 (standard deviation: ±12) after vaccine introduction. Segmented mixed effects regression model showed there was a 33% (95% CI, 30% to 38%) decrease in DAD admissions immediately after the vaccine was introduced to the Kenya immunization program in July 2014. There was no change in admissions due to non-febrile admissions pre-and post-vaccine introduction. Conclusion: The rotavirus vaccine, after introduction into the Kenya routine immunization program resulted in reduction of all-cause admissions of diarrhoea and dehydration in children to public hospitals.

Effectiveness of a 24-hour access outpatient clinic for patients with chronic conditions in hospital outpatient follow-up: a registry-based controlled cohort study of healthcare utilisation and mortality

ObjectiveTo evaluate the effectiveness of a 24-hour telephone access outpatient clinic (24-hour access clinic) in terms of healthcare utilisation and mortality in patients with five chronic conditions (chronic obstructive pulmonary...

The Economic Burden of Recurrence in Triple-Negative Breast Cancer Among Working Age Patients in the United States.

Triple-negative breast cancer (TNBC) is associated with a high recurrence risk. However, the magnitude of direct and indirect costs associated with recurrence is lacking in the literature. Adults 18-65years old diagnosed with TNBC were identified from the OptumHealth Reporting and Insights claims database (1999-2017) and stratified by recurrence. For patients with recurrence, theindex date was defined as 30days before recurrence; for patients without recurrence, it was randomly assigned based on the distribution of time between first treatments and index dates of the recurrence cohort. All-cause and breast cancer-related healthcare resource utilization (HRU), direct and indirect costs, and work loss up to 1 year were compared between cohorts using generalized linear models. Kaplan-Meier analyses and Cox proportional hazards models compared the risk of leaving the workforce. Among the 2340 patients analyzed, mean age was 54years and > 75% of patients had stage 0-2 cancer. Among the 1170 patients with recurrence, 236 were categorized as having metastatic recurrence and 934 as having locoregional recurrence. Relative to patients without recurrence, those with recurrence had significantly higher all-cause and breast cancer-related HRU. For instance, adjusted incidence rates (IRs) for all-cause inpatient admissions were 3.67 and 10.19 times higher for patients with locoregional and metastatic recurrence, respectively (p < 0.001). Adjusted all-cause healthcare costs were $8575/month higher for metastatic recurrence and $3609/month higher for locoregional recurrence vs. patients without recurrence (p < 0.001). Adjusted IRs for work loss days were approximately two times higher for locoregional and metastatic recurrence vs. without recurrence (p < 0.001). Patients with locoregional recurrence incurred $335/month more indirect costs vs. patients without recurrence; those with metastatic recurrence incurred $769/month more (p < 0.05). Patients with recurrence had a 63% higher rate of leaving the work force (p = 0.003). The incremental direct and indirect economic burden associated with recurrent TNBC is substantial relative to non-recurrence.

Malnutrition and Frailty Are Critical Determinants of 6-Month Outcome in Hospitalized Elderly Patients With Heart Failure Harboring Surgically Untreated Functional Mitral Regurgitation.

Background: Hospitalized patients with acute decompensated heart failure (ADHF) frequently exhibit aggravating mitral regurgitation (MR). Those patients do not always undergo surgical mitral valve repair, but particularly in the elderly, they are often treated by conservative medical therapy. This study was aimed to investigate factors affecting 6-month outcomes in hospitalized patients with heart failure (HF) harboring surgically untreated MR.Methods: We screened the presence of MR in hospitalized patients with HF between September 2017 and May 2020 in the Yamaguchi Prefectural Grand Medical (YPGM) center. At the time of discharge of these patients, individuals with surgically unoperated MR, including primary and secondary origin, were consequently recruited to this single-center prospective cohort study. The patients with severe MR who undergo surgical mitral valve treatment were not included in this study. The primary endpoint was all-cause readmission or all-cause death and the secondary endpoint was HF-related endpoint at 6 months after discharge. The Cox proportional hazard regression analyses were employed to assess the predictors for the composite endpoint.Results: Overall, 489 patients with ADHF were admitted to the YPGM center. Of those, 146 patients (30% of total patients with HF) (median age 83.5 years, 69 men) were identified as harboring grade II MR or greater. Consequently, all the recruited patients were diagnosed as functional MR. During a median follow-up of 186.0 days, a total of 55 patients (38%) reached the primary or secondary endpoints (HF death and readmission in 31 patients, other in 24 patients). As a result of multivariate analysis, geriatric nutritional risk index [hazard ratio (HR) = 0.932; 95% CI = 0.887–0.979, p = 0.005], age (HR = 1.058; 95% CI = 1.006–1.112, p = 0.027), and left ventricular ejection fraction (HR = 0.971; 95% CI = 0.945–0.997, p = 0.030) were independent predictors of all-cause death or all-cause admission. Body mass index (HR = 0.793; 95% CI = 0.614–0.890, p = 0.001) and ischemic heart disease etiology (HR = 2.732; 95% CI = 1.056–7.067, p = 0.038) were also independent predictors of the HF-related endpoints.Conclusion: Malnutrition and underweight were substantial predictors of adverse outcomes in elderly patients with HF harboring surgically untreated moderate-to-severe functional MR.

Continuity of care, measurement and association with hospital admission and mortality: a registry-based longitudinal cohort study

ObjectiveTo assess whether continuity of care (COC) with a general practitioner (GP) is associated with mortality and hospital admissions for older patients We argue that the conventional continuity measure may...

Renin-Angiotensin System Blocker in COVID-19. A Single Center Study.

Early during the Coronavirus disease 2019 (Covid-19) pandemic, concerns were raised regarding potential adverse outcomes in patients taking angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs). These concerns were based on animal studies showing increased ACE-2 expression in mice treated with ACEI/ARB. This is a single-center, retrospective, cohort study of 289 patients diagnosed with 2019 Novel Coronavirus (SARS-CoV-2) hospitalized between March of 2020 and June of 2020. The study was intended to investigate the impact of ACEIs and/or ARBs on in-hospital mortality, intensive care unit (ICU) admission, postadmission hemodialysis requirement, and the need for mechanical ventilation in patients with COVID-19. This cohort of 289 patients included 139 of 289 women (48%) with a mean age of 61 ± 19 years. Patients using ACEIs/ARBs were older (69.68 vs. 57.9 years; P < 0.0001), more likely to have a history of hypertension (97% vs. 36%; P < 0.0001), diabetes mellitus (48% vs. 20.9%; P < 0.0001), chronic heart failure (11.39% vs. 4.29%; P < 0.0512), coronary artery disease (20.25% vs. 7.14%; P < 0.0025), stroke/Transient Ischemic Attack (7.59% vs. 2.38%; P < 0.0761), chronic kidney disease (11.39% vs. 3.33%; P < 0.0167), atrial fibrillation/flutter (18.99% vs. 7.14%; P < 0.0080), and dementia (22.7% vs. 11.4%; P < 0.0233) compared with the nonuser group. There was significantly higher in-hospital mortality in patients using ACEIs/ARBs than nonusers, respectively (32.9% vs. 15.2%; P < 0.0015). However, a multivariate logistics regression analysis performed to adjust for common confounders demonstrated no significant difference in all-cause in-patient mortality (P 0.7141). Admission to ICU, postadmission hemodialysis requirement, and mechanical ventilation showed no significant differences between the 2 groups (P = NS). This study suggests that the use of ACEIs and ARBs in patients with COVID-19 was not found to significantly increase all-cause in-hospital mortality, ICU admissions, and hemodialysis and mechanical ventilation requirements.

Interrupted time-series analysis showed unintended consequences of non-pharmaceutical interventions on pediatric hospital admissions

ObjectiveCOVID-19-associated non-pharmaceutical interventions (NPI) have disrupted respiratory viral transmission. We quantified the changes in pediatric hospital admissions in 2020 from five different NPI phases in Western Australia for acute lower respiratory infections (ALRI) in children in the context of all-cause admissions.Study Design and SettingWe assessed anonymised hospitalization data from Perth Children's Hospital (Jan 2015-Dec 2020) for all-cause admissions, ALRI, febrile illnesses and trauma (negative control) in those <17 years. We evaluated absolute changes in admissions and the weekly change estimated from interrupted time-series models.ResultsThe absolute number of admissions was comparable in 2020 (15,678) vs. 2015 to 2019 average (15,310). Following the introduction of strict NPIs, all-cause admissions declined by 35%, recovered to pre-pandemic levels, then increased by 24% following NPI cessation. ALRI admissions in children <5 years initially declined by 89%, which was sustained throughout the gradual easing of NPI until an increase of 579% (997% in <3 months) following the final easing of NPI. Admissions for trauma showed minimal changes in 2020 compared to preceding years.ConclusionCOVID-19-associated NPI had significant unintended consequences in health service utilization, especially for ALRI and infants <3 months, prompting the need to understand viral transmission dynamics in young children.

Abstract 13350: Pulmonary Embolism Readmission Trend Over the Years: A National Readmission Database Study

Introduction: Acute pulmonary embolism(PE) is known to be associated with significant short term and long term complications. However with evolution of PE management, the outcomes of PE related complications and need for readmission has not been well studied. Our aim of this study is to see the trend in readmissions in PE patients from the years 2010 to 2018. Methods: We utilized the National Readmission Database from 2010 to 2018 to identify hospitalized patients with a principal diagnosis of acute pulmonary embolism. Identified the total number of readmissions for acute PE from 2010 to 2018. Multivariate cox regression model was used to identify independent predictors of readmission. Results: The number of patients with 30-day readmissions have gradually increased from 14,508 in 2010 to 19,703 in 2018. The proportion of females admitted was higher than males in all years.The 30-day all cause readmission after principal admission for PE decreased from 11.2% to 9.7% from 2010 to 2014 but increased to 11.8% in 2018 (p&lt;0.001). Risk adjusted readmission specific for PE showed a decrease from 1.2 to 1% (p=0.023) from 2010 to 2018, with the proportion decreasing from 11.9% to 9.5% during the same period. There was no significant difference in the inpatient mortality (p=0.382) and length of stay (p=0.658) during the study period. There was an increasing trend in the total hospital charges from 2010 (13,374$) to 2018 (15,104$) but the difference was not statistically different (p=0.086). Conclusion: Our study suggests that there is a statistically significant decrease in PE specific readmission, with a decrease followed by an increase in all-cause admission after a PE. There is also no significant difference in mortality and length of stay. These findings warrant further studies to elucidate the mechanism for decrease PE-specific readmission but possible causes for the increase in all-cause readmission in the hope of optimizing management and continuing improving outcomes.

Abstract 10167: Coronavirus Disease 2019 Pandemic and Incidence of Takotsubo Syndrome: A Retrospective Study

Introduction: During the Coronavirus Disease 2019 (COVID-19) pandemic individuals have been exposed to unprecedented levels of psychological, social, and financial stress. Given the association between Takotsubo Syndrome (TS) and stress exposure, we hypothesized that the incidence of TS would increase during the Covid-19 pandemic. Methods: We performed a retrospective review of electronic medical records of patients admitted to three large hospitals in RI, United States. The proportion of TS admission (based on Mayo Clinic criteria)/all-cause admissions during the first pandemic year (3/1/2020-2/28/2021) was compared with that of the previous, non-pandemic, year (3/1/2019-2/28/2020). We collected information on demographics, medical history, and length of hospitalization. T-test and chi-square were used to compare continuous and categorical variables, respectively. A p value (2-sided) &lt; .05 was considered significant. Results: The number of all-cause admissions was lower during the pandemic vs. the pre-pandemic year (229,906 vs. 316,299), p &lt; .001. During the pandemic year, 39/229,906 patients were admitted with TS, compared to 35/316,299 in the pre-pandemic period. Characteristics of TS patients were similar except for the duration of hospital stay (Table 1). TS incidence proportion was 0.017% during the pandemic period vs. 0.011% (p .07, Fig. 1), and the rate ratio was 1.53 (95% CI: 0.97, 2.42). Conclusions: Despite the limitations of this study (small sample size; retrospective design), findings suggest the incidence of TS was higher during the pandemic year. These findings need to be confirmed in a larger and more diverse population.

Abstract 10744: Efficacy of Remote Pulmonary Artery Hemodynamic Monitoring in Reducing Heart Failure Readmissions Among Patients with Obstructive Sleep Apnea of Varying Severity

Introduction: Obstructive sleep apnea (OSA) and heart failure (HF) often co-exist. Remote pulmonary artery (PA) hemodynamic monitoring has shown to decrease HF readmissions. However, there is limited data regarding its efficacy in patients with OSA of varying severity. Hypothesis: Outcomes of remote PA hemodynamic monitoring using CardioMEMS device in reducing HF hospitalization in patients with mild [apnea-hypopnea index (AHI)=5-14], moderate (AHI=15-30) and severe OSA (AHI&gt;30). Methods: Retrospective data was collected for HF patients who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. Number of hospitalizations, emergency department (ED) and HF clinic visits data was collected for 1-year pre and 1-year post-implantation. Mortality data was collected at 1-year post-implantation. Severity of OSA was based on AHI documented in the sleep study. Analysis was done using Kruskal-Wallis test for comparison between OSA groups. Mortality was compared with Pearson’s chi-squared test. Results: CardioMEMS device was implanted in 177 patients during the study period. Of this, 108(61%) patients had OSA diagnosed at the time of implantation. Among OSA patients, 52(48%) had severe OSA. There was a statistically significant decrease in overall mean HF admissions from 1.80(± 1.55) to 0.62(± 1.07), 65.6%, p&lt;0.001 and mean HF ED visits from 1.37(± 1.50) to 0.5(± 0.95), 63.5%, p&lt;0.001 in 1-year pre-and post-implantation among all OSA patients. When comparing different OSA groups, there was no statistically significant difference between them in all-cause admissions, HF admissions, ED visits, ED HF visits, and HF clinic visits 1-year pre and post-implantation. No statistically significant difference was observed in mortality. Conclusions: PA hemodynamic monitoring using CardioMEMS device had a net benefit in reducing HF admissions and HF ED visits in OSA patients and this benefit remained unchanged across different OSA groups.

Abstract 9917: Stroke Survivors with Asthma Have Worse Cardiovascular Outcomes

Introduction: Studies have shown that asthmatics have higher risk for cardiovascular (CV) disease and all-cause mortality than non-asthmatics. However, only a few studies have examined the role asthma has on CV outcomes of stroke survivors. Hypothesis: Stroke survivors with asthma have higher risk of CV outcomes (1- and 5-year all-cause mortality, 1- and 5-year admission for stroke recurrence, first occurrence of MI, or HF) than matched stroke survivors without asthma. Methods: A total of 271,260 patients, 18-years-old and older, with index stroke and without a history of HF, MI, or COPD from January 1, 1995 to December 31, 2015 were identified in the Myocardial Infarction Data Acquisition System, a database of all admissions to non-federal hospitals in New Jersey. A matched analysis was performed by separating the cohort into asthmatics (n=11,702) and non-asthmatics (n=34,950) and matched 1 asthmatic up to 3 non-asthmatics. Data was analyzed by matching patient and clinical characteristics. The association of asthma with each of the above outcomes was assessed using logistic regression, log-rank test, and Cox models. Results: There was no difference in 1-and 5-year all-cause mortality (p=0.102 and p=0.488, respectively). Patients with asthma were more likely to be readmitted for stroke within 1 year (hazard ratio (HR)= 1.08, 95% CI 1.00-1.16, p=0.041) and had first admission for HF at 1 year (HR 1.38, 95% CI 1.09-1.73, p=0.006) compared to matched controls. Also, they were more likely to be readmitted for stroke within 5 years (HR 1.08, 95% CI 1.02-1.15, p=0.007) and to be admitted for first HF within 5 years (HR 1.27, 95% CI 1.12-1.44, p&lt;0.001) (Figure). There were no significant differences in 1-year and 5-year first MI admissions. Conclusion: Stroke survivors with asthma have higher risk for stroke readmission and first HF admission compared to matched controls. Randomized studies are needed to confirm these findings and stimulate focused efforts to mitigate this risk.

Blood Differential Gene Expression in Patients with Chronic Heart Failure and Systemic Iron Deficiency: Pathways Involved in Pathophysiology and Impact on Clinical Outcomes.

Background: Iron deficiency is a common disorder in patients with heart failure and is related with adverse outcomes and poor quality of life. Previous experimental studies have shown biological connections between iron homeostasis, mitochondrial metabolism, and myocardial function. However, the mechanisms involved in this crosstalk are yet to be unfolded. Methods: The present research attempts to investigate the intrinsic biological mechanisms between heart failure and iron deficiency and to identify potential prognostic biomarkers by determining the gene expression pattern in the blood of heart failure patients, using whole transcriptome and targeted TaqMan® low-density array analyses. Results: We performed a stepwise cross-sectional longitudinal study in a cohort of chronic heart failure patients with and without systemic iron deficiency. First, the full transcriptome was performed in a nested case-control exploratory cohort of 7 paired patients and underscored 1128 differentially expressed transcripts according to iron status (cohort1#). Later, we analyzed the messenger RNA levels of 22 genes selected by their statistical significance and pathophysiological relevance, in a validation cohort of 71 patients (cohort 2#). Patients with systemic iron deficiency presented lower mRNA levels of mitochondrial ferritin, sirtuin-7, small integral membrane protein 20, adrenomedullin and endothelin converting enzyme-1. An intermediate mitochondrial ferritin gene expression and an intermediate or low sirtuin7 and small integral membrane protein 20 mRNA levels were associated with an increased risk of all-cause mortality and heart failure admission ((HR 2.40, 95% CI 1.04–5.50, p-value = 0.039), (HR 5.49, 95% CI 1.78–16.92, p-value = 0.003), (HR 9.51, 95% CI 2.69–33.53, p-value < 0.001), respectively). Conclusions: Patients with chronic heart failure present different patterns of blood gene expression depending on systemic iron status that affect pivotal genes involved in iron regulation, mitochondrial metabolism, endothelial function and cardiovascular physiology, and correlate with adverse clinical outcomes.

Outcomes of remote pulmonary artery hemodynamic monitoring in heart failure patients with obstructive sleep apnea

Abstract Introduction Obstructive sleep apnea (OSA) is often associated with heart failure (HF). Remote pulmonary artery (PA) hemodynamic monitoring has shown to decrease HF related readmissions. However, there is paucity of data regarding its efficacy and mortality in patients with OSA. Purpose Real-world analysis of outcomes of remote PA hemodynamic monitoring using CardioMEMS device in reducing HF hospitalization in patients with OSA [apnea–hypopnea index (AHI) ≥5]. Methods Retrospective data was collected for patients with HF who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. The number of hospitalizations, emergency department (ED) and HF clinic visits data was collected for 1-year pre and 1-year post device implantation. Mortality data was also collected at 1-year post-implantation. Patients who were diagnosed with OSA based on AHI ≥5 on sleep study at the time of implantation were included in the study. Analysis was done using Kruskal-Wallis test for comparison between heart failure patients with and without OSA. Mortality was compared with Pearson's chi-squared test. Results CardioMEMS device was implanted in 177 patients during the study period. Of this population, 108 (61%) patients had known OSA at the time of implantation. There was a statistically significant decrease in overall mean HF admissions from 1.80 (± 1.55) to 0.62 (± 1.07), 65.6%, p&amp;lt;0.001 and mean HF ED visits from 1.37 (± 1.50) to 0.5 (± 0.95), 63.5%, p&amp;lt;0.001 in 1-year pre- and post-implantation among OSA patients. When comparing outcomes between HF patients with and without OSA, there was no statistically significant difference observed between them in all-cause admissions, HF admissions, ED visits, ED HF visits, and HF clinic visits 1-year pre and post implantation. Also, no statistically significant difference was observed in mortality between the groups at 1-year post-implantation. Conclusions PA hemodynamic monitoring using CardioMEMS device had a net benefit in reducing HF admissions and HF ED visits in OSA patients which was similar in patients without OSA. Funding Acknowledgement Type of funding sources: None.

Real-World Outcomes and Costs Following 6 Months of Treatment with the Long-Acting Injectable (LAI) Aripiprazole Lauroxil for the Treatment of Schizophrenia.

BackgroundContinuous antipsychotic therapy is recommended as part of long-term maintenance treatment of schizophrenia, and gaps in antipsychotic treatment have been associated with increased risks of relapse and rehospitalization. Because the use of long-acting injectable (LAI) antipsychotics may reduce the likelihood of undetected medication gaps, initiating an LAI medication may affect resource utilization and costs. The LAI aripiprazole lauroxil (AL) was approved in the United States (US) in 2015 for the treatment of schizophrenia in adults.ObjectiveThe objective of this retrospective observational cohort study was to examine treatment patterns, resource utilization, and costs following initiation of AL for the treatment of schizophrenia in adults.MethodsA retrospective analysis of Medicaid claims data identified a cohort of patients (N = 485) starting AL shortly after Food and Drug Administration approval in October 2015. Treatment patterns, resource utilization, and costs were compared 6 months before and after treatment initiation. Subgroup analyses were conducted based on the type of antipsychotic (LAI, oral, or none) received before initiation of AL.ResultsOver 6 months of follow-up, patients received an average of 4.6 injections out of a maximum of six (77%). After initiating AL, all-cause inpatient admissions decreased by 22.4%; other significant reductions were observed in mental health–related admissions and emergency room (ER) visits. All-cause inpatient costs decreased by an average of US$2836 per patient (p < 0.05) in the 6-month post-AL period, whereas outpatient pharmacy costs increased by US$4121 (p < 0.05), resulting in no significant difference in overall costs between the pre- and post-AL periods. The subgroup of patients who had been prescribed an oral antipsychotic before starting AL had significant reductions in proportion of patients with inpatient and ER visits and costs, but also reported a significant increase in pharmacy costs.ConclusionsAL was associated with a significant reduction in inpatient costs and an increase in outpatient pharmacy costs, resulting in no changes in total healthcare costs over 6 months. The adherence rate and reductions in inpatient use may indicate the potential for greater clinical stability among patients initiated on AL compared with their previous treatment.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40263-021-00849-2.

The Relationship Between Governing Board Composition and Medicare Shared Savings Program Accountable Care Organizations Outcomes: an Observational Study.

Early studies of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) suggested that physician leadership was an important driver of ACO success, but it is unknown whether the demographic and professional composition of current MSSP ACO governing boards is associated with ACOs' publicly reported outcomes. To investigate whether governing boards with higher physician participation and greater female involvement have better outcomes. Cross-sectional observational study. All 2017 MSSP ACOs identified by the Center for Medicare and Medicaid Services ACO Public Use Files (PUF). We collected governing board composition from ACO websites in 2019. Outcome metrics included risk-standardized readmission and unplanned admissions rates. We used descriptive statistics and linear regression models to examine the association between board composition and outcomes. Of the 339 ACOs that still existed in 2019 and had available data, 77% had physician-majority boards and 11.5% had no women on their boards. Eighty-nine percent reported a Medicare beneficiary on their board, of which about one-third had a woman representative. The average number of members on MSSP ACO boards was 12, with a mean of 67% physicians and 24% women. Board composition varied minimally by ACO characteristics, such as geographic region, number of beneficiaries, or type of participants. Higher levels of physician participation in ACO governing boards were associated with lower all-cause unplanned admission rates for patients with heart failure (p = - 0.26, p < 0.001) and for patients with multiple chronic conditions (p = - 0.28, p = 0.001). The number of women on the board was not associated with any outcome differences. MSSP ACO governing boards were predominately male and physician-led. Physician involvement may be important for achieving quality goals, while lack of female involvement showcases an opportunity to diversify boards.

Left atrial pressure overload and prognosis in elderly patients with heart failure and preserved ejection fraction: a prospective multicenter observational study

ObjectivesThe severity of diastolic dysfunction is assessed using a combination of several indices of left atrial (LA) volume overload and LA pressure overload. We aimed to clarify which overload is...