Care For Congestive Heart Failure Research Articles

Abstract 14287: Real-World Healthcare Resource Utilization Among Patients With Hypertension or Congestive Heart Failure and Comorbid Alcohol Use Disorder

Introduction: Excessive alcohol consumption has been associated with increased risk of cardiovascular (CV) disease. Hypertension (HTN) is a known risk factor for CV disease, in general, including congestive heart failure (CHF). Healthcare resource utilization (HRU) and costs associated with comorbid alcohol use disorder (AUD) among patients with HTN or CHF were evaluated. Methods: This retrospective cohort study identified adults with moderate-to-severe AUD from patients with ≥1 inpatient, or ≥2 outpatient claims on separate days, for HTN or CHF (MarketScan® and Medicare [1/1/2016-12/31/2020], Medicaid [1/1/2016-12/31/2019] databases), and ≥1 year of continuous healthcare enrollment prior to diagnosis (baseline) and 3 months after. Monthly HRU and costs were compared between propensity-score matched patients based on AUD presence using rate ratios in generalized linear models. Results: Of 4,015,785 patients with HTN, 1% were diagnosed with AUD. Use of HTN pharmacotherapy was similar for all patients, except for less frequent use of angiotensin receptor blockers (ARBs) in those with AUD. HTN patients with comorbid AUD had a higher risk of inpatient visits (89%), ED visits (39%), longer inpatient stays (98%), and outpatient visits (9%) relative to non-AUD patients. Of 294,892 patients with CHF, 2% had comorbid AUD. CHF pharmacotherapy use was similar for all patients, except for less frequent ARB use in those with AUD. CHF with comorbid AUD had a higher risk of inpatient visits (31%), ED visits (25%), and longer inpatient stays (34%) relative to non-AUD patients. Outpatient visits were 5% lower in CHF patients with AUD. AUD was associated with higher acute care costs, fewer pharmacy claims, and lower pharmacy costs in both HTN and CHF cohorts. Patients with AUD in both cohorts were more likely to be younger, male, enrolled in Medicaid, with a higher comorbidity burden. Conclusion: In this real-world study, the presence of AUD in patients with either HTN or CHF was associated with greater comorbidity burden, higher acute care utilization and costs, and lower outpatient pharmacy utilization relative to patients without AUD. These findings suggest that AUD impacts care for both HTN and CHF, which could be an opportunity for improved screening and treatment.

Le programme PRADO–IC, programme d'aide au retour à domicile des patients insuffisants cardiaques : description, évaluation, perspectives

IntroductionReturn to home after discharge for congestive heart failure (CHF) is associated with prolonged and recurrent hospitalizations, the prognosis remains poor. Since 2013, the Caisse Nationale d'Assurance Maladie (CNAM) with the Société Française de Cardiologie (SFC) has set up a support program PRADO-IC (support program for returning home after hospitalization for heart failure). The aim of this studywas to describe the program, to present epidemiologic data, and the evaluations by the CNAM, and by clinical studies, then to expose strengths limits and perspectives. ResultsAfter the inclusion a CPAM advisor organize the outcome, the care of the outpatient is based on his general practitioner (GP) and a private nurse trained in CHF care during a three-months program. Between 2017 and 2019, 20 264 patients per year were hospitalized in Ile de France, 8.8% were included in PRADO-IC. The retrospective CNAM evaluations were positive: follow up criteria were improved and mortality rate at 6 months was lower (10.3% vs. 14.1%). However, clinical retrospective study of Troyes hospital (n = 89), and Paris Saint Joseph Hospital (n = 633), did not confirm these results: rate mortality and/or re-hospitalization were not different between patients and control. Several prospective studies are underway; results will be soon available.Limits of PRADO-IC are discussed like the lack of inclusion criteria, lack of geriatric evaluation, or the pivotal role based on GP, and the short term of duration. Strengths are its existence, national reach, multi-disciplinary approach, educational contents. Clinical studies showed that the PRADO-IC program concerned to the most severe patients. Despite this, the one-year mortality and the HF readmission rate are the same than out-program patients. ConclusionPRADO-IC is the one and the only national transition of care program for IC patients. First evaluations are positive but prospective evaluation studies are needed in order to limit methodologic bias.

Care delivery team composition effect on hospitalization risk in African Americans with congestive heart failure.

The care delivery team (CDT) is critical to providing care access and equity to patients who are disproportionately impacted by congestive heart failure (CHF). However, the specific clinical roles that are associated with care outcomes are unknown. The objective of this study was to examine the extent to which specific clinical roles within CDTs were associated with care outcomes in African Americans (AA) with CHF. Deidentified electronic medical record data were collected on 5,962 patients, representing 80,921 care encounters with 3,284 clinicians between January 1, 2014 and December 31, 2021. Binomial logistic regression assessed associations of specific clinical roles and the Mann Whitney-U assessed racial differences in outcomes. AAs accounted for only 26% of the study population but generated 48% of total care encounters, the same percentage of care encounters generated by the largest racial group (i.e., Caucasian Americans; 69% of the study population). AAs had a significantly higher number of hospitalizations and readmissions than Caucasian Americans. However, AAs had a significantly higher number of days at home and significantly lower care charges than Caucasian Americans. Among all CHF patients, patients with a Registered Nurse on their CDT were less likely to have a hospitalization (i.e. 30%) and a high number of readmissions (i.e., 31%) during the 7-year study period. When stratified by heart failure phenotype, the most severe patients who had a Registered Nurse on their CDT were 88% less likely to have a hospitalization and 50% less likely to have a high number of readmissions. Similar decreases in the likelihood of hospitalization and readmission were also found in less severe cases of heart failure. Specific clinical roles are associated with CHF care outcomes. Consideration must be given to developing and testing the efficacy of more specialized, empirical models of CDT composition to reduce the disproportionate impact of CHF.

212 Proof of Concept: An EHR-fueled Risk Surveillance Tool for Managing Care Delivery Equity in Hospitalized African Americans with Congestive Heart Failure

OBJECTIVES/GOALS: 1) Characterize racial differences in congestive heart failure care delivery. 2) Examine the extent to which specific clinical roles were associated with improved care outcomes (i.e., hospitalizations, readmissions, days between readmissions, and charges) of African Americans (AA) with CHF. METHODS/STUDY POPULATION: EMR data was extracted from the Arkansas Clinical Data Repository (AR-CDR) on patients (ages 18-105) who received care between January 1, 2014 and December 31, 2021. Variables included age, sex, race, ethnicity, rurality, clinical diagnosis, morbidities, medical history, medications, heart failure phenotypes, and care delivery team composition. Binomial logistic regression ascertained the effects of these variables on patient’s care outcomes. A Mann Whitney-U test identified racial differences in outcomes. Psychometrically, classical test theory and item response theory assessed items for the risk surveillance tool. RESULTS/ANTICIPATED RESULTS: The study identified 5,962 CHF patients who generated 80,921 care encounters. The results revealed the disproportionate impact of CHF prevalence, hospitalizations, and readmissions on AAs. AAs had a significantly higher number of hospitalizations (i.e., 50% more) than Caucasians. Specific clinical roles (i.e., MDs, RNs, Care Managers) were consistently associated with 30% or greater decrease in odds of hospitalization and readmission, even when stratified by heart failure phenotype. Classical test theory results (e.g., Cronbach’s alpha; 0.88) indicated the set of items on the risk surveillance tool accurately reflect a patient risk for improved outcomes. DISCUSSION/SIGNIFICANCE: The findings stimulate the need for 1) EHR-based tools that manage care delivery equity and 2) investigations of specific clinical roles in risk stratifying and operationalizing the care plans of AAs, advancing formal access-to-care frameworks by ensuring access to clinical roles that are associated with improved outcomes.

A Public Health Critical Race Praxis Informed Congestive Heart Failure Quality Improvement Initiative on Inpatient General Medicine.

Prior evaluation at our hospital demonstrated that, compared to White patients, Black and Latinx patients with congestive heart failure (CHF) were less likely to be admitted to the cardiology service rather than the general medicine service (GMS). Patients admitted to GMS (compared to cardiology) had inferior rates of cardiology follow-up and 30-day readmission. To develop and test the feasibility and impacts of using quality improvement (QI) methods, in combination with the Public Health Critical Race Praxis (PHCRP) framework, to engage stakeholders in developing an intervention for ensuring guideline-concordant inpatient CHF care across all patient groups. We compared measures for all patients admitted with CHF to GMS between September 2019 and March 2020 (intervention group) to CHF patients admitted to GMS in the previous year (pre-intervention group) and those admitted to cardiology during the pre-intervention and intervention periods (cardiology group). Our primary measures were 30-day readmissions and 14- and 30-day post-discharge cardiology follow-up. There were 79 patients admitted with CHF to GMS during the intervention period, all of whom received the intervention. There were similar rates of Black and Latinx patients across the three groups. Compared to pre-intervention, intervention patients had a significantly lower 30-day readmission rate (18.9% vs. 24.8%; p=0.024), though the cardiology group also had a decrease in 30-day readmissions from the pre-intervention to intervention period. Compared to pre-intervention, intervention patients had significantly higher 14-day and 30-day post-discharge follow-up visits scheduled with cardiology (36.7% vs. 24.8%, p=0.005; 55.7% vs. 42.3%, p=0.0029), but no improvement in appointment attendance. This study provides a first test of applying the PHCRP framework within a stakeholder-engaged QI initiative for improving CHF care across races and ethnicities. Our study design cannot evaluate causation. However, the improvements in 30-day readmission, as well as in processes of care that may affect it, provide optimism that inclusion of a racism-conscious framework in QI initiatives is feasible and may enhance QI measures.

Abstract TMP36: Determining The Association Between Characteristics Of Congestive Heart Failure And Cognition

Introduction: It is not well known if specific measures of congestive heart failure (CHF) severity are associated with cognitive performance. We therefore aim to determine if there is an association between CHF characteristics and cognitive test scores, controlling for risk factors. Methods: 230 CHF outpatients presenting to an outpatient CHF clinic with no dementia, preceding transthoracic echocardiogram (TTE) within 1 year, and ability to provide consent were included. A trained psychometrist administered the Mini Mental State Exam (MMSE), Rey Complex Figure (RCF) Copy and Immediate Recall test, and Letter Number Sequencing (LNS) test. The New York Heart Association (NYHA) heart failure classification and heart failure type (HFpEF vs HFrEF) were collected at time of consent and verified with medical records. Two measures of diastolic function (deceleration time (DT), E/A ratio) were collected from TTEs. Multivariable linear regression models were used to estimate the association between each cardiac function measure and cognitive test (Z scores), adjusted for confounders, in distinct models. Results: Patients were mean age 67 years (SD 13.6), 34% Black, and 49% female. Median time from TTE to cognitive test was 97 days (IQR 31.5 - 198). NYHA class 3-4 patients had on average a worse LNS score when compared to NYHA class 1-2 patients, which remained significant after adjusting for covariates (β: -0.52; 95%CI: -0.87, -0.17). A worse NYHA class was associated with a worse RCF copy score, but only in univariate analysis (Table 1) and not with RCF immediate recall. HFpEF was associated with a worse immediate recall but not after adjustment. Diastolic dysfunction measures had no association with any cognitive test, nor any CHF measure with MMSE. Conclusion: In a cohort of CHF patients, we found an association between a worse stage of heart failure and worse performance on some, but not all cognitive tests. These data suggest that brain health is a critical outcome in CHF care.

Examination about more realistic prognosis evaluation method, how long the patients with congestive heart failure can spend at home

Abstract Background From August 2015, for efficient medical care in congestive heart failure (CHF) cases, we had introduced a unique clinical pathway (PATH) provided the immediate use of Tolvaptan and comprehensive education by multi-disciplinary staff after admission. And by introduction of PATH, we confirmed the shortening effect of hospitalization period with CHF and the suppressive effect of readmission with CHF after discharge. But since almost CHF patients repeat hospitalization and discharge due to change of their medical condition, the investigation for only first readmission rate after discharge is not enough to assess the entire long clinical course of CHF. Recently we found one report about evaluation method for CHF clinical prognosis, how long CHF patients can stay healthy at their own home after discharge within a certain period. This evaluation method is considered to take into account the long clinical course of CHF. Purpose We investigated whether the CHF patients introduced PATH on admission could stay longer at their home than CHF patients without PATH. Methods Between April 2014 and July 2019, 471 CHF cases, who ware admitted in our hospital at first and could be followed up for at least 1 month after discharge, ware enrolled. We divided them to two groups, PATH- group before introducing PATH (until July 2015, 142 cases), and PATH+ group applied PATH (after August 2015, 329 cases). Between both groups, we investigated the readmission rate (RR) with CHF and the total period (TP) that patients could spend at home within1, 3, 6 and 12month after discharge. Results There were no significant differences in mean age, pre-hospital living status, or clinical status at admission between the two groups. On the other hand, due to efficient CHF care, the average length of hospital stay was significantly shorter (figure1). RR within 1, 3, 6 and 12 months after discharge ware all lower in PATH+ group. And TP within 1, 3, 6 and 12 months after discharge ware all longer in PATH+ group (figure2). Conclusion By introducing our unique clinical pathway for congestive heart failure cases requiring hospitalization, we could confirm not only the improvement of their conventional clinical prognosis index but also the improvement of their new and more realistic clinical prognosis index after discharge. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Examination of the acute efficacy and safety about aggressive use of tolvaptan for early rising after admission in super-elder patients with congestive heart failure

Abstract Background From August 2015, for shortening of hospitalization period through efficient medical care in acute phase, we had introduced a unique clinical pathway (PATH) for congestive heart failure (CHF) cases. In PATH, since immediate taking of Tolvaptan, which is an strong oral diuretic and approver for use in the treatment of CHF cases since 2010 in Japan, after admission is specified, early diuresis makes it possible to achieve early rising from bed and streamline each medical care such as oxygen inhalation, continuous infusion, and urethral catheterization. Early rising from bed is particularly important for super-elder CHF patients who merge often frail. On the other hand, for super-elder CHF patients, it is feared that aggressive use of Tolvaptan may frequently cause dehydration, renal damage caused by it, or hypernatremia, which is a peculiar side effect about the drug. Purpose In this study, we examined the usefulness and safety of active use of Tolvaptan by introducing PATH in patients with super-elder CHF patients. Methods We set up three groups, NE group consist of 37 CHF cases (90 years old or over) who admitted in our hospital before (without) introduction of PATH between April 2014 and July 2015, PE group consist of 130 CHF cases (90 years old or over) and PY group consist of 466 CHF cases (under 90 years old) who ware admitted with introduction of PATH between August 2015 and July 2020. And in each group, we investigated various medical conditions in their acute phase after admission and the incidence of adverse events related to oral administration of tolvaptan, and examined the differences between three groups. Results Between NE group and PE group, there were no significant differences in mean age, pre-hospital living status, or clinical status at admission (Figure 1). But due to lean and efficient CHF care, the average length of hospitalization period was significantly shorter in PE group. And, in PE group, each medical care was performed as efficiently as in PY group, but the progression of renal damage or hypernatremia that required unscheduled discontinuation of tolvaptan use occurred more frequently in PE group (Figure 2). Conclusions Aggressive Tolvaptan use through our unique clinical pathway for congestive heart failure cases seemed to be useful even in super-elder patients. Although we thought that the safety of active use of tolvaptan for super-elder patients was well tolerated considering the results of this study, the incidence of adverse events such as hypernatremia was clearly higher in super-elder patients than in non-super-elder patients. It seemed that we should pay close attention to the clinical data of super-elder patients after introduction of tolvaptan. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

VExUS Nexus: Bedside Assessment of Venous Congestion.

Organ dysfunction in the setting of heart failure is mainly determined by backward transmission of increased right atrial pressure. Although traditional point-of-care ultrasound applications such as inferior vena cava and lung ultrasound have been increasingly incorporated in the clinical care of congestive heart failure, they do not directly evaluate the hemodynamic consequences of high right atrial pressure on organ blood flow. Congestion induces alterations in the venous flow patterns of abdominal organs that can be readily assessed using Doppler imaging. These alterations have been consistently associated with congestive organ dysfunction and adverse clinical outcomes. In this article, we provide a comprehensive overview of the bedside assessment of venous congestion using Doppler imaging. The review focuses mainly on the normal and abnormal Doppler patterns of the hepatic, portal, and intrarenal veins along with clinical examples of how to incorporate this tool in the management of patients with venous congestion.

Psychometrics of the Persian Version of the Team Assessment Questionnaire in Providing Care for Heart Failure Patients.

Background:Teamwork in the health care domain is the preferred mode of care delivery. Few instruments have been developed to assess teamwork in the field of health care, particularly in Iran. This study aimed to validate the Persian version of the Team Assessment Questionnaire (P-TAQ) in care for Congestive Heart Failure (CHF) patients.Materials and Methods:In this cross-sectional study, the validity (face, content, and construct validity) and the reliability (internal consistency and stability) of the cross-cultural adaptation of the Persian version of the Team Assessment Questionnaire (P-TAQ) were assessed.Results:The P-TAQ had adequate face and content validity. The confirmatory factor analysis confirmed the seven dimensions of the questionnaire. The internal consistency of the P-TAQ was 0.91, and the Intraclass Correlation Coefficient (ICC) was 0.89.Conclusions:The P-TAQ is a valid questionnaire in terms of dimensions and items. Assessing teamwork is an essential component of delivering adequate care. By examining the status of teamwork using this questionnaire, it is possible to promote teamwork and to understand its strengths and weaknesses. Future research is necessary to better understand the P-TAQ so that it can be used for the assessment of teamwork outcomes regarding patient safety, cultural barriers, and medical errors.

931. Congestive Heart Failure in Persons Living with HIV: Are we providing standard of care?

BackgroundWith antiretroviral therapy, Human Immunodeficiency Virus (HIV) infection has become a life-long chronic condition. Persons Living with HIV (PLWH) have increased risk of cardiovascular diseases including congestive heart failure (CHF) and increased morbidity and mortality from these diseases due to factors such as HIV-induced chronic inflammation. This study will assess if providers at University Hospital in Newark, NJ are providing standard of care for CHF in PLWH.MethodsThis study was approved by Rutgers IRB (Pro2020000391). A database of 154 charts including all patients with diagnoses of both HIV and CHF was generated using ICD-10 codes for HIV and CHF. After screening, 79 patient charts were eligible. Patients were excluded if their CHF was managed elsewhere, if they were misdiagnosed or deceased. Nine were diagnosed with heart failure with preserved ejection fraction (HFpEF) defined as an ejection fraction above 50%. Seventy were diagnosed with heart failure with reduced ejection fraction (HFrEF) defined as an ejection fraction below 40%. Treatment was assessed using the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines.Recommendations for treatment of HFrEF Recommendations for treatment of HFpEF ResultsFor patients with HFrEF, 10% of eligible patients were not prescribed aldosterone antagonists due to an incorrect contraindication. Thirty eight percent of patients requiring consideration for device therapy were not considered. Fourteen percent of patients did not have NYHA/ACC/AHA class documented. Three additional charts were found to not follow class-based management. Thirty five percent of patients with hypertension did not have guideline-based titrated therapy. In terms of HFpEF, 43% of patients did not have proper hypertension treatment.Heart Failure with Reduced Ejection Fraction Heart Failure with Preserved Ejection Fraction ConclusionAdherence to evidence-based guidelines for CHF in PLWH is important due to their increased risk of mortality and morbidity. Improvements such as documentation of heart failure class, contraindications to medications, and consideration for devices may improve outcomes going forward.Disclosures All Authors: No reported disclosures

Abstract 17380: Can Understanding of National Search Engine Queries Inform Heart Failure Prevention? National Internet Search Engine Queries Correlates With CHF Prevalence but Not Outcomes

Introduction: Congestive heart failure (CHF) remains an epidemic with rising prevalence and a contributing cause of 1 in 9 deaths in the United States. An understanding of internet search engines for congestive heart failure as informational and initial diagnostic tools may enable targeted education strategies. Hypothesis: There is a correlation between CHF google search and outcomes. Methods: We used google trends, a publicly available google tool, to identify search frequency for CHF and related terms like early signs of heart failure, congestive heart failure facts over a 2 year period from 2014-2016 across regions of the United States. We then evaluated the prevalence of hospitalization and mortality rates among Medicare beneficiaries based on Center for Disease Control (CDC) data. Utilizing Pearson correlation (R) test, we determined the association between relative search frequency (RSF) in various states versus CHF hospitalization and mortality rates. Results: Across the 50 states in United States, there were 25 searches related to the search terms. There was a moderate positive correlation (R 0.4-0.7) between CHF hospitalization (R= 0.43) and mortality (R=0.51) with relative search frequency in google trends. Conclusions: We demonstrated a correlation between internet search and CHF prevalence and hospitalization. The emergence of data analytics in CHF care may enable greater understanding of patient questions in CHF to better target education and prevention.

Role of Vitamin D Supplementation in Heart Failure Patients With Vitamin D Deficiency and Its Effects on Clinical Outcomes: A Literature Review.

Vitamin D deficiency has become a global pandemic affecting approximately one billion people worldwide. Much attention has been paid to the association of low serum 25-hydroxyvitamin D (25(OH)D) levels and various chronic diseases, especially heart failure (HF). A clear role of vitamin D deficiency has been established, with increased mortality and morbidity in heart failures. However, previous randomized control trials have failed to show improvement in clinical outcomes with calciferol supplementation in these patients. Therefore, it is still unclear whether calciferol therapy can be added to the standard care in congestive heart failure (CHF) patients with deficiency. Hence, to evaluate the role of vitamin D supplementation in CHF patients with low serum 25(OH)D, we conducted an extensive search in the PubMed and Google Scholar databases using various combinations of keywords. All potentially eligible studies that evaluated the effects of vitamin D supplementation on clinical outcomes in HF patients were retrieved and extensively studied. We also checked the references of all eligible studies to identify additional relevant publications. In this study, we reviewed various mechanisms of vitamin D affecting the cardiovascular system and examined the impact of deficiency on heart failures in terms of mortality and hospitalizations. In conclusion, vitamin D supplementation has failed to improve the clinical outcomes in HF patients. The possible long-term benefits of supplementation cannot be excluded. Therefore, for future clinical trials, we recommend considering large sample sizes, longer follow-up durations, along with optimal dosage and appropriate dosing frequency.

Managing the performance of general practitioners and specialists referral networks: A system for evaluating the heart failure pathway

High quality chronic disease management requires coordinated care across different healthcare settings, involving multidisciplinary teams of professionals, and performance evaluation systems able to measure this care. Inter-organizational performance should be measured considering the professional relationships between general practitioners (GPs) and specialists, who are usually linked through informal referral networks.The aim of this paper is to identify and evaluate the performance of naturally occurring networks of GPs and hospital-based specialists providing care for congestive heart failure (CHF) patients in Tuscany, Italy. The analysis focuses on the identification and classification of networks, following CHF patients (n = 15,841) through primary care and inpatient care using administrative data, and on the assessment of process and outcome indicators for CHF patients in these referral networks.We demonstrate the existence of informal links between GPs and hospitals based on patterns of patient flow. These networks which are not geographically based vary in the intensity of relationships and quality of care. Such referral networks may represent the most effective accountability level for chronic disease management, since they encompass the multiple care settings experienced by patients. Overall, an integrated approach to evaluation and performance management that considers the naturally occurring links between professionals working in different settings may enable more efficient, integrated care and quality improvements.

Primary care performance of alternatively licenced physicians in Ontario, Canada: a cross-sectional study using administrative data

ObjectivesMedical Regulatory Authorities (MRAs) provide licences to physicians and monitor those physicians once in practice to support their continued competence. In response to physician shortages, many Canadian MRAs developed alternative...

CardioMEMS in a Busy Cardiology Practice: Less than Optimal Implementation of a Valuable Tool to Reduce Heart Failure Readmissions.

Introduction Congestive heart failure is a leading cause of cardiovascular morbidity and mortality that results in a significant financial burden on healthcare expenditure. Though various strategies have been employed to reduce hospital readmissions, one valuable tool that remains greatly underutilized is the CardioMEMS (Abbott), a remote pulmonary artery pressure-monitoring system, which has been shown to help reduce heart failure rehospitalizations in the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) trial. Methods ICD-9/ICD-10 codes for chronic heart failure were used to identify patients who presented with congestive heart failure. Of this group, those eligible for CardioMEMS device placement, as based on the CHAMPION trial definition, were selected. Subsequently, a retrospective review of the electronic medical records was completed. All patients were on ACC/AHA guideline-directed medical therapy and had at least one hospital admission for NYHA class III symptoms. Results 473 patients met the inclusion criteria, of which, 85 patients were found to be eligible for implantation of CardioMEMS device based on the CHAMPION trial definition. Only 18/85 patients received the device, roughly 21%, and the overall CardioMEMS implantation rate was only 4% (18/473) of the total cohort. Conclusion Despite the benefits to patients and reducing healthcare expenditure, there has been a poor adaptation of this groundbreaking technology. Our study revealed that 79% of eligible heart failure patients did not receive the device. Therefore, efforts need to be undertaken to improve physician and patient education of the device to complement the current standard of care for congestive heart failure.

Clinical Use of Digitalis: A State of the Art Review.

The history of digitalis is rich and interesting, with the first use usually attributed to William Withering and his study on the foxglove published in 1785. However, some knowledge of plants with digitalis-like effects used for congestive heart failure (CHF) was in evidence as early as Roman times. The active components of the foxglove (Digitalis purpurea and Digitalis lanata) are classified as cardiac glycosides or cardiotonic steroids and include the well-known digitalis leaf, digitoxin, and digoxin; ouabain is a rapid-acting glycoside usually obtained from Strophanthus gratus. These drugs are potent inhibitors of cellular membrane sodium-potassium adenosine triphosphatase (Na+/K+-ATPase). For most of the twentieth century, digitalis and its derivatives, especially digoxin, were the available standard of care for CHF. However, as the century closed, many doubts, especially regarding safety, were raised about their use as other treatments for CHF, such as decreasing the preload of the left ventricle, were developed. Careful attention is needed to maintain the serum digoxin level at ≤ 1.0ng/ml because of the very narrow therapeutic window of the medication. Evidence for benefit exists for CHF with reduced ejection fraction (EF), also referred to as heart failure with reduced EF (HFrEF), especially when considering the combination of mortality, morbidity, and decreased hospitalizations. However, the major support for using digoxin is in atrial fibrillation (AF) with a rapid ventricular response when a rate control approach is planned. The strongest support of all for digoxin is for its use in rate control in AF in the presence of a marginal blood pressure, since all other rate control medications contribute to additional hypotension. In summary, these days, digoxin appears to be of most use in HFrEF and in AF with rapid ventricular response for rate control, especially when associated with hypotension. The valuable history of the foxglove continues; it has been modified but not relegated to the garden or the medical history book, as some would advocate.

COSTS OF HOME-BASED TELEMEDICINE PROGRAMS: A SYSTEMATIC REVIEW.

The aim of this study was to systematically investigate existing literature on the costs of home-based telemedicine programs, and to further summarize how the costs of these telemedicine programs vary by equipment and services provided. We undertook a systematic review of related literature by searching electronic bibliographic databases and identifying studies published from January 1, 2000, to November 30, 2017. The search was restricted to studies published in English, results from adult patients, and evaluation of home telemedicine programs implemented in the United States. Summarized telemedicine costs per unit of outcome measures were reported. Twelve studies were eligible for our review. The overall annual cost of providing home-based telemedicine varied substantially depending on specific chronic conditions, ranging from USD1,352 for heart failure to USD206,718 for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes as a whole. The estimated cost per-patient-visit ranged from USD24 for cancer to USD39 for CHF, COPD, or chronic wound care. The costs of home-based telemedicine programs varied substantially by program components, disease type, equipment used, and services provided. All the selected studies indicated that home telemedicine programs reduced care costs, although detailed cost data were either incomplete or not presented in detail. A comprehensive analysis of the cost of home-based telemedicine programs and their determinants is still required before the cost efficiency of these programs can be better understood, which becomes crucial for these programs to be more widely adopted and reimbursed.

The day of the week and acute heart failure admissions: Relationship with acute myocardial infarction, 30-day readmission rate and in-hospital mortality

BackgroundIn-hospital care may be constrained during the weekend due to lesser resources. Impact on outcomes of weekend versus weekday care in congestive heart failure (HF) needs further study. MethodsAdmissions with a primary diagnosis of HF using ICD-9CM codes were studied. 22,287 HF-admissions from Einstein Medical Center (2003−2013) and 2,248,482 HF-admissions from the 2002–2012 Nationwide Inpatient Sample (NIS) were analyzed separately. Primary outcomes were 30-day HF-readmission and in-hospital mortality. Logistic regression models were used to evaluate outcomes. ResultsWeekends experienced lower rates of admission and discharge. Mondays experienced the highest admission rate and Fridays experienced the highest discharge rate. Friday was independently associated with highest 30-day HF-readmission rates (Adjusted OR 1.12, CI 1.01–1.23; p=0.02) in addition to risk factors such as African-American race, hypertension, diabetes, hyperlipidemia, end-stage renal disease and coronary artery disease. Within the NIS sample, 85,479 in-hospital deaths (3.8%) were recorded. Compared to weekdays, patients admitted over the weekend had greater comorbidities, higher incidence of acute myocardial infarction (AMI) (15.8% vs. 16.8%; p<0.01), higher Charlson-comorbidity index and underwent less procedures such as echocardiography, right heart catheterization, coronary angiography, coronary revascularization or mechanical circulatory support. Weekend HF admission predicted higher in-hospital mortality (aOR 1.07, 95%CI 1.05–1.08; p<0.01) on multivariate analysis. This relationship was applicable for teaching and non-teaching hospitals. ConclusionFriday was associated with the highest discharge and 30-day HF-readmission rate. Weekend HF admissions experienced more AMI, had greater comorbidities, received less cardiac procedures and predicted higher in-hospital mortality. Higher weekend mortality may be related to the greater degree of severity of illness among admitted patients.

Processes and Outcomes of Congestive Heart Failure Care by Different Types of Primary Care Models

BackgroundHaving nurse practitioners (NPs) as primary care providers for patients with congestive heart failure (CHF) is 1 way to address the growing shortage of primary care physicians (PCPs). Methods and ResultsWe used inverse probability of treatment weighted with propensity score to examine the processes and outcomes of care for patients under 3 care models. Approximately 72.9%, 0.8%, and 26.3% of CHF patients received care under the PCP model, the NP model, and the shared care model, respectively. Patients under the NP or shared care models were more likely than those under the PCP model to be referred to cardiologists (odds ratio 1.35, 95% confidence interval 1.32–1.37; odds ratio 1.32, 95% confidence interval 1.30–1.35) and to get guideline-recommended medications. NPs and PCPs had similar rates of emergency room (ER) visits and Medicare spending after adjusting for processes of care. Patients under the shared care model had a higher burden of comorbidity and experienced a higher rate of ER visits and hospitalizations than those under the PCP model. ConclusionThe delivery of CHF care mirrors the severity of comorbidity in these patients. The high rate of hospitalization and ER visits in the shared care model underscores the need to design and implement more effective chronic disease management and integrated care programs.