Frequent Rehospitalizations Research Articles

Pain management after major surgery in elderly patients

Background After-surgery pain is an extremely variable clinical condition, in a continuously changing evolution, where environmental and personal factors have combinations and results not easily predictable. It puts the subject into a state of physical and mental subjection so as of powerlessness. It could be feared more than the surgery itself and anesthesia. Such fears can bring the patient to delay surgery, increasing its risks, scope and post-surgery pain itself: this may lead to a progression of the pathological condition, and make recovery and convalescence more complicate [1]. After-surgery pain treatment allows to: limit neurovegetative storms and the states of neuroendocrine activation; avoid, as much as possible, the development of “persistent pain” situations; facilitate the re-establishment of the previous psyco-physical function and functional state, so improving the general “patient satisfaction”. The results of recent case studies have shown that after surgery pain management is insufficient; this implies negative economic consequences to the National Health Service, including the increase of unsatisfied patients number, longer hospitalization and frequent rehospitalizations [5]. The aim of our study is to compare the analgesic effect Ketorolac + Tramadole vs the analgesic effect of Meperidine only, in pain management after Major Surgery. We also focused our attention on the possible occurrence of adverse reactions, identified as every effect occurring within 48 hours after surgery (nausea, vomit, headache, vertigo). Methods The study population consists of 70 patients (Table 1) referred to the Department of Gastrointestinal Surgery of Naples University “Federico II”, who underwent to gastrointestinal resection surgery. Patients aged 65 to 86 were included, with ASA II-III, not subjected to pre-surgery pain therapy. We divided the patients in two groups: M group (Meperidine) and T group (Tramadole + ketorolac), homogeneous for age, gender, type of surgery, anesthesy risk, previous clinical and pathological features, to whom were administered different after-surgery analgesic therapies. At the end of surgery each patient had the elastomer according to the protocol and was followed in the next three days, monitoring the possible occurrence of adverse reactions. In both groups, the elastomeric pump was reloaded the day after surgery. We assessed after surgery pain using the Visual Analogue Scale (VAS); this scale consists of a straight line (100 mm long) representing an intensity sequence between the two ends: “no pain” and “the strongest pain imaginable”. The record of pain intensity was written on the “Pain chart” every three hours and suspended when VAS was equal or lower than three, without any treatment, after three registrations in a row.

Using Novel Technology to Determine Mobility Among Hospitalized Heart Failure Patients: A Pilot Study.

BackgroundPatients with heart failure (HF) experience frequent rehospitalizations and poor functional capacity. Early hospital mobility may prevent functional decline, but mobility patterns among hospitalized HF patients are not yet known. Accelerometers may provide a method to monitor and measure patient mobility objectively. Therefore, the purpose of this study was to describe mobility and function using accelerometers among hospitalized HF patients.MethodsWireless accelerometers were attached to the thigh and ankle of previously ambulatory hospitalized HF patients (n = 32) continuously for up to 5 days, beginning on the second day of hospitalization. The mean proportion of time spent lying, sitting, and standing or walking daily was measured. Ability to perform activities of daily living (ADLs) and physical function was measured using the Katz Index and Short Physical Performance Battery (SPPB).ResultsPatients’ mean age was 58.2 ± 13.6 and 78% (n = 25) were male. Mean New York Heart Association Class upon enrollment and at the end of the study period was 2.9 ± 0.8 and 2.2 ± 0.8 respectively. A mean Katz Index of 5.6 ± 1.1 upon enrollment demonstrated minimal dependence on assistance for completion of ADLs (possible scores 0 - 6). However, mobility testing revealed low physical function, with mean SPPB scores of 6.4 ± 3.1 (possible scores 0 - 12). During hospitalization, 70% of the measured hospital stay (16.8 hours/day) was spent lying in bed. The average time spent standing or walking was 4.1%, or 59 minutes per day and the range was 0-10% (0 - 150 minutes).ConclusionsImmobility was pervasive as HF patients spent almost all of their time sitting or lying in bed despite their baseline ambulatory status and improved NYHA class.

COST AND IMPACT OF SELF-REPORT AND TELEMONITORING ON HEART FAILURE READMISSION: A CASE REPORT

ObjectivesChronic heart failure is a progressive pathological process with frequent rehospitalisation, low survival rate and high medical cost. Early detection of signs of decompensation events is critical for reducing hospital...

Epidemiology, management, and outcomes of sustained ventricular arrhythmias after continuous-flow left ventricular assist device implantation

Left ventricular assist devices (LVADs) are pivotal treatment options for patients with end-stage heart failure. Despite robust left ventricular unloading, the right ventricle remains unsupported and susceptible to hemodynamic perturbations from ventricular arrhythmias (VAs). Little is known about the epidemiology, management, resource use, and outcomes of sustained VAs in continuous-flow LVAD patients. We reviewed data from all consecutive patients receiving a continuous-flow LVAD at the University of North Carolina from January 2006 to February 2011. Patient demographics, pharmacotherapies, resource use, and outcomes were recorded. Descriptive statistics were generated, and multivariable logistic regression was used to assess the independent association of clinical variables on the development of postimplantation VAs. Of 61 patients, 26 (43%) had sustained VAs after LVAD. Most were male (65%), had history of hypertension (65%), and had nonischemic cardiomyopathy (62%). Patients with VAs after LVAD more often had preimplant VAs (62% vs 14%, P < .01), prior implantable cardioverter-defibrillator (92% vs 71%, P = .04), and history of implantable cardioverter-defibrillator discharge (38% vs 11%, P < .01). Although length of stay was similar, those with postimplant VAs had greater rehospitalization rates, greater antiarrhythmic drug use, and frequently required external defibrillation. Using multivariable logistic regression, only history of prior VA was associated with postimplant arrhythmias (odds ratio 13.7, P < .001). Ventricular arrhythmias in LVAD patients are common, often refractory to conservative therapy, and associated with frequent rehospitalization. Post-LVAD VAs, however, did not significantly impact survival or transplantation rates. Arrhythmia burden should be considered before LVAD placement, and future study should focus on the impact of VAs on quality of life.

Reducing Chronic Obstructive Pulmonary Disease Readmissions

Exacerbation and frequent rehospitalization in chronic obstructive pulmonary disease exacts a heavy toll on the US health care system. To address these issues, new initiatives have been proposed that are largely based on financial penalties to promote patient education and postdischarge care. However, as laudable as these goals are, improving outcomes in the chronic obstructive pulmonary disease population is more confounding than it may first appear. Chronic hypoxia, cognitive dysfunction, poor nutrition, and economic disadvantage are just a few of the challenges that require creative solutions and ongoing support. Case managers need to utilize all the potential products and services that can assist in improving outcomes for these patients. Durable medical equipment providers are often viewed as purveyors of medical equipment that offer little in the form of clinical support. However, in many cases these providers represent an overlooked resource that provides individualized, highly structured patient education and ongoing support programs. The challenge is in identifying those durable medical equipment providers that offer patients contemporary technology, and have both the resources and the commitment to provide patient support that is amenable to the goals of the hospital. This article reviews many of the confounding issues that contribute to the frequent rehospitalization of chronic obstructive pulmonary disease patients. Recommendations to improve patient education and oxygen therapy outcomes are provided along with suggestions to aid in the vetting of durable medical equipment providers. Acute care hospitals, long-term acute care hospitals, extended care facilities, integrated delivery systems. 1. An understanding of the complex variables that play in the management of chronic obstructive pulmonary disease will help the case manager to plan an effective course of care. 2. Case managers need to ensure that patients receive long-term oxygen technology that supports their lifestyle, promotes compliance, and ultimately achieves the desired outcomes. 3. Case managers must advocate for coordinated, ongoing patient education and stress the need for continuing reinforcement. 4. Case managers must ensure that patients under their care be matched with durable medical equipment providers that provide the technology and support that favors positive clinical outcomes.

Enhancing eHealth Information Systems for chronic diseases remote monitoring systems

Statistics and demographics for the aging population in Europe are compelling. The stakes are then in terms of disability and chronic diseases whose proportions will increase because of increased life expectancy. Heart failure (HF), a serious chronic disease, induces frequent re-hospitalizations, some of which can be prevented by up-stream actions. Managing HF is quite a complex process: long, often difficult and expensive. In France, nearly one million people suffer from HF and 120,000 new cases are diagnosed every year. Managing such patients, a telemedicine system tools associated with motivation and education can significantly reduce the number of hospital days that believes therefore that the patient is hospitalized for acute HF. The current development projects are fully in prevention, human security, and remote monitoring of people in their living day-to-day spaces, from the perspective of health and wellness. These projects encompass gathering, organizing, structuring and sharing medical information. They also have to take into account the main aspects of interoperability. A different approach has been used to capitalize on such information: data warehouse approach, mediation approach (or integration by views) or integration approach by link (or so-called mashup). In this paper, we will focus on ontologies that take a central place in the Semantic Web: on one hand, they rely on modeling from conceptual representations of the areas concerned and, on the other hand, they allow programs to make inferences over them.

An on-line education and coaching programme to promote self-care in heart failure patients

Introduction: In Europe 14 million people suffer from heart failure (HF). HF is associated with high mortality rates and frequent re-hospitalizations. More than 50% of the re-admissions can be prevented by appropriate self-care. However, currently the level of selfcare is low, mainly due to poor patient education. Aims and objectives: One of the objectives of the HeartCycle project is to promote HF self-care by offering education and coaching which is tailored to the characteristics of the individual patient. When HF patients adhere to their medication regime, eat a low-sodium diet, limit fluid intake, are physically active, and monitor symptoms, readmission rates are lower. Methods: The education and coaching is based on the NHS Lothian Heart Manual and delivered via the Motiva telehealth system. It is automatically tailored to the patient’s knowledge level and behaviour as assessed via questionnaires. To raise commitment, patients set their own goals and make their own action plans. They record their progress in an electronic diary such that the system can provide appropriate feedback. Results and conclusions: This presentation will explain the novel education and coaching approach that we developed. The HeartCycle trial, planned for 2011, will provide insight into the effectiveness of this approach.

Noninvasive Monitoring of Left Ventricular End-Diastolic Pressure Reduces Rehospitalization Rates in Patients Hospitalized for Heart Failure: A Randomized Controlled Trial

BackgroundIn patients admitted for heart failure (HF), unrecognized elevation of left ventricular end-diastolic pressure (LVEDP) at the time of discharge may have a role in the high rehospitalization rate for HF on follow-up. Methods and ResultsIn a small, prospective study (n = 50), patients admitted for HF were randomized to management guided by daily noninvasive estimated LVEDP monitoring (Group I, open) to a target LVEDP of <20 mm Hg or management based on clinical assessment alone without knowledge of the estimated LVEDP (Group II, blinded). Noninvasive estimated LVEDP was measured by the VeriCor monitor, which uses the Valsalva maneuver to derive the LVEDP. The primary endpoints were the reduction of estimated LVEDP at discharge and the HF rehospitalization rate on follow-up. Estimated LVEDP was significantly reduced at discharge in the open group compared with the blinded group (mean estimated LVEDP 19.7 ± 1.3 mm Hg vs 25.6 ± 1.5 mm Hg, respectively, P = 0.01). The rehospitalization rates for HF on follow-up were significantly improved in the open group compared with the blinded group (at 1 month: 0% vs 25%, respectively [P = .05]; at 3 months: 0% vs 32% [P = .01]; at 6 months: 4% vs 36% [P = .01]; at 1 year: 16% vs 48% [P = .03]). ConclusionsWhen HF is managed by clinical assessment only, estimated LVEDPs remain high at discharge, resulting in early and frequent rehospitalization for HF. Therapy guided by estimated LVEDP monitoring optimizes filling pressures and reduces HF rehospitalization rates.

The dilemma, causes and approaches to avoid recurrent hospital readmissions for patients with chronic heart failure

Heart failure is a progressive illness that carries significant morbidity and mortality. This highly prevalent illness leads to frequent, costly hospitalizations with approximately 50% of patients being readmitted within 6months of initial hospitalization. While rehospitalization has been extensively studied in the past, little progress has been made in terms of reducing readmission rates of heart failure patients in the last decade despite increasing costs with impending resource limitations. We discuss disease-centered, physician-centered, and patient-centered factors that lead to rehospitalization as well as community/resource availability factors that contribute to rehospitalization of patients suffering from chronic heart failure. In addition, predictors of hospitalization and interventions that reduce hospitalization will be critically evaluated. With a complete understanding of heart failure rehospitalization, we hope the future holds more effective ways to prevent heart failure progression and thus rehospitalization, improved risk-stratification models to identify patients high-risk for rehospitalization, and sustained interventions that are customized according to the etiology of the clinical decline of heart failure patients that ultimately results in frequent rehospitalizations.

Improvements in Cognition Following Hospital Discharge of Community Dwelling Seniors

Seniors frequently struggle during the transition home following an acute hospitalization resulting in frequent rehospitalizations. Studies consistently show a lack of comprehension of discharge instructions. To determine the frequency of low cognition at hospital discharge among community dwelling seniors and the changes in cognition that occur one month following hospitalization. Face-to-face surveys were performed at hospital discharge and one month later in the home of the subject. The Mini-Mental Status Examination (MMSE), Backward Digit Span, and 15 Word Immediate and Delayed Recall Tests were used to evaluate cognition. Low cognition was determined to be a score of less than 25 on the MMSE for subjects with high school education and less than 18 for subjects with less than high school education. Two hundred community-dwelling seniors ≥ 70 years, admitted to acute medicine services >24 hours, consenting to their own procedures, not having previously documented cognitive loss, and not admitted for cognitive changes. Upon hospital discharge, 31.5% of subjects had previously unrecognized low cognition. One month later, 58% of these patients no longer had low cognition (p < 0.001). Of those subjects with low cognition, the MMSE improved by an average of 4 points one month post-discharge. Within the MMSE, subjects experienced significant improvements in the areas of orientation, registration, repetition, comprehension, naming, reading, writing, and calculation. Low cognition at discharge is common among elderly patients without dementia, and cognition often improves one month post-hospitalization. Seniors may not comprehend discharge instructions, and patient self-management may be better taught as an outpatient following discharge rather than at the time of hospital discharge. Discharge interventions should incorporate screening of seniors for low cognition prior to hospital discharge to provide optimal transitional care.

Educational bulletin board AIDS heart failure patients in complying to approved diet

Background: Evidence supports a diet low in sodium and cholesterol for heart failure (HF) patients. Frequent rehospitalizations of HF patients often occur due to fluid volume excess (FVE) which can be direcly linked to dietary sodium and/or fluid intake. Discharge at a dry weight along with educational resources about diet and recipes should decrease the readmission rate and improve quality of life

N-Terminal Pro–B-Type Natriuretic Peptide–Guided, Intensive Patient Management in Addition to Multidisciplinary Care in Chronic Heart Failure: A 3-Arm, Prospective, Randomized Pilot Study

This study was designed to investigate whether the addition of N-terminal pro-B-type natriuretic peptide-guided, intensive patient management (BM) to multidisciplinary care (MC) improves outcome in patients following hospitalization due to heart failure (HF).Patients hospitalized due to HF experience frequent rehospitalizations and high mortality.Patients hospitalized due to HF were randomized to BM, MC, or usual care (UC). Multidisciplinary care included 2 consultations from an HF specialist who provided therapeutic recommendations and home care by a specialized HF nurse. In addition, BM included intensified up-titration of medication by HF specialists in high-risk patients. NT-proBNP was used to define the level of risk and to monitor wall stress. This monitoring allowed for anticipation of cardiac decompensation and adjustment of medication in advance.A total of 278 patients were randomized in 8 Viennese hospitals. After 12 months, the BM group had the highest proportion of antineurohormonal triple-therapy (difference among all groups). Accordingly, BM reduced days of HF hospitalization (488 days) compared with the hospitalization for the MC (1,254 days) and UC (1,588 days) groups (p < 0.0001; significant differences among all groups). Using Kaplan-Meier analysis, the first HF rehospitalization (28%) was lower in the BM versus MC groups (40%; p = 0.06) and the MC versus UC groups (61%; p = 0.01). Moreover, the combined end point of death or HF rehospitalization was lower in the BM (37%) than in the MC group (50%; p < 0.05) and in the MC than in the UC group (65%; p = 0.04). Death rate was similar between the BM (22%) and MC groups (22%), but was lower compared with the UC group (39%; vs. BM: p < 0.02; vs. MC: p < 0.02).Compared with MC alone, additional BM improves clinical outcome in patients after HF hospitalization. (BNP Guided Care in Addition to Multidisciplinary Care; NCT00355017).

Judge Rejects State's Plan to Improve Mental Hospitals

Back to table of contents Previous article Next article Legal NewsFull AccessJudge Rejects State's Plan to Improve Mental HospitalsRich DalyRich DalySearch for more papers by this authorPublished Online:4 Dec 2009https://doi.org/10.1176/pn.44.23.psychnews_44_23_028AbstractGeorgia continues to face the threat that it could lose control of its public mental hospitals to the federal government after a judge rejected a reform plan by the state.On September 30 U.S. District Judge Charles Pannell rejected Georgia's settlement agreement that aims to fix the state's ailing mental health network over five years. The court had initially accepted the settlement agreement in January as part of an effort to address problems identified by the U.S. Department of Justice and patient advocacy groups. But the judge rejected the settlement agreement after the Justice Department raised fresh allegations of neglect, abuse, and substandard medical care in the state psychiatric system.“The judge recognized that these problems are endemic,” said Ron Honberg, J.D., legal director of the National Alliance on Mental Illness, in an interview with Psychiatric News.In an October court filing in response to the judge's decision, state officials wrote that the state has made improvements and that it is in “significant compliance” with the January settlement.The voluntary settlement agreement stems from a Justice Department lawsuit (also filed last January) over allegations that the state was failing to prevent needless suffering and death at Georgia's state psychiatric hospitals.Advocates and now the Justice Department objected to the settlement agreement because it lacked details and timelines, as well as ways to improve Georgia's community-based mental health services. Under-funded community psychiatric programs result in unnecessarily lengthy stays as well as frequent rehospitalization in state psychiatric hospitals, said the critics.“For many, the only barrier to discharge is that they have nowhere to go,” said Alison Barkoff, a senior staff attorney at the Bazelon Center for Mental Health Law and an attorney in the case, in an interview with Psychiatric News.The lack of community-based treatment has led psychiatric hospitals to discharge patients directly to jails, homeless shelters, or motels instead of community treatment programs.The state will now have until January to continue its reform efforts before it must again report to the judge on its progress. If the judge is not satisfied, he could order vast, costly changes to the state's mental health network, and Georgia could lose control of its psychiatric hospitals.Patient Advocates ConcernedThe judge's September decision came after also hearing from a group of patient advocates, including the Carter Center, which criticized the state's mental health reform plans as lacking specific details to improve the system.“The agreement [reached in January] amounts to little more than a promise by Georgia to do better,” wrote advocates in a letter to the judge.The advocates' concerns were echoed by the Justice Department, which alleged both “significant risks of harm” to patients in a state psychiatric hospital and failure to ensure that patients “are adequately evaluated for placement in the most integrated setting.” Such evaluations are required by the Supreme Court's 1999 Olmstead decision—also focused on the Georgia state psychiatric system—which requires states to develop appropriate community-based services for people with disabilities who are institutionalized but are capable of living independently with support services.“Regularly, the hospitalized individual is kept in the hospital unnecessarily and/or discharged to a personal care home without necessary services and supports,” wrote Susan Jamieson, director of the Mental Health and Disability Rights Unit at the Atlanta Legal Aid Society, to the court.William McDonald, M.D., president-elect of the Georgia Psychiatric Physicians Association and an advisor to the state on implementing the reforms, told Psychiatric News that the state has made progress in making reforms that were not fully under way until July. In that short time, he said, Georgia has taken “real strides” in improving both psychiatric hospitals and community-based care.Among the improvements are additions to available community-based supportive housing and an agreement by the Medical College of Georgia to assume leadership of one state psychiatric hospital, McDonald said.Barkoff challenged that assessment and noted that her clients have reported no improvements in community-based mental health services around the state.Funding NeededMcDonald maintained that the state will provide enough changes to address issues raised by the lawsuit and settlement; however, the degree of success could depend on legislators' willingness to provide additional funding increases soon.“Like a lot of states, with mental health [funding], you have to fight for it,” McDonald said. Mental health care “is not always first in line.”Barkoff countered that many improvements could come with little or no additional funding. “What we're talking about is downsizing the hospitals and allocating that money to the community setting,” Barkoff said.The court also is considering holding a “status conference” that could be used to expand the settlement agreement to explicitly order improvements to the Georgia community-based treatment system.The settlement agreement reached in January is posted at <www.bazelon.org/pdf/Georgia_settlement.pdf>. ISSUES NewArchived

The impact of ischemic cholangiopathy in liver transplantation using donors after cardiac death: The untold story

Liver transplantation (LT) from donation after cardiac death (DCD) donors is increasingly being used to address organ shortages. Despite encouraging reports, standard survival metrics have overestimated the effectiveness of DCD livers. We examined the mode, kinetics, and predictors of organ failure and resource utilization to more fully characterize outcomes after DCD LT. We reviewed the outcomes for 32 DCD and 237 donation after brain death (DBD) LT recipients at our institution. Recipients of DCD livers had a 2.1 times greater risk of graft failure, a 2.5 times greater risk of relisting, and a 3.2 times greater risk of retransplantation compared with DBD recipients. DCD recipients had a 31.6% higher incidence of biliary complications and a 35.8% higher incidence of ischemic cholangiopathy. Ischemic cholangiography was primarily implicated in the higher risk of graft failure observed after DCD LT. DCD recipients with ischemic cholangiography experienced more frequent rehospitalizations, longer hospital stays, and required more invasive biliary procedures. Related to higher complication rates, DCD recipients necessitated greater resource utilization. This more granular data should be considered in the decision to promote DCD LT. Modification of liver allocation policy is necessary to address those disadvantaged by a failing DCD graft.

Hospitalization Subsequent to Diagnosis in Young Patients With Diabetes in Chicago, Illinois

Rehospitalization after a diabetes diagnosis in youth signals the failure of outpatient management. We examined risk factors for rehospitalization among young patients with diabetes. We queried 535 participants diagnosed before 18 years of age from the Chicago Childhood Diabetes Registry. Demographic, social, and clinical data were used in logistic models of diabetes-related rehospitalization, as well as, among those rehospitalized, frequent (> or = once per 2 years' duration) versus infrequent rehospitalization rates. Mean (range) duration was 5.1 years (0.1-19.2 years). The sample was 55% non-Hispanic black, 11% non-Hispanic white, 26% Hispanic, and 7% other/mixed race; 86% had presumed type 1 diabetes; and 47% were underinsured. Overall, 46% reported rehospitalization for diabetes. In multivariable logistic regression, ever being rehospitalized was significantly associated with diabetes duration (per year, odds ratio [OR]: 1.26; P < .01), female gender (OR: 1.67; P = .01), underinsurance (versus private insurance; OR: 1.79; P < .01), presumed phenotype (non-type 1 diabetes versus type 1; OR: 0.32; P < .01), and diagnosis at a community hospital (versus tertiary care facility; OR: 1.96; P < .01) and tended to be higher for those of nonwhite race (OR: 1.94; P = .07). Among those rehospitalized, multivariable associations with frequent rehospitalization were presumed phenotype (non-type 1 diabetes versus type 1; OR: 2.74; P = .04), head of household not working (versus employed; OR: 1.88; P = .02), and younger age at questionnaire (per year; OR: 0.94; P = .01). Rehospitalization is common in young patients with diabetes, especially for those with limited resources, indicating the need for improved outpatient services. Comprehensive initial education and support available to young patients with diabetes diagnosed at tertiary care facilities and their families may have lasting protective effects.

Clinical and resource-use outcomes of risperidone long-acting injection in recent and long-term diagnosed schizophrenia patients: results from a multinational electronic registry

ABSTRACTBackground: Non-adherence to pharmacological treatment leading to frequent relapses and rehospitalizations is a major issue of concern among schizophrenia patients, especially those who are recently diagnosed. Risperidone long-acting injection (RLAI) has been shown to be efficacious, improve compliance, and increase long-term retention rate on therapy.Objective: To determine clinical outcomes and hospitalizations before and after the initiation of RLAI among schizophrenia patients with recent (≤2 years) diagnosis relative to those who had long-term (> 2 years) diagnosis.Research design and methods: The electronic Schizophrenia Treatment Adherence Registry (e-STAR) is an observational study of patients with schizophrenia who start treatment with RLAI. Data were recorded at baseline, retrospectively for the 12 months prior to baseline, and prospectively every 3 months for 24 months. Data on patients with a defined length of diagnosis were pooled from eight countries.Main outcome measures: Clinical Global Impression of Illness Severity (CGI-S), Global Assessment of Functioning (GAF) scores, and hospitalization data were key outcomes.Results: The magnitude of improvement in CGI-S scores was greater in the recent versus long-term diagnosis group [Δ −1.48 vs. Δ −0.95 (12 months); Δ −1.6 vs. Δ −1.09 (24 months)]. There were parallel improvements in GAF scores [Δ 19.4 vs. Δ 13.7 (12 months); Δ 22.3 vs. Δ 16.8 (24 months)]. The decline in the proportion of patients hospitalized from the retrospective to the prospective period was greater in the recent versus long-term diagnosis group (Δ −36.0 vs. Δ −19%, respectively) at 12 months. This was also true for the number of hospital stays (Δ −0.6 vs. Δ −0.3, respectively) and length of stay (days) (Δ −20.9 vs. Δ −6.9, respectively) at 12 months. Common adverse events in both groups included psychiatric, gastrointestinal, musculoskeletal and reproductive system and breast disorders.Conclusions: Treatment with RLAI is associated with improved outcomes in recently diagnosed and chronic patients. However, the magnitude of improvement was higher in recently diagnosed patients.

INTERMACS Profiles of Advanced Heart Failure: The Current Picture

The current classification of patients with New York Heart Association Class IV symptoms does not offer adequate description to allow optimal selection of patients for the current options of medical and pacing therapies, cardiac transplantation and mechanical circulatory support. Seven clinical profiles and an arrhythmia modifier were developed and implemented into the first year of data collection for the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). The INTERMACS Coordinators' Council provided ongoing feedback regarding the characterization of patients receiving implantable devices. The definition of 7 clinical profiles revealed that 80% of current devices are being used in the 2 profiles with the highest levels of clinical compromise. The INTERMACS Coordinators' Council helped to identify gaps in the characterization of hospitalized patients on temporary assist devices and of homebound patients with resting symptoms, which has led to revised definitions of Profile 3 and 4 and the addition of 2 new modifiers, for temporary circulatory support devices in the hospital, and for frequent rehospitalization of patients at home. Patients considered for mechanical circulatory support can now be classified using the 7 profiles plus 3 modifiers developed through INTERMACS. Further understanding these profiles and their impact on outcome should help to better select patients and therapies in the advanced stages of disease.

The impact of dyspnea on health-related quality of life in patients with coronary artery disease: Results from the PREMIER registry

Both angina and dyspnea are prevalent symptoms among post-myocardial infarction (MI) patients. Given their frequent overlap, little is known about the degree to which these symptoms provide independent information in this population. Using the multicenter Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER), 1,835 patients were administered the Rose Dyspnea Scale (scores range 0-4; higher scores indicate worse dyspnea), Seattle Angina Questionnaire (SAQ; lower scores indicate worse angina), and 12-item Short Form physical component (PCS; lower scores indicate worse physical health status) at 1 and 12 months post-MI. Multivariable regression was used to examine the association between dyspnea and quality of life (QOL) in both cross-sectional and longitudinal analyses as well as its association with rehospitalizations and mortality. At 1-month follow-up, 863 patients (47%) reported dyspnea, and 340 (19%) noted moderate to severe dyspnea. After adjusting for sociodemographic and clinical factors including SAQ angina frequency, higher dyspnea scores remained strongly associated with worse QOL in both cross-sectional (1-U dyspnea increase = 2.5-point PCS decrease and 2.4-point SAQ QOL decrease) and longitudinal analyses (1-U dyspnea increase from 1 month to 1 year = 3.8-point PCS decrease and 3.5-point SAQ QOL decrease), and with increased risk of 1-year rehospitalization (hazard ratio 1.15/1 U of dyspnea, 95% CI 1.07-1.24) and 3-year mortality (hazard ratio 1.34/1 U of dyspnea, 95% CI 1.19-1.51; P < .001 for all analyses). Among post-MI patients, dyspnea is common and strongly associated with impaired QOL, more frequent rehospitalization, and reduced survival--independent of both clinical factors and angina. These findings suggest that dyspnea is an important component of disease-specific health status for post-MI patients, and its assessment should be strongly considered in both research studies and clinical practice.

Decrease in the 30-day heart failure (HF) Rehospitalization Rate after the implementation of a HF managed protocol

Heart failure (HF) is associated with high morbidity and mortality rates, including frequent rehospitalization. The 30-day HF Rehospitalization Rate is an outcome quality indicator used to measure the quality of care.

MedPAC Eyes Hospital-SNF Readmissions

MedPAC Eyes Hospital-SNF Readmissions