Get With The Guidelines-Heart Failure Research Articles

Associations of Patient Demographic Characteristics and Regional Physician Density With Early Physician Follow-Up Among Medicare Beneficiaries Hospitalized With Heart Failure

Early physician follow-up after a heart failure (HF) hospitalization is associated with lower risk of readmission. However, factors associated with early physician follow-up are not well understood. We identified 30,136 patients with HF ≥65 years at 225 hospitals participating in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE) registry or the Get With The Guidelines-Heart Failure (GWTG-HF) registry from January 1, 2003 through December 31, 2006. We linked these clinical data to Medicare claims data for longitudinal follow-up. Using logistic regression models with site-level random effects, we identified predictors of physician follow-up within 7 days of hospital discharge. Overall 11,420 patients (37.9%) had early physician follow-up. Patients residing in hospital referral regions with higher physician concentration were significantly more likely to have early follow-up (odds ratio 1.29, 95% confidence interval 1.12 to 1.48, for highest vs lowest quartile). Patients in rural areas (0.84, 0.78 to 0.91) and patients with lower socioeconomic status (0.79, 0.74 to 0.85) were less likely to have early follow-up. Women (0.87, 0.83 to 0.91) and black patients (0.84, 0.77 to 0.92) were less likely to receive early follow-up. Patients with greater co-morbidity were less likely to receive early follow-up. In conclusion, physician follow-up within 7 days after discharge from a HF hospitalization varied according to regional physician density, rural location, socioeconomic status, gender, race, and co-morbid conditions. Strategies are needed to ensure access among vulnerable populations to this supply-sensitive resource.

Patterns and Predictors of Evidence-Based Medication Continuation Among Hospitalized Heart Failure Patients (from Get With the Guidelines–Heart Failure)

Hospitalized patients with heart failure and decreased ejection fraction are at substantial risk for mortality and rehospitalization, yet no acute therapies are proven to decrease this risk. Therefore, in-hospital use of medications proved to decrease long-term mortality is a critical strategy to improve outcomes. Although endorsed in guidelines, predictors of initiation and continuation of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), β blockers, and aldosterone antagonists have not been well studied. We assessed noncontraindicated use patterns for the 3 medications using the Get With the Guidelines-Heart Failure (GWTG-HF) registry from February 2009 through March 2010. Medication continuation was defined as treatment on admission and discharge. Multivariable logistic regression using generalized estimating equations was used to determine factors associated with discharge use. In total 9,474 patients were enrolled during the study period. Of those treated before hospitalization, overall continuation rates were 88.5% for ACE inhibitors/ARBs, 91.6% for β blockers, and 71.9% for aldosterone-antagonists. Of patients untreated before admission, 87.4% had ACE inhibitors/ARBs and 90.1% had β blocker initiated during hospitalization or at discharge, whereas only 25.2% were started on an aldosterone antagonist. In multivariate analysis, admission therapy was most strongly associated with discharge use (adjusted odds ratios 7.4, 6.0, and 20.9 for ACE inhibitors/ARBs, β blockers, and aldosterone antagonists, respectively). Western region, younger age, and academic affiliation were also associated with higher discharge use. Although ACE inhibitor/ARB and β-blocker continuation rates were high, aldosterone antagonist use was lower despite potential eligibility. In conclusion, being admitted on evidence-based medications is the most powerful, independent predictor of discharge use.

Toward More Optimal Use of Primary Prevention Implantable Cardioverter-Defibrillators

The implantable cardioverter-defibrillator (ICD) has been shown in several randomized clinical trials to improve the survival of patients with systolic heart failure (HF).1–4 As a result, practice guidelines designate ICD therapy as a class I indication in many patients with HF.5–7 Notwithstanding the evidence from randomized clinical trials and practice guidelines, several studies have demonstrated significant underutilization of primary prevention ICDs in many HF patients who are potentially eligible for this therapy.8,9 Some of these studies also described racial and sex-based disparities in the use of this device.8–10 In one investigation of a national HF registry, the majority of patients with a history of myocardial infarction and a left ventricular ejection fraction (LVEF) ≤35% did not receive an ICD, and black patients were significantly less likely than their white counterparts to receive one.8 In another study that used Medicare Claims data, women were 3 times less likely than men to receive an ICD for a primary prevention indication.10 In a third study of ICD use among patients with HF and an LVEF ≤30% in the American Heart Association's (AHA) Get With the Guidelines-Heart Failure (GWTG-HF) program, only a third of these patients had an ICD in place or an ICD planned after discharge.9 Importantly, this analysis showed major race- and sex-based disparities.9 Articles see p 146 and 152 To appreciate the gravity of these findings, two facts must be emphasized. First, sudden cardiac death is the leading cause of death in the United States.11,12 Second, the ICD is the most effective therapy currently available to prevent sudden cardiac death.13 Thus, underutilization of ICD therapy and racial and sex-based disparities in its use constitute major public health problems that must be …

A Validated Risk Score for In-Hospital Mortality in Patients With Heart Failure From the American Heart Association Get With the Guidelines Program

Effective risk stratification can inform clinical decision-making. Our objective was to derive and validate a risk score for in-hospital mortality in patients hospitalized with heart failure using American Heart Association Get With the Guidelines-Heart Failure (GWTG-HF) program data. A cohort of 39 783 patients admitted January 1, 2005, to June 26, 2007, to 198 hospitals participating in GWTG-HF was divided into derivation (70%, n=27 850) and validation (30%, n=11 933) samples. Multivariable logistic regression identified predictors of in-hospital mortality in the derivation sample from candidate demographic, medical history, and laboratory variables collected at admission. In-hospital mortality rate was 2.86% (n=1139). Age, systolic blood pressure, blood urea nitrogen, heart rate, sodium, chronic obstructive pulmonary disease, and nonblack race were predictive of in-hospital mortality. The model had good discrimination in the derivation and validation datasets (c-index, 0.75 in each). Effect estimates from the entire sample were used to generate a mortality risk score. The predicted probability of in-hospital mortality varied more than 24-fold across deciles (range, 0.4% to 9.7%) and corresponded with observed mortality rates. The model had the same operating characteristics among those with preserved and impaired left ventricular systolic function. The morality risk score can be calculated on the Web-based calculator available with the GWTG-HF data entry tool. The GWTG-HF risk score uses commonly available clinical variables to predict in-hospital mortality and provides clinicians with a validated tool for risk stratification that is applicable to a broad spectrum of patients with heart failure, including those with preserved left ventricular systolic function.

Characteristics and in-hospital outcomes for nonadherent patients with heart failure: Findings from Get With The Guidelines-Heart Failure (GWTG-HF)

Medication and dietary nonadherence are precipitating factors for heart failure (HF) hospitalization; however, the characteristics, outcomes, and quality of care of patients with nonadherence are unknown. Recognizing features of nonadherent patients may provide a means to reduce rehospitalization for this population. GWTG-HF registry data were collected from 236 hospitals and 54,322 patients from January 1, 2005 to December 30, 2007. Demographics, clinical characteristics, in-hospital outcomes, and quality of care were stratified by precipitating factor for HF admission. Multivariate logistic regression analysis was used to determine the association of nonadherence with length of stay (LOS) and in-hospital mortality. Clinicians documented dietary and/or medication nonadherence as the reason for admission in 5576 (10.3%) of HF hospitalizations. Nonadherent patients were younger and more likely to be male, minority, uninsured, and have nonischemic HF. These patients had lower ejection fractions (34.9% vs 39.6%, P < .0001), more frequent previous HF hospitalizations, higher brain natriuretic peptide levels (1813 vs 1371 pg/mL, P < .0001), and presented with greater signs of congestion. Despite this, nonadherent patients had shorter LOS (odds ratio 0.94, 95% CI 0.92-0.97) and lower in-hospital mortality (odds ratio 0.65, 95% CI 0.51-0.83) in multivariate analysis. Although nonadherent patients received high rates of Joint Commission core measures, rates of other evidence-based treatments were less optimal. Nonadherence is a common precipitant for HF admission. Despite a higher risk profile, nonadherent patients had lower in-hospital mortality and LOS, suggesting that it may be easier to stabilize nonadherent patients by reinstituting sodium and/or fluid restriction and resuming medical therapy.

Influence of age on the management of heart failure: Findings from Get With the Guidelines–Heart Failure (GWTG-HF)

Heart failure (HF) is common among elderly adults. Although multiple studies demonstrate age-related declines in the utilization of evidence-based therapies for coronary artery disease, there are few analyses of HF patients to distinguish possible age-related management differences. We analyzed 57,937 HF admissions from January 2005 through April 2007 in 257 hospitals participating in the American Heart Association's Get With The Guidelines-Heart Failure program. Patient characteristics and management were stratified by age groups < or = 65, 66-75, 76-85, and >85 years. Multivariable regression analyses were used to assess the influence of age on use of therapies and inhospital mortality. The mean patient age was 73 +/- 14 years; 18.7% were >85 years of age. Prescriptions of most HF therapies were relatively reduced with age but still remained high overall. Although 88.6% of patients < or = 65 years of age with left ventricular systolic dysfunction were prescribed angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and 90.9% were prescribed beta-blockers, among those >85 years of age with left ventricular systolic dysfunction, 79% were prescribed angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and 82.7% were prescribed beta-blockers. Regression analysis that accounted for typical confounders demonstrated that older age was associated with diminished utilization of most evidence-based treatment measures as well as increased mortality. Get With The Guidelines-Heart Failure data demonstrate that guidelines recommended therapies are frequently utilized for older patients with HF, including patients >85 years old. Nonetheless, age-related differences in therapy persist, suggesting that opportunities to improve care still remain.

Hospital Variation and Characteristics of Implantable Cardioverter-Defibrillator Use in Patients With Heart Failure: Data From the GWTG-HF (Get With The Guidelines–Heart Failure) Registry

The aim of this study was to describe hospital variation and factors associated with adherence to guidelines for implantable cardioverter-defibrillator (ICD) therapy. Studies have shown incomplete application of ICD therapy in eligible heart failure (HF) patients. New or discharge prescription rates for ICD therapy (ejection fraction <or=30% without documented ICD contraindications) for hospitals were calculated from participants in the GWTG-HF (Get With The Guidelines-Heart Failure) registry during January 2005 to June 2007. With hierarchical modeling, hospitals' patient case-mix adjusted ICD rate and hospital factors associated with ICD use were determined. The association of ICD rate and other quality of care indicators and procedure use was determined. Overall use of ICD in-hospital or planned implantation rate was 20%. This rate ranged widely among hospitals, from 1% among the lowest tertile to 35% among the top tertile (p < 0.01). After adjusting for patient case mix, independent hospital characteristics associated with higher ICD use were percutaneous coronary intervention, coronary artery bypass grafting, and heart transplant capability as well as larger hospital bed size (p < 0.01). Hospital Centers for Medicare and Medicaid Services/Joint Commission on the Accreditation of Healthcare Organizations performance measures (discharge instructions, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use, smoking cessation; p >or= 0.05) were similar across ICD, whereas higher ICD-rate hospitals had higher adherence to GWTG-HF performance measures (beta-blocker use, evidence-based beta-blocker use, aldosterone-antagonist, hydralazine/nitrate; p < 0.05) except warfarin in patients with atrial fibrillation (p = 0.18). There is significant unexplained hospital variation in the use of ICD therapy among potentially eligible HF patients. However, hospitals that use ICD therapy more often also have more rapidly adopted other newer evidence-based HF therapies.