Higher Rates Of Rehospitalization Research Articles

P788Discharge echocardiographic parameters of RV and LV function but not of changes in cardiac unloading are related to 12-month prognosis during hospitalization for acute decompensated heart failure

Abstract Introduction Acute decompensated heart failure (ADHF) is associated with a high mortality and rehospitalization rate. The aim of this study was to assess whether echocardiographic markers of systolic and diastolic function, and their changes under treatment during hospitalization for ADHF, would predict 12-months mortality. Methods Adult patients admitted to our emergency department for ADHF between June 2015 and January 2018 were included if a complete transthoracic echocardiography (TTE) could be obtained within 12 hours of admission. TTE was repeated upon discharge. Baseline clinical and echocardiographic characteristics were collected on admission and at discharge, and outcome at 12 months was obtained by telephone interview. All parameters are given as median [interquartile range]. Results A total of 221 patients were identified but 45 excluded because of in-hospital death (n=8), early transfer to another hospital (n=31) or refusal to perform discharge TTE (n=6), leaving 176 patients for final analysis. Age was 83 [74–87] years, 95 (54%) were men and 89 (51%) were in sinus rhythm. Baseline TTE was performed within 6.6h [4.1–11.9] of admission and median duration of hospital stay was 13 days [9–19]. Admission ejection fraction (EF) was 45% [37–54] (29% HFrEF, 37% HFmrEF, 34% HFpEF). Between admission and discharge, significant changes were observed for global longitudinal LV strain (−10.3 [−7.2 to 15.1] to −11.8% [−8.1 to 15.0], p=0.017), mitral E velocity (100 [80–124] to 96 cm/s [74–117], p=0.001), E/e' ratio (16 [12–20] to 15 [11–19], p=0.003, RV basal diameter (41 [36–45] to 41mm [34–44], p=0.007), tricuspid regurgitation gradient (41 [34–52] to 35 mmHg [28–44], p=0.0001 and vena cava diameter (22 [19–26] to 19 mm [15–23],. Deaths occurred in 35 (20%) at 12 months follow-up. In our multivariable model, none of the changes in TTE parameters was predictive of mortality. Age (OR 1.09, p0.01), LVEF (OR 0.95, p0.02) and TAPSE (OR 0.86, p0.01) measured at discharge, but not LV or RV strain, were identified as independent predictors of 12-months mortality (see figure). Survival according to LVEF and TAPSE Conclusion Several changes in TTE parameters were observed during hospitalization for ADHF, reflecting effective cardiac unloading with diuretic treatment. However, none of these changes appears to have prognostic significance. LVEF and TAPSE at discharge were identified as the only independent echocardiographic predictors of 12-months mortality, in addition to age. Acknowledgement/Funding Swiss Heart Foundation

Causes, Trends, and Predictors of 90-Day Readmissions After Spontaneous Coronary Artery Dissection (from A Nationwide Readmission Database)

Spontaneous coronary artery dissection (SCAD) is a frequently missed diagnosis in patients presenting with acute coronary syndrome (ACS). Our aim was to evaluate the causes, trends, and predictors of 90-day hospital readmission in patients presenting with SCAD. The Nationwide Readmissions Database (2013 to 2014) was utilized to identify patients with primary discharge diagnosis of SCAD using the International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic code 414.12. The primary outcome was 90-day readmission. Among 11,228 patients admitted with the primary diagnosis of SCAD, 2,424 patients (21.6%) were readmitted within 90 days (68% women, 82% <65 years of age). Common causes for 90-day readmission were ACS (25%), acute heart failure (11%), acute respiratory failure (7%), and arrhythmias (5%). Multivariate predictors of 90-day readmissions were hypertension, chronic obstructive pulmonary disease, peripheral arterial disease, discharge to facility and increased length of stay (LOS) during index admission. Multivariate predictors of increased healthcare-related costs were older age, female gender, discharge to facility, and increased LOS. Over half of the readmissions (52%) occurred in first 30 days after discharge. In conclusion, we found a high rate of rehospitalization among SCAD patients, particularly within the first 30 days of index hospitalization. ACS, heart failure, and acute respiratory failure were the most common reasons for readmission. Hypertension, chronic obstructive pulmonary disease, peripheral arterial disease, and increased LOS were independent predictors of readmission. Further studies are warranted to confirm these predictors of readmission in this high-risk population.

Readmissions after left ventricular assist device implantation: Considerations for nurse practitioners.

Left ventricular assist device (LVAD) therapy is becoming a widespread treatment for advanced heart failure. Implantation of an LVAD introduces complications that contribute to high rates of rehospitalization. This study examines the presenting signs and symptoms in LVAD patients at the time of readmission and explores the prevalence of psychosocial factors that are significantly associated with readmissions in this patient population. This is a retrospective review of 226 patients who had an LVAD implanted at a single transplant center. Data were extracted from individual electronic health record review and analyzed for readmissions within 6 months of discharge from the index hospitalization. Post-LVAD readmission rates are high and occur more frequently in destination therapy (DT) patients. Anxiety and depression are significant predictors of readmission. These factors negatively affect post-LVAD quality of life, particularly in DT patients. By understanding the etiologies and factors related to readmission after an LVAD, nurse practitioners can identify and address these issues before they result in rehospitalization to improve post-LVAD quality of life. With these considerations, ongoing nonemergent discussions of goals of care and quality of life are imperative because more patients will be offered the choice of an LVAD as a potentially life-long treatment.

Outcomes of cryoballoon or radiofrequency ablation in symptomatic paroxysmal or persistent atrial fibrillation

AimsTo evaluate the effectiveness and safety of cryoballoon ablation (CBA) compared with radiofrequency ablation (RFA) for symptomatic paroxysmal or drug-refractory persistent atrial fibrillation (AF).Methods and resultsProspective cluster cohort study in experienced CBA and RFA centres. Primary endpoint was ‘atrial arrhythmia recurrence’, secondary endpoints were as follows: procedural results, safety, and clinical course. A total of 4189 patients were included: CBA 2329 (55.6%) and RFA 1860 (44.4%). Cryoballoon ablation population was younger, with fewer comorbidities. Procedure time was longer in the RFA group (P = 0.01). Radiation exposure was 2487 (CBA) and 1792 cGycm2 (RFA) (P < 0.001). Follow-up duration was 441 (CBA) and 511 days (RFA) (P < 0.0001). Primary endpoint occurred in 30.7% (CBA) and 39.4% patients (RFA) [adjusted hazard ratio (adjHR) 0.85, 95% confidence interval (CI) 0.70–1.04; P = 0.12). In paroxysmal AF, CBA resulted in a lower risk of recurrence (adjHR 0.80, 95% CI 0.64–0.99; P = 0.047). In persistent AF, the primary outcome was not different between groups. Major adverse cardiovascular and cerebrovascular event rates were 1.0% (CBA) and 2.8% (RFA) (adjHR 0.53, 95% CI 0.26–1.10; P = 0.088). Re-ablations (adjHR 0.46, 95% CI 0.34–0.61; P < 0.0001) and adverse events during follow-up (adjHR 0.64, 95% CI 0.48–0.88; P = 0.005) were less common after CBA. Higher rehospitalization rates with RFA were caused by re-ablations.ConclusionsThe primary endpoint did not differ between CBA and RFA. Cryoballoon ablation was completed rapidly; the radiation exposure was greater. Rehospitalization due to re-ablations and adverse events during follow-up were observed significantly less frequently after CBA than after RFA. Subgroup analysis suggested a lower risk of recurrence after CBA in paroxysmal AF.Trial RegistrationClinicalTrials.gov (NCT01360008), https://clinicaltrials.gov/ct2/show/NCT01360008.

Digitalis Therapy and Risk of Recurrent Ventricular Tachyarrhythmias and ICD Therapies in Atrial Fibrillation and Heart Failure

Objective: This study sought to assess the impact of treatment with digitalis on recurrences of ventricular tachyarrhythmias in implantable cardioverter defibrillator (ICD) recipients with atrial fibrillation (AF) and heart failure (HF). Background: The data regarding outcomes of digitalis therapy in ICD recipients are limited. Methods: A large retrospective registry was used, including consecutive ICD recipients with episodes of ventricular tachyarrhythmia between 2002 and 2016. Patients treated with digitalis were compared to patients without digitalis treatment. The primary prognostic outcome was first recurrence of ventricular tachyarrhythmia at 5 years. Kaplan-Meier and multivariable Cox regression analyses were applied. Results: A total of 394 ICD recipients with AF and/or HF was included (26% with digitalis treatment and 74% without). Digitalis treatment was associated with decreased freedom from recurrent ventricular tachy­arrhythmias (HR = 1.423; 95% CI 1.047–1.934; p = 0.023). Accordingly, digitalis treatment was associated with decreased freedom from appropriate ICD therapies (HR = 1.622; 95% CI 1.166–2.256; p = 0.004) and, moreover, higher rates of rehospitalization (38 vs. 21%; p = 0.001) and all-cause mortality (33 vs. 20%; p = 0.011). Conclusion: Among ICD recipients suffering from AF and HF, treatment with digitalis was associated with increased rates of recurrent ventricular tachyarrhythmias and ICD therapies. However, the endpoints may also have been driven by interactions between digitalis, AF, and HF.

Overexpression of Long Noncoding RNAs (lncRNA) NF-κβ-Interacting Long Noncoding RNA (NKILA) in Ankylosing Spondylitis is Correlated with Transforming Growth Factor β1 (TGF-β1), Active Disease and Predicts Length of Treatment.

BackgroundLong noncoding RNAs (lncRNA) NF-κβ-interacting long noncoding RNA (NKILA) is downregulated in various types of cancers, while its involvement in other diseases is unknown. In the present study we found that plasma lncRNA NKILA was expressed at higher levels in active ankylosing spondylitis patients than in healthy controls.Material/MethodsAccording to Youden’s index, active disease patients were divided into high and low lncRNA NKILA groups.ResultsPatients in the high lncRNA NKILA level group had significantly longer length of treatment and higher re-hospitalization rate at 3 years after discharge. Plasma levels of TGF-β1 were also higher in active ankylosing spondylitis patients than in healthy controls. Levels of plasma lncRNA NKILA and TGF-β1 were significantly and positively correlated in ankylosing spondylitis patients but not in healthy controls.ConclusionsOverexpression of lncRNA NKILA in ankylosing spondylitis is correlated with active disease and predicts length of treatment. LncRNA NKILA may participate in ankylosing spondylitis through the interaction with TGF-β1, which is a key player in this disease.

Electrical storm is associated with impaired prognosis compared to ventricular tachyarrhythmias

BackgroundBecause data on electrical storm (ES) is limited, this study sought to compare the prognosis of patients with ES to those with ventricular tachyarrhythmias on mortality, rehospitalization and major adverse cardiac events (MACE). MethodsIn this retrospective study consecutive implantable cardioverter defibrillator (ICD) recipients presenting with ES were compared to patients surviving ventricular tachyarrhythmias (ventricular tachycardia (VT) or fibrillation (VF); non-ES) on admission from 2002 to 2016. The primary endpoint was all-cause mortality, secondary endpoints were rehospitalization and MACE at 2.5 years of follow-up. Results764 consecutive patients with an ICD were included (11% with ES, 89% with VTA). ES was associated with higher rates of all-cause mortality (37% vs. 20%, log-rank p = 0.001; HR 2.084; 95% CI 1.416–3.065, p = 0.001). However, only in secondary preventive ICD recipients, ES remained significantly associated with mortality (39% vs. 20%; log rank p = 0.001; HR 2.235, 95% CI 1.378–3.625, p = 0.001). Furthermore, ES was associated with higher rates of rehospitalization (44% vs. 12%, log-rank p = 0.001; HR 4.763, 95% CI 3.237–7.009, p = 0.001), mainly due to VT (22% vs. 4%, p = 0.001) and acute heart failure (AHF) (17% vs. 4%, p = 0.001) and higher rates of MACE (40% vs. 23%; log rank p = 0.001; HR 1.838; 95% CI 1.273–2.654, p = 0.002). Increasing risks of death and rehospitalization were still observed even after multivariable adjustment. ConclusionES was associated with increased rates of all-cause mortality, rehospitalization, respectively due to VT and AHF, as well as MACE at 2.5 years compared to patients with ventricular tachyarrhythmias apart from ES.

Abstract 221: Transcatheter Aortic Valve Replacement is Associated with a Reduction in Hospitalization Rates: Insights from Nationwide Readmission Database

Background: In inoperable patients with severe aortic stenosis, transcatheter aortic valve replacement (TAVR) reduced mortality and hospitalization as compared with medical therapy. However, hospitalization rates after TAVR remain high, given the age and comorbidities of patients undergoing TAVR. Studies have thus far focused on rehospitalization after TAVR and have not examined the decline in hospitalizations achieved with TAVR. We sought to compare hospitalization rates in the 3 months before and after TAVR and further examine these changes in patients with and without LV dysfunction. Methods: We used the 2014 Nationwide Readmission Database (NRD) to identify patients who underwent TAVR between April and September, to allow for assessment of hospitalizations 3 months before and after TAVR. We compared hospitalization rates before and after TAVR using McNemar tests and also examined rates among patients with heart failure with reduced ejection fraction (HFrEF) and those without HFrEF. Results: Among 10416 who underwent TAVR between 4/1/14-9/30/14, mean age was 81.1 ± 8.4 years, 45.4% were men, mean number of chronic condition was 9.6 ± 3.1, and 40.6% had HFrEF. The rate of all-cause hospitalization in the 3 months before TAVR was 34.1%, which decreased to 25.5% in the 3 months after TAVR (p &lt;0.001; Figure). Among patients with HFrEF, rates changed from 40.2% before TAVR to 26.8% after (p &lt;0.001), as compared with 29.8% to 24.6% among patients without HFrEF (p&lt;0.001). Mixed effects logistic regression to examine patient characteristics associated with change in hospitalization rates after TAVR will be performed. Conclusion: Although patients who are treated with TAVR have high rates of rehospitalization after the procedures, TAVR is associated with a reduction in all-cause hospitalization, which appears to be even more pronounced among patients with HFrEF. Further investigation is needed to better understand the patient factors associated with response to TAVR, in terms of hospitalization

Prognostic value of transthoracic echocardiography parameters in patients with chronic heart failure: A Tunisian cohort

Heart failure (HF) has a dark prognosis due to the high rate of mortality and re-hospitalization. The aim of our study was to identify among the echocardiographic parameters those predictive of mortality and re-hospitalization in patients with chronic heart failure with reduced ejection fraction after 6 months. We performed a prospective cohort involving 110 patients, hospitalized for HF with ejection fraction (EF) < 40% in our cardiology department, from October 2013 to October 2015. All patients were explored by transthoracic 2D echocardiography associated to a 2D speckle tracking study of the two ventricles. After 6 months of regular follow-up, 19 patients died and 36 patients were hospitalized. In multivariate analysis, six parameters were identified as independent predictor factors of mortality: an EF < 30% (OR = 6, P = 0.01), a global longitudinal strain of the left ventricle (LV GLS) < −10% (OR = 3, P = 0.02), a tricuspid annular plane systolic excursion (TAPSE) < 12 mm (OR = 12, P < 0.001),a right ventricular fractional area change (RV-FAC) < 33% (OR = 8, P < 0.001), a peak of systolic tricuspid annular motion velocity S’ < 10 cm/s (OR = 5, P < 0.01) and a GLS of RV (RV GLS) < −15% (OR = 9, P < 0.001). Independent factors of re-hospitalization were: a RV GLS < −10% (OR = 5.8, P = 0.02), a TAPSE < 12 mm (OR = 6.4, P < 0.001), a RV-FAC < 33% (OR = 7.6, P < 0.001), a peak of S’ < 10 cm/s (OR = 10, P < 0.01), a peak Ea wave velocity < 6.5 cm/s (OR = 8, P < 0.001) and a peak Aa wave velocity < 12.5 cm/s (OR = 3.55, P = 0.01). The evaluation of echocardiographic parameters in patients with chronic heart failure may provide a precise prognosis of this serious disease. This non-invasive exam seems to be extremely valuable and potentially useful for guiding the therapeutic and follow-up strategies in heart failure in order to reduce the problem posed for the global healthcare systems through the increasing rate of mortality and hospitalization caused by this invalid disease.

Value of MitraClip in Reducing Functional Mitral Regurgitation

Patients with heart failure who have secondary severe mitral regurgitation due to left ventricular dysfunction have a poor prognosis, with high rates of rehospitalization and mortality. Percutaneous mitral valve repair using the MitraClip (Abbott) has been shown to be safe and effective in secondary severe mitral regurgitation with heart failure. The number of MitraClip procedures performed has increased significantly, as recently published large, randomized clinical studies have shown. However, these studies have drawn different conclusions. This review aims to summarize the current evidence for the MitraClip procedure and provide information for its safe and successful implementation, comparing the studies that examined the use of MitraClip versus medical therapy alone or surgical repair for severe secondary mitral regurgitation.

Prognostic impact of recurrences in patients with electrical storm

Objectives. The study sought to assess the prognostic impact of recurrences of electrical storm (ES-R) on mortality, rehospitalization and major adverse cardiac events (MACE). Background. Data on the prognostic impact of ES-R is rare. Methods. All consecutive ES patients with an implantable cardioverter defibrillator (ICD) were included retrospectively from 2002 to 2016. Patients with ES-R were compared to patients without ES-R. The primary endpoint was all-cause mortality, secondary endpoints were in-hospital mortality, rehospitalization and MACE. Results. A total of 87 consecutive ES patients with an ICD were included, of which 26% presented with ES-R at 2.5 years of follow-up. ES-R patients revealed lower LVEF compared to non-ES-R patients (91% vs. 61%; p = .081). There was a numerically higher rate of the primary endpoint of all-cause mortality at 2.5 years (50% vs. 32%; log-rank p = .137). Furthermore, ES-R was associated with increasing rates of rehospitalization (64% vs. 37%; p = .031; HR 1.985; 95% CI 1.025–3.845; log-rank p = .042), especially of acute heart failure (32% vs. 12%; p = .001; HR 3.262; 95% CI 1.180–9.023; log rank p = .023). MACE were higher in ES-R patients (55% vs. 35%; p = .113; log rank p = .141). ES patients with LVEF ≤35% were 12.4 times more likely to develop ES-R (HR 12.417; 95% CI 1.329–115.997; p = .027). Conclusion. At long-term follow-up of 2.5 years, ES-R was associated with numerically higher rates of long-term all-cause mortality and significantly higher rates of rehospitalization due to acute heart failure. LVEF ≤35% was associated with increased risk of ES-R.Condensed This study examined retrospectively the impact of recurrences of electrical storm (ES-R) on survival in 87 patients. ES-R was associated with numerically higher long-term all-cause mortality, whereas significantly higher rates of rehospitalization, respectively of acute heart failure were observed.HighlightsES-R is associated with numerically higher rates of all-cause mortality at long-term follow-up.ES-R is associated with significantly higher rates of rehospitalization and numerically higher rates of MACE at long-term follow-up, mainly due to acute heart failure.Patients with LVEF ≤35% were 12.4 times more likely to develop ES-R.

The presence of late potentials after percutaneous coronary intervention for the treatment of acute coronary syndrome as a predictor for future significant cardiac events resulting in re-hospitalization

IntroductionWe previously reported that LP positive patients after percutaneous coronary intervention (PCI) had higher rate of re-hospitalization in the small-scale study (135 patients). In this study, we evaluated correlation between LP and later cardiac events leading to re-hospitalization more extensively in greater population. Methods and resultsA 24-h high-resolution (HR) ambulatory electrocardiogram (ECG) was performed in 421 patients that received PCI for the treatment of acute coronary syndrome (ACS) within 30 days. Various baseline characteristics and post-PCI ECG parameters including LP were examined for correlation with later re-hospitalization. LP was evaluated based on 3 different conditions, i.e., the worst, mean and best values, from 24-h signal-averaged QRS wave data. During the post-PCI follow-up period (611 ± 489.0 days), 90 patients were re-hospitalized due to cardiac events. Multivariate analysis identified only positive LP based on the worst value as an independent predictor for re-hospitalization with OR 2.26. Most of re-hospitalization cases (>75%) were predominantly attributed to ischemic events. LP positive population had significantly higher incidences of ischemic events as well as overall re-hospitalization compared to LP negative population. The predictive power of LP was decreased when it was combined with other variables. The receiver operating characteristic analysis determined the LP cut-off values consistent with the LP positive criteria previously reported and standardized. ConclusionThe presence of LP in the 24-h HR ambulatory ECG post-PCI was an independent predictor for a risk of re-hospitalization due to ischemic cardiac events in ACS patients.

The Impact of Physiological Factors on 30-day Unplanned Rehospitalization in Adults with Heart Failure

ABSTRACTHeart failure (HF) patients have high rates of 30-day unplanned rehospitalization. This study assessed the impact of physiological factors on 30-day HF unplanned rehospitalization. Methods: The cross-sectional study used secondary data from electronic medical records of 270 patients. Results: Findings revealed several factor types were related to 30-day HF unplanned rehospitalization such as chronic kidney disease (p = 0.001), the use of CPAP machine (p = 0.028), and B-type natriuretic peptide (p = 0.050). Conclusion: Many physiological factors were associated with 30-day HF unplanned rehospitalization. Identifying these factors will help health care providers to plan a variety of interventions that reduce 30-day HF unplanned rehospitalization.

Health literacy and adherence to treatment of patients with heart failure.

To relate the level of functional health literacy with adherence and barriers to non-adherence, rehospitalization, readmission and death in patients with heart failure. A cross-sectional, analytical study with patients admitted to the emergency room with a diagnosis of heart failure. Literacy was assessed by the Newest Vital Sign. Patient adherence to medication treatment and barriers to non-compliance were assessed 90 days after discharge by the Morisky-Green test and the Brief Medical Questionnaire, respectively. 100 patients participated in the study. The mean age was 63.3 years (± 15.2), with a predominance of white women. Medication adherence was low in 41.1% of participants, of which 55.9% presented inadequate literacy. Re-hospitalization and death were present in patients with inadequate literacy (p<0.001). The low level of literacy was directly related to lower adherence and the presence of barriers to medication adherence, as well as higher rehospitalization rates and death.

Effect of a Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Hospitalized Patients With Chronic Obstructive Pulmonary Disease

Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life. To evaluate a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers. This single-site randomized clinical trial was conducted in Baltimore, Maryland, with 240 participants. Participants were patients hospitalized due to COPD, randomized to intervention or usual care, and followed up for 6 months after hospital discharge. Enrollment occurred from March 2015 to May 2016; follow-up ended in December 2016. The intervention (n = 120) was a comprehensive 3-month program to help patients and their family caregivers with long-term self-management of COPD. It was delivered by COPD nurses (nurses with special training on supporting patients with COPD using standardized tools). Usual care (n = 120) included transition support for 30 days after discharge to ensure adherence to discharge plan and connection to outpatient care. The primary outcome was number of COPD-related acute care events (hospitalizations and emergency department visits) per participant at 6 months. The co-primary outcome was change in participants' health-related quality of life measured by the St George's Respiratory Questionnaire (SGRQ) at 6 months after discharge (score, 0 [best] to 100 [worst]; 4-point difference is clinically meaningful). Among 240 patients who were randomized (mean [SD] age, 64.9 [9.8] years; females, 61.7%), 203 (85%) completed the study. The mean (SD) baseline SGRQ score was 63.1 (19.9) in the intervention group and 62.6 (19.3) in the usual care group. The mean number of COPD-related acute care events per participant at 6 months was 0.72 (95% CI, 0.45-0.97) in the intervention group vs 1.40 (95% CI, 1.01-1.79) in the usual care group (difference, 0.68 [95% CI, 0.22 to 1.15]; P = .004). The mean change in participants' SGRQ total score at 6 months was -1.53 in the intervention and +5.44 in the usual care group (adjusted difference, -6.69 [95% CI, -12.97 to -0.40]; P = .04). During the study period, there were 15 deaths (intervention: 7; usual care: 8) and 337 hospitalizations (intervention: 135; usual care: 202). In a single-site randomized clinical trial of patients hospitalized due to COPD, a 3-month program that combined transition and long-term self-management support resulted in significantly fewer COPD-related hospitalizations and emergency department visits and better health-related quality of life at 6 months after discharge. Further research is needed to evaluate this intervention in other settings. ClinicalTrials.gov Identifier: NCT02036294.

Aortic Insufficiency During Contemporary Left Ventricular Assist Device Support: Analysis of the INTERMACS Registry

ObjectivesThis study sought to evaluate the impact of moderate to severe aortic insufficiency (AI) on outcomes in patients with continuous flow left ventricular assist devices (CF-LVADs). BackgroundDevelopment of worsening AI is a common complication of prolonged CF-LVAD support and portends poor prognosis in single-center studies. Predictors of worsening AI and its impact on clinical outcomes have not been examined in a large cohort. MethodsWe conducted a retrospective analysis of patients with CF-LVAD in the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) study. Development of significant AI was defined as the first instance of at least moderate AI. Primary outcomes of interest were survival after development of significant AI and time to adverse events, including device complications and rehospitalizations. ResultsAmong 10,603 eligible patients, 1,399 patients on CF-LVAD support developed moderate to severe AI. Prevalence of significant AI progressively increased over time. Predictors of worsening AI included older age, female sex, smaller body mass index, mild pre-implantation AI, and destination therapy strategy. Moderate to severe AI was associated with significantly higher left ventricular end-diastolic diameter, reduced cardiac output, and higher levels of brain natriuretic peptide. Significant AI was associated with higher rates of rehospitalization (32.1% vs. 26.6%, respectively, at 2 years; p = 0.015) and mortality (77.2% vs. 71.4%, respectively, at 2 years; p = 0.005), conditional upon survival to 1 year. ConclusionsDevelopment of moderate to severe AI has a negative impact on hemodynamics, hospitalizations, and survival on CF-LVAD support. Pre- and post-implantation management strategies should be developed to prevent and treat this complication.

Tackling the care crisis in PD in East-Saxony, Germany – #Improve diagnosis and therapy in Parkinson's disease #Telemedicine-based care management #Intersectoral and interdisciplinary collaboration #Cost containment and quality improvement

Introduction: Four major problems in Parkinson's disease PD frame the current care crisis in Saxony and beyond in Germany: 1. Prevalence of PD in Germany is reported with 220:100.000. Data from AOK Plus in Saxony shows that the PD population with ICD code G20. idiopathic PD is at 20,000 which is far higher than what would be expected from prevalence alone. In Saxony alone, the population in need is already 2.5 times higher than expected with growing trends due to life expectancy. 2. Specialist care of PD nowadays takes place predominantly in larger cities, while in many rural regions there is an under-supply. Due to limited capacities of office-based neurologists time and specialised knowledge, motor fluctuations in advanced PD are often recognized at a late stage, leading to suboptimal treatment, unnecessary handicaps in daily life, frequent shifts to neurological clinics where patients are usually hospitalized for often unnecessary multi-modal complex treatment. This blocks capacities at expert centres, leading to long waitinglists and patients with advanced PD do not receive timely access to advancded threrapies Deep-Brain-Stimulation, Apomorphin infusion, Duodopa pumps. 3. Lack of objective measurements prevents effective and timely management of PD in clinical practice, especially in the outpatient setting. Current methods patient histories, diaries show validity and reliability problems and test and retest scores in current methods e.g. UPDRS have low intra and inter-rated reliability. 4. Uncontrolled PD e.g. dyskinesia, fluctuations is associated with significantly higher overall costs than controlled PD. Cost drivers of PD include onset of motor fluctuations & dyskinesias and increasing costs with worse motor off/on & UPDRS state. Bad mobility is a predictor of hospitalization and a high re-hospitalization rate. Method: Care Concept - Introduction of telemedicine-based care management for improved diagnosis and treatment of PD will sustainably change intersectoral and interdisciplinary collaboration, especially in East-Saxony with low supply. Through health economic evaluation based on profitability calculation, a prospective analysis of saving potentials and quality of care improvements was conducted. Results: By incorporating specialized expertise of movement disorder experts via telemedical approach, diagnostic accuracy can be improved. In particular, if improving guideline-based treatment across all care sectors inter-sectoral and interdisciplinary through a consistently structured and controlled care process. Objective measurement by means of the Parkinson-Kineto-Graph PKG, can accurate depict motor symptoms which drives the decision to start or change treatment dose; type, timing. For patients, this can improve the quality of life and increases safety, by preventing events e.g. fractures caused by fall. Cost savings based on population in East-Saxony achievable: ∼€18.9mio overall – savings that could provide economical provision of care for PD for 3 years. Savings can be achieved through case shifts from inpatient to outpatient care, non-medical and reduced drug costs. Conclusions: The new care approach is tackling the crisis at its roots. It changes the current treatment setting to address the need for specialised care. Specialists’ knowledge on the treatment of PD can be made available locally, releaving the distress of office-based neurologists by enabling them to treat their patients most accurately.

Downregulation of lncRNA TUG1 is involved in ankylosing spondylitis and is related to disease activity and course of treatment.

Long non-coding RNA taurine-upregulated gene 1 (lncRNA TUG1) promotes osteosarcoma, while its involvement in other bone diseases, such as ankylosing spondylitis (AS) is unknown. Expression of TUG1 in serum and open sacroiliac biopsies of AS patents and healthy controls was detected by real-time quantitative PCR (qRT-PCR). Ankylosing spondylitis disease activity score (ASDAS) system was used to evaluate disease activity. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic value of lncRNA TUG1 for AS. Chi-square test was performed to analyze the correlations between TUG1 expression and patients' clinicopathological data. Patients were divided into 2 groups (high and low expression groups) according to the median expression level of TUG1 and were followed-up for 5 years after discharge. Treatment courses and rehospitalization rate were compared between two groups. It was observed that TUG1 expression level was significantly lower in AS patients than in healthy controls in both serum and biopsies. Reduced expression level of TUG1 distinguished AS patients from controls. LncRNA TUG1 expression was significantly correlated with patients' smoking habits, disease activity, and course of disease. Patients in high expression group showed longer hospitalization time and higher rehospitalization rate. We therefore conclude that expression of lncRNA TUG1 was inhibited in AS patients and downregulation of lncRNA TUG1 is related to higher disease activity, longer course of treatment and higher rehospitalization rate.

Avoidable visits to the emergency department(ED) and their association with sex, age and race in a cohort of low socio-economic status patients on hemodialysis in the Bronx.

BackgroundIn national samples drawn from the USRDS, female patients utilize the hospital ED and inpatient services at a higher rate than their male counterparts and have a higher rate of re-hospitalization. We wanted to explore the association of sex with avoidable ED visits made by a cohort of patients on hemodialysis in a mostly minority, lower socioeconomic status (SES), population in the Bronx to test the applicability of the USRDS findings.MethodsWe used Montefiore’s clinical database to build a cohort of patients on hemodialysis with a first ED visit between 2013 and 2017. All ED visits after the index ED visit and those within one year prior to the index visit were recorded. None of the ED visits resulted in a hospitalization and were thus labeled “avoidable”. Bivariate analysis tested the association of demographic and clinical variables with sex. We used negative binomial regression to test the association of each variable with avoidable ED visit count. The multivariate model used negative binomial regression with avoidable ED visit count as outcome and sex as the exposure variable and included ancestral variables age and race. Potential mediators were added to the model to measure their effects on the association of sex with avoidable ED visits.ResultsFour thousand six hundred and seventy three subjects on hemodialysis were identified as having at least one avoidable ED visit, in the period of 2013–2017 at one of four ED sites affiliated with Montefiore Medical Center in the Bronx. Over 5 years (2012–2017), the median number of ED visits made by the study sample was 4 (25–75% IQR: 2–8). Female patients on hemodialysis in our cohort were older, more commonly black, had lower SES scores, less commonly had commercial insurance and were less commonly married than their male counterparts. Female sex was not significantly associated with a higher rate of avoidable ED visits in the total cohort.(1.053(0.99–1.12) Female sex was significantly associated with outcome in non-Hispanic whites only and in those subjects younger than 44 years old.(IRR 1.30(1.06–1.69), 1.17(1.00–1.38) in non-Hispanic White and younger age group, respectively.) Marital status, SES and hemoglobin levels possibly mediated the association of sex and outcome in our population. (>25% change in the coefficient for sex with respect to outcome when variable added to the model).ConclusionIn this single center study of a lower-socioeconomic status, mostly minority dialysis population, the association of female sex with avoidable ED visits was not significant. These results suggest the association of sex with hospitalization outcomes, described by national datasets that determine quality indicators, are not consistent across different types of populations with some mediation possible by SES and marital status in poorer neighborhoods.

Current status of readmission rate and related factors in chronic heart failure

Chronic heart failure (CHF) has the characteristics of high morbidity, high mortality and high rehospitalization rate, especially high rehospitalization rate. Now it has become a serious social public problems. Factors influencing the rate of CHF rehospitalization include age and gender, etiology, lifestyle, medication compliance, etc. According to the above factors, clinical doctors can make all kinds of CHF disease management program, thus reducing the CHF rehospitalization rates and the patient's family and social burden. Key words: Heart failure; Patient readmission; Risk factors; Review