Heart Failure Admission Rates Research Articles

The use of sodium-glucose co-transporter 2 inhibitors in the inpatient setting: Is the risk worth taking?

In the outpatient setting, sodium-glucose co-transporter 2 inhibitors (SGLT2i) are recognized as effective agents to optimize glycaemia and also developing robust evidence for cardiovascular (CV) and renal protection in people with type 2 diabetes, particularly those at higher risk. However, data on the safety and efficacy of these drugs in hospitalized patients remain limited. The purpose of this review is to discuss the balance between risks and benefits of SGLT2i use in the inpatient setting. PubMed, Embase and Google Scholar databases were searched to identify relevant published work. Available evidence on the mechanisms of action and the safety profile of SGLT2i in the context of their use in hospitalized individuals are summarized and discussed in this narrative review. The rationale behind the use of these agents in the inpatient setting is based on the low risk of hypoglycaemia, the practical dosing scheme and the potential to decrease subsequent heart failure admission rates. In addition, data from animal studies indicate the ability of SGLT2i to ameliorate oxidative stress, suppress sympathetic activity, enhance autophagy and promote cardiac remodelling, when administered in the acute phase of CV episodes. On the other hand, these drugs have been linked to specific adverse events related to their mechanism of action, including an increased risk of euglycaemic diabetic ketoacidosis and volume depletion, which raises concerns over their usefulness in inpatients, particularly individuals with multimorbidities. Potential benefits deriving from the use of SGLT2i in the inpatient setting cannot mitigate possible risks, at least until robust evidence on their efficacy in hospitalized individuals become available. The concept of administering these agents in the acute phase of CV episodes, in people with or without diabetes, requires further evaluation in appropriately designed clinical studies.

One-year all-cause mortality risk among atrial fibrillation patients in Middle East with and without diabetes: The Gulf SAFE registry

BackgroundAtrial fibrillation (AF) poses a great risk of mortality, especially when associated with diabetes mellitus (DM). ObjectivesWe aimed to investigate the rate and risk factors for mortality among AF patients with and without DM in the population from the Middle East where it has never been investigated before. MethodsWe analyzed the Gulf-SAFE registry, involving patients with nonvalvular AF from the Middle East, for one-year all-cause mortality. The predictive capability of the CHA2DS2-VASc score for death was also investigated. ResultsAmong a total of 2043 AF patients 606 had DM. Patients with DM were older and had significantly higher prevalence of multiple comorbidities (p < 0.05, respectively). Among patients with DM, age ≥ 75 (relative risk 2.34, 95% confidence interval 1.19–4.61), heart failure (HF) (RR 2.14, 95%CI 1.03–4.43), peripheral vascular disease (PVD) (RR 3.36, 95%CI 1.22–9.30) and chronic kidney disease (CKD) (RR 2.60, 95%CI 1.16–5.81) were independent risk factors for one year all-cause mortality. Patients with DM had significantly higher rates of heart failure and AF-related hospital admissions, all-cause mortality and composite outcome rates, in one year follow up. Among patients with DM, the CHA2DS2-VASc score was predictive of one-year all-cause mortality with c-index of 0.741 (95%CI 0.688–0.794). ConclusionsAF patients in Middle East with DM have a higher risk for all-cause mortality, HF and AF admission and composite outcome, compared to patients without DM. Multiple risk factors contribute to the higher mortality rate among patients with DM.

Cardiologist Participation in Accountable Care Organizations and Changes in Spending and Quality for Medicare Patients With Cardiovascular Disease.

Despite widespread adoption of Medicare accountable care organizations (ACOs), healthcare spending reductions have been modest. This may relate to variable participation in ACOs by specialist physicians, who disproportionately drive spending. To examine whether specialist participation in Medicare ACOs was associated with changes in healthcare spending and clinical quality, we analyzed national Medicare data. Working with a 20% random sample of Medicare beneficiaries (2008 to 2015), we identified those with cardiovascular disease. We estimated linear regression models at the beneficiary-quarter level to evaluate changes in healthcare spending and clinical quality after the start of the Shared Savings Program in 2012. We then examined whether changes in spending and quality across ACOs were conditional on cardiologist participation. Our study included ≈1.6 million beneficiaries per year. Although the number of ACOs increased over the study period (from 114 in 2012 to 392 in 2015), the proportion with any cardiologist participation remained stable (from 80% in 2012 to 83% in 2015). Compared with unaligned beneficiaries, those cared for by ACOs without cardiologist participation were associated with a spending reduction (per quarter) of -$75 (95% CI, -$105 to -$46; P<0.001). Care receipt in an ACO with cardiologist participation was associated with an additional difference in spending of -$56 (95% CI, -$87 to -$25; P<0.001), driven by lower spending for skilled nursing facilities, evaluation and management services, procedural care, and testing. While heart failure admission rates were similar among aligned and unaligned beneficiaries, ACO care was associated with fewer all-cause readmissions (P<0.001) and emergency department visits (P<0.001). Rates of these outcomes did not vary by cardiologist participation. Annual spending for beneficiaries with cardiovascular disease was ≈$200 lower when cared for by ACOs with cardiologist participation (compared with those without). These spending reductions did not come at the expense of clinical quality.

Predictors of 90-Days Readmissions for New Onset Heart Failure after Acute Coronary Syndrome

Background Coronary heart disease is one of the leading risk factors for the development of heart failure (HF). Despite major improvements in the management of acute coronary syndromes (ACS), HF remains the most common cause of readmission after ACS, followed by myocardial re-infarction. We sought to evaluate the risks and predictors for HF admission after ACS. Methods Using the national readmission database (NRD), we examined discharge data from 2010 until 2015 and identified all patients age 18 years and older with ACS recorded as the primary discharge diagnosis; we then excluded all patients with a prior diagnosis of HF. Chi-square test and Wilcoxon rank-sum test were used to compare proportions and continuous variables, respectively. We used logistic regression modeling to estimate the unadjusted odds of readmission for the covariates of interest. Results We identified 1,322,335 patients discharged after an ACS (36.2% STEMI). Of these, 56,345 (4.2%) were readmitted within 90-days with a new primary diagnosis of HF. The most common individual risk factors associated with HF admission were the presence of atrial fibrillation (OR 1.71), diabetes (OR 1.62) and lung disease (OR 1.49). The most common predictors for HF admission were STEMI (OR 1.28), development of acute kidney injury (AKI) (OR 1.49), length of stay > 5 days (OR 1.77) and discharge against medical advice (OR 1.88). Revascularization during index admission for ACS was a strong predictor against HF admission (OR of 0.61 and 0.49 for PCI and CABG respectively). Self-pay or private insurance were also associated with lower rates of HF admissions (OR 0.68 and 0.57, respectively). Conclusions Readmission for new-onset HF occurs in close to 5% of patients after ACS. The presence of atrial fibrillation, diabetes, development of AKI or prolonged hospitalization identifies a higher risk cohort at the time of discharge.

Health care utilization and mortality associated with heart failure-related admissions among cancer patients.

AimsHeart failure (HF) outcomes continue to improve with widespread use of new therapies. Concurrently, cancer survival has dramatically improved. Yet whether cancer patients share similar strategies and outcomes of inpatient HF treatment to those without HF is unknown. We sought to assess the contemporary impacts of cancer on inpatient HF outcomes over time.Methods and resultsThe retrospective National Inpatient Sample (2003–15) and National Readmissions Database (2013–14) registries were queried for adults admitted for HF and stratified for cancer status, excluding cases of metastatic disease. Temporal trends in HF admissions, hospital charge rates, length of hospitalization, HF‐related procedure utilization, in‐hospital mortality, and hospital readmissions were analysed. Over 13 years of follow‐up, there were 12 769 077 HF admissions (mean age 73 years, 50.8% female, 30.8% non‐White), among which 1 413 287 (11%) had a co‐morbid cancer diagnosis. Cancer patients were older, were predominantly male, and tended to be smokers. Over time, HF admission rates among cancer patients increased, despite a concurrent decrease among patients without cancer (P < 0.0001). After propensity matching, in‐hospital mortality was significantly higher among cancer HF patients (5.1% vs. 2.9%, P < 0.0001). Additionally, HF‐related procedure utilization was disproportionately lower among cancer patients (0.30 vs. 0.35 procedures/HF hospitalization, P < 0.001); the presence of cancer was associated with increased costs, length of hospitalizations, and all‐cause readmissions, but fewer HF readmissions (P < 0.0001, each).ConclusionsWhile the incidence of HF hospitalizations has increased among cancer patients, they do not appear to share the same rates of advanced HF care, readmissions trends, or reductions in in‐hospital mortality. Future studies targeting modifiable factors related to these differences are needed.

Burden and Outcomes of Heart Failure Hospitalizations in Adults With Chronic Kidney Disease

BackgroundData on rates of heart failure (HF) hospitalizations, recurrent hospitalizations, and outcomes related to HF hospitalizations in chronic kidney disease (CKD) are limited. ObjectivesThis study examined rates of HF hospitalizations and re-hospitalizations within a large CKD population and evaluated the burden of HF hospitalizations with the risk of subsequent CKD progression and death. MethodsThe prospective CRIC (Chronic Renal Insufficiency Cohort) study measured the estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (ACR) at baseline. The crude rates and rate ratios of HF hospitalizations and 30-day HF re-hospitalizations were calculated using Poisson regression models. Cox regression was used to assess the association of the frequency of HF hospitalizations within the first 2 years of follow-up with risk of subsequent CKD progression and death. ResultsAmong 3,791 participants, the crude rate of HF admissions was 5.8 per 100 person-years (with higher rates of HF with preserved ejection fraction vs. HF with reduced ejection fraction). The adjusted rate of HF was higher with a lower eGFR (vs. eGFR >45 ml/min/1.73 m2); the rate ratios were 1.7 and 2.2 for eGFR 30 to 44 and <30 ml/min/1.73 m2 (vs. >45 ml/min/1.73 m2), respectively. Similarly, the adjusted rates of HF hospitalization were significantly higher in those with higher urine ACR (vs. urine ACR <30 mg/g); the rate ratios were 1.9 and 2.6 for urine ACR 30 to 299 and ≥300 mg/g, respectively. Overall, 20.6% of participants had a subsequent HF re-admission within 30 days. HF hospitalization within 2 years of study entry was associated with greater adjusted risks for CKD progression (1 hospitalization: hazard ratio [HR]: 1.93; 95% confidence interval [CI]: 1.40 to 2.67; 2+ hospitalizations: HR: 2.14; 95% CI: 1.30 to 3.54) and all-cause death (1 hospitalization: HR: 2.20; 95% CI: 1.71 to 2.84; 2+ hospitalizations: HR: 3.06; 95% CI: 2.23 to 4.18). ConclusionsWithin a large U.S. CKD population, the rates of HF hospitalizations and re-hospitalization were high, with even higher rates across categories of lower eGFR and higher urine ACR. Patients with CKD hospitalized with HF had greater risks of CKD progression and death. HF prevention and treatment should be a public health priority to improve CKD outcomes.

Renin-Angiotensin System Blockade and Risk of Heart Failure After Myocardial Infarction Based on Left Ventricular Ejection Fraction: A Retrospective Cohort Study.

The goal of this study was to determine the association between the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) and follow-up heart failure (HF) according to left ventricular ejection fraction (LVEF) in patients with acute myocardial infarction (AMI). This cohort study used a retrospective registry of 8169 consecutive patients discharged with a diagnosis of AMI from two university hospitals in Spain between 2010 and 2016. We used a multivariable competing risk analysis, survival-time inverse probability weighting (IPW) propensity score adjusting, and propensity score matching (PSM) to investigate the association between ACEI/ARB treatment and follow-up HF. During the follow-up (3.3 ± 2.2years), 1296 patients were admitted for HF (5.2 per 100 person-years). ACEI/ARB use was not associated with fewer follow-up HF admissions in patients with LVEF > 40% (univariate analysis: sub-hazard ratio [sHR] 1.10; 95% confidence interval [CI] 0.95-1.27; p = 0.197; IPW adjusting analysis: sHR 1.11; 95% CI 0.95-1.29; p = 0.192; PSM analysis: sHR 1.12; 95% CI 0.92-1.36; p = 0.248). However, ACEI/ARB use was associated with a significant reduction in HF admission rates in patients with LVEF ≤ 40% (univariate analysis: HR 0.70; 95% CI 0.56-0.88; p = 0.003; IPW adjusting analysis: HR 0.64; 95% CI 0.50-0.83; p = 0.001; PSM analysis: HR 0.65; 95% CI 0.46-0.92; p = 0.014). Among hospitalized survivors of AMI, the use of ACEIs/ARBs was associated with a lower risk of follow-up HF in patients with LVEF ≤ 40% but not in those with LVEF > 40%. Further prospective studies are needed to confirm our results.

Trends in In-Hospital Mortality, Length of Stay, Nonroutine Discharge, and Cost Among End-Stage Renal Disease Patients on Dialysis Hospitalized With Heart Failure (2001–2014)

Heart failure (HF) is a common cause of morbidity and mortality among end-stage renal disease (ESRD) patients on dialysis. We aimed to assess the trends and outcomes in primary and secondary HF hospitalizations among ESRD patients with the use of a nationally representative database. We analyzed data from the National Inpatient Sample and the US Census Bureau to calculate annual national rates of in-hospital mortality, length of stay, disposition with a focus on nonroutine discharge (discharge to a health care facility rather than to home), and adjusted median cost among patients with ESRD on dialysis with primary or secondary HF admissions from 2001 to 2014. An estimated 812,090 primary and 2,887,432 secondary HF admissions occurred from 2001 to 2014. The prevalence of comorbidities increased during the study period. Primary HF admission rates increased from 2001 to 2006 and decreased from 2007 to 2014, whereas secondary HF admissions increased significantly during the study period (P < .001). We found statistically significant declines of primary and secondary admission in-hospital mortality, with annual percentage changes of -3.1% and -2.6% respectively (P < .001 for both). In addition, the lengths of stay decreased significantly for primary and secondary HF admissions (P < .001 for both). However, nonroutine discharges increased significantly for both. Subgroup analysis showed higher in-hospital mortality for men, patients >65 years of age, whites, and those on peritoneal dialysis. The cost of hospitalization did not change significantly for primary and secondary HF admissions. Among ESRD patients on dialysis with primary or secondary HF admission diagnosis, comorbidity prevalence increased but in-hospital mortality and length of stay decreased significantly from 2001 to 2014.

Decoupling Between Diastolic Pulmonary Arterial Pressure and Pulmonary Arterial Wedge Pressure at Incremental Left Ventricular Assist Device (LVAD) Speeds Is Associated With Worse Prognosis After LVAD Implantation

Decoupling between diastolic pulmonary arterial pressure (dPAP) and pulmonary arterial wedge pressure (PAWP) is an index of pulmonary vasculature remodeling and provides prognostic information. Furthermore, decoupling may change during incremental left ventricular assist device (LVAD) speed changes. In this prospective study, patients underwent an echocardiographic and hemodynamic ramp test after LVAD implantation and were followed for 1 year. The change in decoupling (dPAP - PAWP) between the lowest and highest LVAD speeds during the ramp test was calculated. Survival and heart failure admission rates were assessed by means of Kaplan-Meier analysis. Eighty-seven patients were enrolled in the study: 54 had a Heartmate II LVAD (60.8 ± 9.3 years of age and 34 male) and 33 had an HVAD LVAD (58.6 ± 13.2 years of age and 20 male). Patients who experienced greater changes in decoupling (Δdecoupling >3 mm Hg) had a persistently elevated dPAP at incremental LVAD speed and had worse 1-year heart failure readmission-free survival compared with the group without significant changes in the degree of decoupling (41% vs 75%; P = .001). An increase in decoupling between dPAP and PAWP at incremental LVAD speed changes was associated with worse prognosis in LVAD patients.

Trends in Heart failure Hospitalization, In-hospital Mortality, Length of Stay and Disposition, Among ESRD patients on Dialysis (2001-2014)

Background Cardiovascular diseases and specifically Heart failure (HF) is a common cause for morbidity and mortality among end stage renal disease (ESRD) patients on dialysis. We aimed to assess trends and outcomes in primary HF hospitalizations among ESRD patients utilizing a nationally representative database. Methods We utilized data from the National Inpatient Sample and the US Census Bureau to calculate annual national rates of primary HF admissions, in-hospital mortality, length of stay and disposition among patients with End-Stage Renal Disease (ESRD) on dialysis for years 2001 to 2014. Results An estimated 812,090 primary HF admissions occurred during the study period. Rates of admissions increased from 2001 to 2006 and decrease from 2007 to 2014 (Figure). We found a significant decline of in-hospital mortality with annual percentage change of -3.1% (p Conclusion Among ESRD patients on dialysis hospitalized for HF, in-hospital mortality and length of stay decreased significantly from 2001 to 2014.

Targeting ‘Hotspots’ in Heart Failure Admissions: A Visual Geographical Profile of the Australian Capital Territory and Southern New South Wales

Background: Heart failure (HF) remains a leading cause for morbidity and mortality, with enormous costs arising from HF hospitalisations. Our centre receives patients from a wide geographical area that includes the Australian Capital Territory and Southern New South Wales. We utilised the location of our patients with HF to identify geographical areas of high rates of HF admissions, or ‘hotspots’.

The influence of anti-hyperglycemic drug therapy on cardiovascular and heart failure outcomes in patients with type 2 diabetes mellitus.

Patients with type 2 diabetes mellitus (DM) are at a substantially increased risk of heart failure (HF) and HF mortality. Despite the lack of evidence that tight glycemic control reduces the incidence of cardiovascular (CV) events, a growing body of evidence suggests that the choice of glucose-lowering agents may influence outcomes including HF. Thiazolidinediones are associated with a significant risk of HF. For metformin, sulphonylureas and insulin, little data is available to indicate the impact on HF. The glucagon-like peptide-1 (GLP-1) agonists, liraglutide and semaglutide, have been shown to reduce major CV events, but did not affect rates of hospitalization for HF. Clinical trials have demonstrated diverse effects of Dipeptidyl peptidase-4 (DPP-4) inhibitors on HF; saxagliptin showed an increased risk of HF admissions, alogliptin was associated with higher rates of new HF admissions, while sitagliptin had a neutral effect. The sodium-glucose cotransporter 2 (SGLT2) inhibitors, empagliflozin and canagliflozin, have been recently shown to reduce the incidence of HF and cardiovascular mortality in patients with and without a history of HF. This review will summarize key findings of the impact of glucose-lowering agents on CV safety and HF-associated outcomes, present available data on the underlying mechanisms for the benefits of the SGLT2 inhibitors on HF, and discuss strategies to improve outcomes in patients with DM and high CV risk.

320 - Recent Trends and Outcomes of LVAD Implantation in the ESRD Population: Analysis of 2010 - 2014 National Inpatient Sample Database

Introduction: Left ventricular assist device (LVAD) utilization has consistently increased in recent years. It is unclear if this upward surge in LVAD utilization has benefited patients with end-stage renal disease (ESRD). Furthermore data on comparative outcomes in this population subset are scarce because these patients were excluded from major LVAD trials. Method: We used the Nationwide Inpatient Sample (NIS), the largest all-payer inpatient database in the United States, to determine the recent trends of LVAD implantation in patients with ESRD. We also studied the trends, gender and racial disparities and in-hospital mortality associated with LVAD implantation in this high risk group. Results: Between 2010 and 2014, a total of 15,865 LVADs were implanted nationwide with a consistent increase across the years (2395 in 2010 to 3855 in 2014). 415 total LVAD implantations occurred in patients with ESRD, with a significant increase in implantation identified from 2010 (3.3%) compared to 2014 (5.2%, P trend < 0.05). Despite adjustment for heart failure (HF) admission rates, there was significant sex and racial disparities in LVAD utilization among ESRD patients, favoring men and Caucasians which has stayed consistent across the 5 year study period. Overall, high in-hospital mortality (54%) was observed in patients with ESRD who underwent LVAD implantation, however a trend showing decreased in hospital mortality was noted from 2010 to 2014 (69% to 48%, P trend < 0.05). Multivariable logistic regression analysis revealed pulmonary hypertension, age > 60 years and diabetes mellitus as independent predictors of in-hospital mortality in ESRD patients undergoing LVAD implantation. Conclusion: Our analysis confirms that 1) number of LVAD implants in the ESRD population have increased significantly between years 2010–2014; 2) There is significant gender and racial disparity in LVAD utilization among this comorbidity group, favoring men and Caucasians across all the 5 year study period; 3) In spite of high in-hospital mortality in this sub-group, there has been consistent decrease in the mortality from years 2010–2014; 4) Pulmonary hypertension, age > 60 years and diabetes mellitus are independent predictors of in-hospital mortality in ESRD patients undergoing LVAD implantation.

SGLT-2 Inhibitors in Heart Failure: Implications for the Kidneys.

This review aims to summarize the renal effects of sodium-glucose transporter-2 (SGLT-2) inhibitors and their potential implications in heart failure pathophysiology. In patients with diabetes and established atherosclerosis, the SGLT-2 inhibitor empagliflozin versus placebo significantly reduced the rate of heart failure admissions with 35%. Moreover, empagliflozin slowed kidney disease progression and reduced the need for renal replacement therapy. SGLT-2 inhibitors inhibit proximal tubular sodium and chloride reabsorption, leading to increased nephron flux throughout the distal renal tubules, most notably at the level of the macula densa. Afferent arteriolar vasoconstriction is promoted through tubulo-glomerular feedback and reduces glomerular capillary hydrostatic pressure, relieving podocyte stress and explaining renal preservation. Further, plasma volume is contracted and natriuresis promoted without inducing neurohumoral activation. Finally, SGLT-2 inhibitors may improve endothelial function and energy metabolism efficiency. Together, these promising features place them as a potential novel treatment for heart failure.

Role of SGLT2 Inhibitors in Patients with Diabetes Mellitus and Heart Failure.

This review aims to summarize the evidence on cardiovascular risks and benefits of glucose-lowering drugs in diabetic patients, with a particular focus on the role of sodium-glucose transporter-2 (SGLT-2) inhibitors and their promising potential as a heart failure treatment. The SGLT-2 inhibitor empagliflozin has emerged as the first glucose-lowering drug to lower cardiovascular mortality in diabetes with an unprecedented 38% relative risk reduction. In addition, empagliflozin significantly reduced the rate of heart failure admissions with 35% when compared to placebo in diabetic patients with established atherosclerosis. SGLT-2 inhibitors should be considered as a first-line drug to achieve glycemic control in diabetic patients at high risk for cardiovascular diseases and heart failure in particular. As SGLT-2 inhibitors target different pathophysiological pathways in heart failure, they might even be considered in the broader population without diabetes, but this remains the topic of further study.

6 CardioMEMS for Effective Management of Heart Failure: Reducing Healthcare Utilization and 30 Day Readmissions

Heart failure (HF) affects over 5 million Americans and is associated with frequent, costly acute care hospitalizations and penalties for high 30-day readmission rates. Although current guidelines emphasize the importance of implementing systems to coordinate and deliver effective care, HF admission rates have increased, while readmission rates have remained essentially unchanged in the past decade. Early recognition of a HF episode is paramount in preventing a readmission. Research from the Champion Trial (J Card Fail. 2011 Jan;17(1):3-10. http://dx.doi.org/10.1016/j.cardfail.2010.08.002) demonstrates that pulmonary artery pressures more accurately reflect volume status changes in the heart failure patient than traditional methods of weight monitoring and physical assessment. These changes in volume status are also shown to precede a change in weight or symptom development by 1-3 weeks. The CardioMEMS Heart Failure Monitoring System is a permanently implantable pulmonary artery sensor device designed to transmit daily pulmonary artery (PA) pressure measurements from the patient’s home to a website available to the healthcare team. Monitoring PA pressure provides tangible data to help guide HF management in an outpatient setting.

Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment.

BackgroundDespite numerous studies of geographic variation in healthcare cost and utilization at the local, regional, and state levels across the U.S., a comprehensive characterization of geographic variation in outcomes has not been published. Our objective was to quantify variation in US health outcomes in an all-payer population before and after risk-adjustment.Methods and FindingsWe used information from 16 independent data sources, including 22 million all-payer inpatient admissions from the Healthcare Cost and Utilization Project (which covers regions where 50% of the U.S. population lives) to analyze 24 inpatient mortality, inpatient safety, and prevention outcomes. We compared outcome variation at state, hospital referral region, hospital service area, county, and hospital levels. Risk-adjusted outcomes were calculated after adjusting for population factors, co-morbidities, and health system factors. Even after risk-adjustment, there exists large geographical variation in outcomes. The variation in healthcare outcomes exceeds the well publicized variation in US healthcare costs. On average, we observed a 2.1-fold difference in risk-adjusted mortality outcomes between top- and bottom-decile hospitals. For example, we observed a 2.3-fold difference for risk-adjusted acute myocardial infarction inpatient mortality. On average a 10.2-fold difference in risk-adjusted patient safety outcomes exists between top and bottom-decile hospitals, including an 18.3-fold difference for risk-adjusted Central Venous Catheter Bloodstream Infection rates. A 3.0-fold difference in prevention outcomes exists between top- and bottom-decile counties on average; including a 2.2-fold difference for risk-adjusted congestive heart failure admission rates. The population, co-morbidity, and health system factors accounted for a range of R2 between 18–64% of variability in mortality outcomes, 3–39% of variability in patient safety outcomes, and 22–70% of variability in prevention outcomes.ConclusionThe amount of variability in health outcomes in the U.S. is large even after accounting for differences in population, co-morbidities, and health system factors. These findings suggest that: 1) additional examination of regional and local variation in risk-adjusted outcomes should be a priority; 2) assumptions of uniform hospital quality that underpin rationale for policy choices (such as narrow insurance networks or antitrust enforcement) should be challenged; and 3) there exists substantial opportunity for outcomes improvement in the US healthcare system.

Abstract 19932: Secular Trends in Complications of Atrial Fibrillation 2004-2012: The Treat-AF Study

Background: Limited data indicates that complications of atrial fibrillation (AF) may be declining. We evaluated secular trends in AF outcomes over 8 years using complete data from the largest integrated health care system in the United States. Methods: Using data from the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the U.S. Department of Veterans Affairs (VA) healthcare system, we identified patients with newly diagnosed, nonvalvular AF between from 2004 to 2012. Using VA and linked Medicare data, we determined the incidence rates for ischemic stroke, intracranial hemorrhage, extracranial hemorrhage, hospitalization for heart failure, and death from inpatient claims and medical record data using validated algorithms. Results: In 184,161 patients with newly diagnosed AF (age 70.4±10.7; CHADS-VASC 2.6±1.7) the incidence rates, expressed as events per 1000 person-years, gradually decreased from 2004 to 2014 for ischemic stroke (12.1 to 8.0), intracranial hemorrhage (4.2 to 2.0), and death (86.3 to 63.7) (p &lt; 0.05 for all, Table 1). Heart failure incidence rates slightly increased (44.3 to 50.6). Extracranial hemorrhage events were relatively stable until 2010, when the events gradually decreased from 19.6 to 16.8 events per 1000 person-years. Conclusions: Among patients with newly-diagnosed AF from 2004-2012, the incidence rates of stroke (both hemorrhagic and ischemic), hemorrhage, and death have declined while heart failure admission rates have slightly increased. Causes and mediators require exploration but major sequelae following AF have dramatically changed.

Musculoskeletal malignant neoplasms hospitalisation in Victoria

The paper describes factors associated with 2,605 hospital admissions for musculoskeletal malignant neoplasms (MMN) over oneyear. The rates per 10,000 population increased significantly (t=5.3, p&lt;.01) with age, with men (4.5 per 10,000 population, 95% CI 4.1-5.0) at greater risk than women (3.3 per 10,000 population, 95% CI 2.8-3.7). The 30-day readmission rate was 19%, thethird highest of all admission categories. The average length of stay was significantly (t=4.5, p&lt;.01) shorter in the metropolitanarea (8.2 days) than in rural communities (10.8 days). The age-standardised rates varied inversely (r=-0.28) with socioeconomicstatus. Communities with high MMN admission rates had high rates of heart failure admissions (r=0.35), alcohol consumption(r=0.34) and receiving Disability Support Pension (r=0.32). There was a significant (t=13.8, p&lt;.001) monthly variability inMMN hospitalisation rates. As a leading cause of hospital readmission and disability, the condition requires closer analysis.

Abstract 13581: Combined Assessment of N-Terminal Pro-B-Type Natriuretic Peptide and High-Sensitivity Troponin T Levels Improves the Prediction of Future Admission for Heart Failure in Outpatients with Hypertension and Preserved Left Ventricular Ejection Fraction

Background: Hypertension is one of the most prevalent cardiovascular diseases and one of the most important causes of heart failure (HF) with preserved left ventricular ejection fraction (LVEF). We prospectively investigated the incremental predictive value of a combination of N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hsTnT), and galectin-3 for HF admission in outpatients with hypertension. Methods: Baseline serum NT-proBNP, hsTnT, and galectin-3 levels were measured in 443 outpatients (mean age, 69.4 years) with hypertension and LVEF ≥ 50%. Using tissue Doppler echocardiography, E/e’ ratio was calculated. Among these patients, 34% had a history of cardiovascular disease, and 46% had a history of diabetes. Results: Galectin-3 levels significantly (p &lt; 0.0001) correlated with E/e’ ratio (r = 0.21) and estimated glomerular filtration rate (eGFR; r = –0.78). During a mean follow-up period of 899 days, there were 40 (9%) HF admissions. Using multivariate Cox regression analysis including 10 clinical, biochemical, and echocardiographic variables, increased NT-proBNP (relative risk, 2.88 per 10-fold increment, p = 0.007) and hsTnT (4.30 per 10-fold increment, p = 0.004) levels, but not ga1ectin-3 levels, were shown to be independent predictors of HF admission. When patients were stratified into four groups according to NT-proBNP levels ≥ a median value of 193.7 pg/mL and/or hsTnT levels ≥ a median value of 14 pg/mL, HF admission rates were 1.1%, 2.1%, 4.3%, and 20%, respectively (p &lt; 0.0001). Furthermore, when NT-proBNP and hsTnT levels were combined, the predictive values for HF admission were increased, as shown by the C-index, net reclassification improvement (NRI), and integrated discrimination improvement (IDI; Table 1). Conclusions: The combined assessment of NT-proBNP and hsTnT levels can improve the prediction of HF admission in outpatients with hypertension.