Recent Hospitalization Research Articles

Use of remote patient monitoring kits to reduce hospitalization and mortality rates for patients with heart failure.

Patients with heart failure (HF) are at an increased risk of volume overload, which can lead to hospital admission. Use of noninvasive remote patient monitoring (RPM) devices utilizing biometric sensors and weighing scales to track vital signs and body weight has uncertain benefits. At the Baptist Health Louisville (BHLOU) HF Clinic, high-risk patients were given RPM kits. The purpose of this study was to determine whether RPM led to reductions in HF hospitalizations and mortality. This single-center, retrospective chart review evaluated adult patients presenting to the BHLOU HF Clinic after a recent hospitalization for HF or need for intravenous diuretics within the past 60 days. The study evaluated patients before and after implementation of RPM kits. The primary endpoints were differences in the rates of 30-day HF hospitalization and 30-day mortality. Secondary endpoints included differences in the number of interventions in 90 days, the 90-day rate of HF hospitalization, and the 90-day rate of mortality. The final analysis included 58 patients in the preimplementation group and 34 patients in the postimplementation group. The rate of 30-day HF hospitalization was 10.3% in the preimplementation group and 0% in the postimplementation group. The rate of 30-day mortality was 3.4% in the preimplementation group and 0% in the postimplementation group. For the secondary endpoints, the number of interventions in 90 days was 3 vs 4, the 90-day rate of HF hospitalization was 22.4% vs 11.8%, and the rate of 90-day mortality was 6.9% vs 5.9% in the preimplementation vs postimplementation group, respectively. Implementation of RPM in patients with acutely decompensated HF led to numerically lower 30-day and 90-day rates of HF hospitalization.

An electronic consultation programme impacts on heart failure patients prognosis: implications for heart failure care

Abstract Background Multidisciplinary care plans that comprise professionals from different levels of care optimize the diagnosis and treatment of patients with heart failure (HF). Purpose Our objective was to analyse the clinical characteristics, 1 year prognosis and the prognostic determinants of patients with a previous diagnosis of HF, categorized by their previous HF-related hospitalization status (<1year or >1 year before or never hospitalized), referred by general practitioners (GPs) to a cardiology department (CD) by an e-consultation. Methods Data were obtained from 4851 HF patients referred by GPs to the cardiology department for an e-consultation from 2013 to 2020. We analysed the clinical characteristics of HF patient. We studied the whole cohort, and then subdivided it into three groups of diagnosis: patients who had never been hospitalized due to HF, patients with a recent HF-related hospitalization (<1 year), and patients with a remote HF-related hospitalization (≥1 year). To assess 1 year prognosis after e-consultation, we analysed the following health outcomes: HF-related hospitalizations, cardiovascular hospitalizations, HF-related mortality, cardiovascular mortality and all-cause mortality (Fig. 1). Qualitative variables are expressed as percentages (%), and quantitative continuous variables as means (standard deviation), or medians (interquartile range) if the distribution was asymmetric. To verify differences between groups, χ2 was used for quantitative variables, and ANOVA for qualitative variables. Results The delay of time to e-consults were solved was 8.6 + 8.6 days with 84.3% solved in <14 days. For the 1 year prognosis evaluation after the e-consult were assessed the cardiovascular hospitalizations, HF-related hospitalizations, HF-related mortality, cardiovascular mortality, and all-cause mortality. Compared with the group without a previous hospitalization, patients with recent and remote HF hospitalization were at higher risk of a new HF-related hospitalization (OR: 19.41 [95% CI: 12.95–29.11]; OR: 8.44 [95% CI: 5.14–13.87], respectively) (Fig 2), HF-related mortality (OR: 2.47 [95% CI: 1.43–4.27]; OR: 1.25 [95% CI: 0.51–3.06], respectively), as well as cardiovascular hospitalizations and mortality and all-cause mortality. Reduction in the time elapsed because e-consultation was solved was associated with lower risk of HF-related mortality (OR: 0.94 [95% CI: 0.89–0.99]), cardiovascular mortality (OR: 0.96 [95% CI: 0.93–0.98]), and all-cause mortality (OR: 0.98 [95% CI: 0.97–1.00]). Conclusions A clinician-to-clinician e-consultation programme between GPs and cardiologists in patients with HF allows to solve the demand of care in around 25% e-consults without an in-person consultation; the patients with a previous history of HF-related hospitalization showed a worse 1 year outcome. A reduction in the time elapsed because e-consultation was solved was associated with a mortality reduction.

Cardiovascular risk prediction in a New Zealand cohort of patients with known cardiovascular disease - a regional individual patient-level data linkage study

Abstract Background National health databases have been underutilised in the development of cardiovascular disease (CVD) risk prediction equations for people with known CVD, yet can inform population level practice and policy—including identification of health equity gaps, high-risk groups, and high-risk localities. With the recent introduction of novel and expensive preventive cardiovascular drugs, stratifying risk in patients with prior CVD could be required to inform cost-effective use of these medications in the future. Purpose We sought to develop 5-year CVD risk equations in adults with known history of CVD in Aotearoa New Zealand, using data from administrative health databases and characterize distribution of risk according to sex. Methods All people above 18 years of age with a history of CVD hospitalization, living in the Auckland and Northland regions of Aotearoa New Zealand (approximately one-third of the national population) on 1 January 2014 were included. Participants were followed for 5 years (31 December 2018) or until death or the outcome of interest, being any fatal or non-fatal CVD hospitalization (ischemic heart disease, heart failure, ischemic stroke, or peripheral artery disease) during follow-up. Sex-specific 5-year CVD risk prediction equations were developed using multivariable Fine and Gray models taking competing risk of non-cardiovascular death into account. Predictor variables included were age; ethnicity; deprivation level; time since most recent CVD hospitalization, history of smoking, heart failure, atrial fibrillation, chronic renal disease, and diabetes mellitus; use of anti-thrombotic, blood pressure-lowering, and lipid-lowering drugs; and blood levels of glycosylated hemoglobin (HbA1c), non-HDL cholesterol, and creatinine. Results The cohort comprised 42,130 men (median age: 68 years [interquartile range (IQR): 59–76]) and 31,717 women (median age: 70 years [IQR: 60–78]) with 12,875 and 8,734 observed events during follow-up, respectively. Sex-specific 5-year CVD risk prediction equations with excellent calibration (accuracy) were developed (Figure 1). Increasing age; high deprivation level; more recent CVD hospitalization; history of smoking, heart failure, atrial fibrillation, chronic renal disease, diabetes mellitus; use of blood-pressure lowering drugs; and high blood levels of HbA1c, non-HDL cholesterol, or creatinine were predictors of elevated risk. There was a wide range of predicted 5-year risk, with 15% of men and 24% of women having a predicted risk below 15%, and 24% and 20%, respectively, having a predicted risk of 40% or above (Figure 2). Conclusion This study demonstrates that it is possible to develop accurate CVD risk prediction equations from administrative health databases for patients with known CVD. Marked heterogeneity in 5-year risk of a subsequent CVD event emphasise that the current ‘one size fits all’ approach to secondary prevention of CVD requires review.Figure 1Figure 2

Candidacy and predicted efficacy of vericiguat in contemporary heart failure outpatient clinics

Abstract Background Vericiguat is a novel drug class (soluble guanylate cyclase stimulator) approved for the treatment of symptomatic heart failure with reduced ejection fraction (HFrEF) patients who are stable after recent decompensation. Its safety and efficacy in high-risk HFrEF patients (ejection fraction <45%) with recent hospitalisation was demonstrated in the VICTORIA trial, along with advantages: lesser impact on blood pressure, sustained efficacy up to eGFR 15 mL/min/1.73m2. Subgroup analyses have shown variability in heart failure hospitalisation (HFH) and cardiovascular death (CVD) reduction according to NT-proBNP levels. While real-world candidacy for Vericiguat have been described in hospitalised patients, data on Vericiguat eligibility within contemporary heart failure outpatient (HF OPD) clinics is limited. Purpose We describe the proportion of HFrEF patients reviewed in HF OPD clinics eligible for vericiguat (according to the VICTORIA trial criteria) and likely to benefit from therapy based on NT-proBNP levels. Methods A retrospective review was performed on HFrEF patients reviewed in HF OPD services in 2022. Hospital records were assessed to identify community managed HFrEF patients experiencing HFH in 2022 and the VICTORIA trial's selection criteria was applied to determine Vericiguat eligibility. Predicted efficacy (reduction in HFH and/or CVD) in Vericiguat eligible patients was based on NT-proBNP level cut-off: >8000 ng/L: no benefit; ≤8000 ng/L: net benefit; ≤5314 ng/L: strong benefit. Stable NT-proBNP value was taken as the peak value within 30 days of discharge of the HFH event. Results 333 HFrEF patients were reviewed in HF OPD services in 2022. 94 (28.2%) patients experienced HFH in 2022, of which 33 (9.9%) occurred after guideline directed medical therapy (GDMT) was optimized in HF OPD review. Pharmacotherapy patterns of patients with HFH were identified at HF OPD review: 24 (33.8%) quadruple GDMT, 18 (25.4%) triple GDMT, 21 (40.8%) dual or single GDMT. 71 (21.3%) patients with HFH met the VICTORIA trial criteria and were eligible for Vericiguat. When subdivided according to NT-proBNP level cut-off, the following predicted efficacy were identified: 52 (15.6%) net benefit, 42 (12.6%) strong benefit, and 19 (5.7%) no benefit. Conclusions In HF OPD services, 28.2% of HFrEF patients may experience HFH within 1 year with 9.9% occurring despite GDMT optimization. 40.8% of community managed HFrEF patients were still only on dual or single GDMT. The proportion of community managed HFrEF patients eligible for Vericiguat is 21.3%. Based on NT-proBNP levels, the proportion likely to experience net and strong beneficial effects from Vericiguat were 15.6% and 12.6% respectively. Considering Vericiguat has advantages over the traditional barriers (hypotension, renal function) of conventional HFrEF pharmacotherapy agents, our findings provide insight into the potential real-world use of Vericiguat within contemporary HF OPD clinics.Figure 1Table 1

Feasibility, efficacy and safety of early and rapid initiation of evidence-based treatment for patients with HFrEF- a real world experience of the "four drugs in four weeks" strategy

Abstract Background Evidence-based treatment for heart failure with reduced ejection fraction (HFrEF) is associated with improved outcomes for patients. However, there is uncertainty as to how treatment with these foundational drugs should best be implemented. Objectives To evaluate whether early and rapid initiation of medications for patients with HFrEF using a 4 x 4 approach (4 pillars of HFrEF therapy in 4 weeks) is feasible, safe, and effective. Methods We recruited consecutive patients from April to July 2021 with a new diagnosis of HFrEF who were either assessed at our urgent HF clinic or had a recent HF hospitalisation. All patients had regular reviews (every 1-2 weeks, combination of telephone and face-to-face) at our hospital-based HF clinic by a HF consultant or senior HF specialist nurse for initiation and up-titration of guideline-recommended therapy including angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor neprilysin inhibitor (ARNI), beta blockers (BB), mineralocorticoid receptor antagonist (MRA) and sodium glucose co-transporter inhibitor (SGLT2i). Results Of 100 patients approached, 19 patients were considered unsuitable for the 4x4 pathway (79% due to severe frailty or significant comorbidities). 81 patients were enrolled (61% male, median (IQR) age: 73 (67-82) years, median (IQR) NT-proBNP: 3764 (1597-7487) ng/L); 39 (48%) patients achieved "4 drugs at 4 weeks". Of the 42 patients who did not, 33 (79%) had contraindication to one or more of the drug classes at the outset, including renal impairment (28%), bradycardia (18%) and hyperkalaemia (15%). Patients who did not achieve "4 drugs at 4 weeks" were older, more symptomatic, and had higher NTproBNP and worse renal function. During a median follow up of 554 days, 6 (7%) patients died and 31 (38%) experienced the combined outcome of all-cause death / hospitalisation. Patients who did not achieve "4 drugs at 4 weeks", compared to those who did, had a 2.5 fold increased risk of the combined outcome (Figure 1). They were also less likely to be up-titrated to targeted doses of HF medications (Figure 2). There was noticeable improvement in NTproBNP with no significant change in renal function or systolic BP in both groups. Compared to those who did not achieve "4 drugs at 4 weeks", those who did showed larger improvement in LVEF (8% vs 2%) at 6 months. 5 patients (6%) experienced significant side effects during medication up-titration: 4 had symptomatic hypotension and 1 had hyperkalaemia. Conclusion The 4x4 strategy is clinically feasible and safe when implemented in selected patients with HFrEF and may be associated with improved outcomes. Our results support larger studies to further investigate the generalisability and effectiveness of the 4x4 strategy.

Initiation, titration, and discontinuation - utilization of heart failure medicines in England (EVOLUTION HF UK)

Abstract Background Guidelines advise early initiation and optimisation of several guideline-recommended pharmacological therapies (GRPTs) for managing heart failure (HF) with reduced ejection fraction. Recent guidelines have expanded this list to include two new classes of agents: sodium-glucose cotransporter 2 (SGLT2) inhibitors and angiotensin receptor neprilysin inhibitor (ARNI). Auditing real-world GRPT use is critical in closing the evidence-practice gap. Purpose To generate insights into utilization patterns of novel and established GRPTs after a recent hospitalization for HF (hHF) in England using administrative healthcare records. Methods New users of GRPTs within 12 months of a hHF discharge were identified using linked national electronic health records (Clinical Practice Research Datalink, Hospital Episode Statistics and Office for National Statistics mortality data) between January 2021 — May 2022. Time to initiation of dapagliflozin (the only SGLT2 inhibitor approved for HF in January 2021), sacubitril/valsartan, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) were considered separately. Titration and discontinuation of the most frequently used drug for each pharmacological class was identified and analysed as representative of the entire class. Doses and discontinuation were assessed in the 12 months following initiation. If a new package isn't collected after the previous one ends, discontinuation is assumed until a new package is collected. Target dose was defined as ≥100% of the guideline-recommended dose. Results Overall, 16,090 new users of GRPTs were identified. Mean times from hHF to GRPT initiation were longer for novel agents (dapagliflozin or sacubitril/valsartan) than for established agents: 195 and 137 vs 48 to 73 days. Similarly, the cumulative percentage of patients initiating a GRPT within 100 days of hHF discharge were lower for novel agents (Figure 1). In the following 12 months, the average target dose achieved was higher for novel agents: 61.8% (dapagliflozin), 32.4% (sacubitril/valsartan), 8.5% (ACE inhibitor: ramipril), 5.9% (ARB: candesartan), 7.6% (beta-blocker: bisoprolol), and 6.6% (MRA: spironolactone). Corresponding discontinuation rates were 32.0%, 24.3%, 36.3%, 38.2%, 23.4%, and 50.1%, respectively (Figure 1 and 2). Conclusion In the UK, early initiation of novel GRPTs after recent hHF in routine clinical practice remains a challenge. For GRPTs requiring uptitration, few patients received the target dose in the 12 months after initiation, and many discontinued treatments. Conversely, dapagliflozin was associated with relatively higher rates of target dose achievement, perhaps because only a single fixed dose is recommended. Our data highlight the need for increased access to appropriate, timely and sustained HF therapeutic optimization.

Association between sex and efficacy of intravenous ferric carboxymaltose in patients with acute heart failure and iron deficiency: an AFFIRM-AHF subgroup analysis

Abstract Background/Introduction Heart failure (HF) pathophysiology, clinical presentation and treatment response is known to differ between males and females (1). In the AFFIRM-AHF trial, intravenous (IV) ferric carboxymaltose (FCM) reduced the risk of HF hospitalisations and improved quality of life vs placebo in patients with iron deficiency who had stabilised following an acute HF (AHF) episode (2,3); the effect of sex on outcomes with iron-repletion therapy in these high-risk patients has not been fully explored. Purpose To investigate the interaction between sex and the effects of FCM vs placebo on clinical outcomes in the AFFIRM-AHF population. Methods In AFFIRM-AHF, patients with left ventricular ejection fraction <50% and iron deficiency (defined as serum ferritin <100 ng/mL, or 100–299 ng/mL if transferrin saturation is <20%) who had stabilised following recent hospitalisation for AHF were randomised 1:1 to receive IV FCM or placebo for up to 24 weeks.2 The primary endpoint was a composite of total HF hospitalisations and cardiovascular (CV) death up to Week 52; secondary endpoints are listed in the Figure.2 In this prespecified analysis, AFFIRM-AHF patients were stratified into male and female subgroups and the interaction between sex and clinical outcomes with FCM vs placebo was explored. Results Of the 1108 patients included in the AFFIRM-AHF full analysis set, 614 (FCM: 314; placebo: 300) were male and 494 (FCM: 244; placebo: 250) were female. At baseline, a New York Heart Association functional class of III and above was more common in females (59.0%) than in males (48.4%). For the primary endpoint, the adjusted annualised event rate per 100 patient-years with FCM vs placebo was 53.3 vs 83.3 in males (rate ratio [RR] 0.64; 95% confidence interval [CI] 0.46–0.89) and 63.1 vs 60.3 in females (RR 1.05; 95% CI 0.72–1.53) (Figure). For all secondary endpoints except time to CV death, effect sizes in male and female subgroups were similar to those for the primary endpoint. The interaction between sex and treatment effect was non-significant for the primary endpoint (P-interaction=0.054) but reached significance for the secondary endpoints of total CV hospitalisations and CV death (P-interaction=0.024) and time to first HF hospitalisation or CV death (P-interaction=0.043). Conclusion(s) The results of this exploratory subgroup analysis suggest that iron deficiency treatment with IV FCM following an AHF episode may be more effective in males than in females; this may be related to baseline differences between sex subgroups, beyond the factors adjusted for in this analysis.Figure

Acute‐onset distal dominant neuropathy after severe acute respiratory syndrome coronavirus 2 vaccination in a male patient with recent dengue infection: A case report

AbstractObjectiveGuillain–Barré Syndrome (GBS) is an autoimmune degenerative disease commonly presenting with acute progressive sensorimotor paralysis, sometimes associated with dysautonomia, facial diplegia and severe respiratory distress. Gastroenteritis due to Campylobacter jejuni and respiratory infection secondary to Epstein–Barr virus usually precede GBS; however, vaccination or recent dengue infection as temporal causes are rarely reported.Case PresentationHere, we present a 20‐year‐old man, who complained of a 5‐day history of a progressively worsening tingling sensation isolated in the hands and feet, and unilateral Bell's palsy on the left side of his face, which occurred 2 weeks after his severe acute respiratory syndrome coronavirus 2 vaccination and 6 weeks from his recent hospitalization from Dengue fever. Except for the left complete unilateral facial paralysis, weakness in the intrinsic hands and feet muscles, and sensory ataxia, the rest of his physical examination was unremarkable. On work‐up, the findings of albuminocytological dissociation and distal sensorimotor demyelinating polyneuropathy in the nerve conduction study supported the diagnosis of GBS.ConclusionThe enhanced immune response from a recent dengue infection and severe acute respiratory syndrome coronavirus 2 vaccination might increase the risk of GBS. The predominantly distal GBS phenotype has rarely been reported in the literature, adding to the peculiarity of this case.

The effect of relative hypotension on 30-day mortality in older people receiving emergency care

Research has observed increased mortality among older people attending the emergency department (ED) who had systolic pressure > 7 mmHg lower than baseline primary care values. This study aimed to (1) assess feasibility of identifying this ‘relative hypotension’ using readily available ED data, (2) externally validate the 7 mmHg threshold, and (3) refine a threshold for clinically important relative hypotension. A single-centre retrospective cohort study linked year 2019 data for ED attendances by people aged over 64 to hospital discharge vital signs within the previous 18 months. Frailty and comorbidity scores were calculated. Previous discharge (‘baseline’) vital signs were subtracted from initial ED values to give individuals’ relative change. Cox regression analysis compared relative hypotension > 7 mmHg with mean time to mortality censored at 30 days. The relative hypotension threshold was refined using a fully adjusted risk tool formed of logistic regression models. Receiver operating characteristics were compared to NEWS2 models with and without incorporation of relative systolic. 5136 (16%) of 32,548 ED attendances were linkable with recent discharge vital signs. Relative hypotension > 7 mmHg was associated with increased 30-day mortality (HR 1.98; 95% CI 1.66–2.35). The adjusted risk tool (AUC: 0.69; sensitivity: 0.61; specificity: 0.68) estimated each 1 mmHg relative hypotension to increase 30-day mortality by 2% (OR 1.02; 95% CI 1.02–1.02). 30-day mortality prediction was marginally better with NEWS2 (AUC: 0.73; sensitivity: 0.59; specificity: 0.78) and NEWS2 + relative systolic (AUC: 0.74; sensitivity: 0.63; specificity: 0.75). Comparison of ED vital signs with recent discharge observations was feasible for 16% individuals. The association of relative hypotension > 7 mmHg with 30-day mortality was externally validated. Indeed, any relative hypotension appeared to increase risk, but model characteristics were poor. These findings are limited to the context of older people with recent hospital admissions.

Abstract 16226: Stressed Out - When Sinus Bradycardia is Not Benign

Background Sinus bradycardia is often a benign and asymptomatic finding in athletes due to an increased vagal tone. However, when patients develop symptoms of decreased exercise tolerance, this warrants further investigation. We present a case of sinus bradycardia caused by adrenal insufficiency in a high-end athlete with exceptional physical reserve which resolved with treatment of the underlying cause and prevented unnecessary pacemaker implantation. Case Presentation A 44-year-old female athlete with no medical history who at baseline runs ultramarathons and weight lifts presented with severely symptomatic bradycardia. After initial recommendation of pacemaker placement during recent hospitalization, patient sought a second opinion. During her hospitalization, the patient underwent extensive work up including basic laboratory work, TSH, CT angiogram of the chest and TTE - all of which were found to be normal. She also had an exercise stress test and was only able to increase her HR to 50% of age-predicted rate. On further review, she was found to be hypothermic and reported menstrual irregularities, raising suspicion for endocrine abnormalities. Bradycardia, hypothermia and chronotropic incompetence prompted further workup which revealed a depressed cortisol with a low ACTH leading to a diagnosis of adrenal insufficiency. Further imaging revealed a pituitary microadenoma. The patient was referred to endocrinology and started therapy with steroids with resolution of her symptoms and is undergoing evaluation for surgical intervention. Conclusion Sinus bradycardia is a well-recognized occurrence in well trained athletes, caused by an increased vagal tone and is usually a benign finding. In our case, a patient underwent extensive work up for lightheadedness and exercise intolerance in the setting of her bradycardia which was unrevealing with initial recommendation of pacemaker placement. Upon further investigation, increased vagal tone alone was not responsible for severely symptomatic bradycardia and chronotropic incompetence. Notably, a combination of bradycardia, hypothermia, and irregular menses, resulted in work up revealing adrenal insufficiency, ultimately avoiding unnecessary pacemaker implant.

Abstract 12361: Predictors and Utilization of Ultrasound Enhancing Agents for Echocardiography in the Outpatient Setting

Background: The national utilization of ultrasound enhancing agents (UEAs) for transthoracic (TTE) or stress (SE) echocardiography in the outpatient setting and their association with downstream utilization of care remains uncertain. Methods: In a set of large, all-payer claims databases (ACTICS Open and Closed Claims) encompassing 90% of the US population, we evaluated rates, predictors of use, and association of UEAs with downstream utilization using linear mixed effects models amongst adult outpatients receiving TTE or SE, 2019-2022. Amongst those with recent hospitalization for AMI, we evaluated the association of UEA receipt and downstream healthcare utilization. Results: A total of 11,270,268 individuals receiving TTE and 744,175 adults receiving SE across 2,407 sites were included (mean age 63, 54.8% female), of which 6.8% receiving TTE and 21.0% receiving SE received UEAs. Patients receiving UEAs were more frequently older, male, and had a greater number of comorbidities. Sites performing UEAs were more frequently large, rural, nonprofits, and teaching facilities. Use varied widely by state ( Figure; 19.7% in Minnesota vs. 1.1% in Delaware) and was not explained by patient or site characteristics (median odds ratios = 4.35). Amongst those receiving TTE after AMI, UEA use was associated with a reduction in cardiac non-stress imaging (adjusted RR 0.77, 95% CI 0.64-0.92, p = 0.004), but no substantial differences in cost, days alive at home, readmission rates, cardiac catheterization, or stress imaging (p > 0.05 for all). Conclusions: In this large, nationally representative cohort study, UEAs were used in 6.8% of TTEs and 21.0% of SEs performed in the outpatient setting but use varied widely across sites, unexplained by patient or site characteristics. Amongst outpatients, UEA receipt after AMI was associated with a reduction in cardiac stress imaging, but not other outcomes.

Abstract 13344: Differential Impact of Self-Care Behaviour on Mortality Between Patients With Stable and Recent Worsening Chronic Heart Failure

Backgrounds: Although self-care is crucial to maintain health and recommended in the guidelines in patients with chronic heart failure (CHF), its prognostic significance is controversial. We hypothesized that self-care is more effective in vulnerable patients with recent hospitalization due to worsening HF (WHF). The aim of this study was to investigate the prognostic significance of self-care behaviour on mortality between patients with stable and recent worsening CHF. Methods: We prospectively examined consecutive 1,873 CHF patients from a Japanese multicenter registry and assessed the European Heart Failure Self-care Behaviour Scale (EHFScBS) at enrollment. The patients were divided into inpatient due to WHF (WHF group) and outpatient stable CHF (stable CHF group). The optimal EHFScBS was defined as more than 70 based on previous reports. The primary outcome was all-cause death. Results: Of studied patients (1,102 male, mean age 72 ± 13 years), 625 (33%) and 1,165 (67%) were classified into WHF and stable CHF groups, respectively. During a median follow-up period of 427 (IQR 273 - 642) days, the primary outcome occurred in 50 patients. In stable CHF group, there was no significant difference on primary outcome between optimal and suboptimal EHFScBS (P = 0.65) (Figure A). On the other hand, patients with suboptimal EHFScBS showed a higher incidence of death than those with optimal score in WHF group (P = 0.01) (Figure B). In WHF group, Cox regressions showed that the EHFScBS score was independently associated with mortality (HR 0.51, 95% CI 0.26-0.99) adjusted for significant covariates including hemoglobin, estimated glomerular filtration rate, serum sodium, log NT-proBNP, and the Meta-Analysis Global Group in Chronic Heart Failure risk score. Conclusions: In patients with recent worsening, not stable CHF, the EHFScBS was associated with subsequent mortality, indicating that the self-care education might be more effective for patients with recent worsening CHF.

High-Dose vs. Standard-Dose Influenza Vaccine and Cardiopulmonary Hospitalization or Mortality: Emulating the INVESTED Trial Using Insurance Claims Data.

The INVESTED trial did not show benefits of high-dose (HD) vaccine vs. standard-dose (SD) for a primary composite outcome of cardiopulmonary hospitalization or all-cause mortality (hazard ratio (HR) = 1.05, 95% confidence interval (CI) = 0.96-1.15) and its components (all-cause mortality HR = 1.01, 95% CI = 0.84-1.21, cardiopulmonary hospitalization HR = 1.05, 95% CI = 0.96-1.16) during three influenza seasons (2016-2019) among participants with recent myocardial infarction or hospitalization for heart failure (HHF). We emulated INVESTED using Medicare claims data to assess whether the real-world evidence (RWE) study reached similar conclusions. We identified 1:1 propensity score (PS)-matched trial-eligible Medicare beneficiaries aged > 65 years and with prior HHF who received an HD or SD vaccine for the 2016-2019 seasons. We also re-analyzed the INVESTED trial data restricting to participants > 65 years with prior HHF to align eligibility criteria more closely with the RWE study. We compared HRs from the trial and RWE study for the main outcomes. Among 53,393 pairs of PS-matched Medicare beneficiaries, the HD vaccine group showed lower risk of the primary composite outcome (HR = 0.96, 95% CI = 0.95-0.98) and all-cause mortality (HR = 0.93, 95% CI = 0.91-0.95), and similar risk of cardiopulmonary hospitalization (HR = 0.98, 95% CI = 0.96-1.00), compared with SD. The RWE and trial results were closely concordant after the trial population was limited to participants > 65 years with prior HHF: trial-based results for the primary composite outcome (HR = 1.02, 95% CI = 0.89-1.17), all-cause mortality (HR = 0.92, 95% CI = 0.72-1.16), and cardiopulmonary hospitalization (HR = 1.02, 95% CI = 0.88-1.18). Although similar to the main trial results, the RWE was closer to the results from trial participants with aligned eligibility criteria. This study affirms the importance of considering different distributions of baseline patient characteristics when comparing trial findings to RWE.

Development and External Validation of a Lymphoma-Specific Venous Thromboembolism Risk Assessment Model

Introduction: Venous thromboembolism (VTE) significantly affects cancer patients undergoing systemic therapy. Existing risk models developed in the pan-cancer population, such as the Khorana score, offer limited discrimination in cancer-specific setting. We aimed to develop and validate a risk assessment model (RAM) tailored for lymphoma patients, accounting for the clinical and sociodemographic heterogeneity across three distinct healthcare systems in the United States. Methods: Electronic health records (EHR) linked to cancer registry 2006-2021 from the Veterans Affairs national healthcare system (VA) with a total of 10,313 lymphoma patients were randomly divided into an 80% derivation cohort and a 20% internal validation cohort. Further external validation was carried out using data from two other healthcare systems - Harris Health System (HHS, N= 854, 2011-2020) and MD Anderson Cancer Center (MDACC, N=1,858, 2017-2020). Patients were included if they had newly diagnosed lymphoma requiring first-line systemic therapy within 1 year of diagnosis. Patients were excluded if they had recent diagnosis of acute VTE within the last 6 months or were prescribed anticoagulant within 1 month before index date. The index date was the time of systemic therapy, and all covariates were extracted on or before the index date. Incident VTE was defined using our published computable phenotype algorithm (PMID 36626707; 37067102). For RAM derivation (Figure 1), 32 candidate predictors were initially chosen based on clinical relevance and EHR data availability. Missing values were imputed via chain random forest. Parsimonious variable categories were selected by a combination of Least Absolute Shrinkage and Selection Operator (LASSO), Recursive Feature Elimination (RFE), and random forest to generate the final logistic regression model. For external validation, complete case analysis was performed using the derived beta coefficients without model refitting. Bootstrapped time-dependent c statistics and calibration curves for 6-month VTE were used to assess discrimination and fit. A pre-determined threshold of 8% VTE at 6-month from the predicted probability was used to stratify high vs. low-risk groups. Competing risk models were used to assess cumulative incidence. Results: At 6 months, the VTE incidence were 5.75% (n=469) in VA derivation and 6.12% (n=124), 8.24% (n=69), and 6.55% (n=112) in the VA, HHS, and MDACC validation cohorts, respectively. The three healthcare systems had different baseline characteristics in demographics, lymphoma types, systemic therapies, and comorbidities. Patients from VA were mostly older males with more comorbidities and remote history of VTE, patients from HHS were mostly uninsured minorities who were younger but with more aggressive histology, while those from MDACC were patients treated at a comprehensive cancer center. The variables in the final RAM included lymphoma type (4 groups ranging from very-low to very-high risk), body mass index, indwelling catheter, cytotoxic vs. targeted therapy, history of VTE, recent hospitalization, and paralysis/immobilization. Table 1 shows the variable prevalence in each cohort. As shown in Figure 1, the new RAM showed promising discrimination for VTE with a C-statistic of 0.69 in the derivation cohort and 0.67, 0.70, 0.72 in the internal and two external validation cohorts. By splitting patients using an 8% predicted risk threshold, the high- vs. low-risk group achieved a clear differentiation in risk stratification despite significant differences in baseline characteristics. This represented a noticeable improvement for lymphoma patients over the Khorana Score, which yielded C-statistics of 0.53-0.56. The overall calibration of the RAM appeared adequate. Conclusions: Using multiple cancer-EHR cohorts with heterogeneous patients and a wide range of lymphoma subtypes, we successfully derived and externally validated an improved RAM for VTE specifically in lymphoma patients requiring early initiation of systemic therapy. Along several well-known patient-specific risk factors, lymphoma type was an important predictor of VTE risk. The new RAM could improve VTE risk stratification and prevention efforts in lymphoma patients.

Long-Term Efficacy and Safety of Fecal Microbiota Transplantation for C. difficile Infections Across Academic and Private Clinical Settings.

Fecal microbiota transplant (FMT) is increasingly performed for Clostridioides difficile infection (CDI), although long-term efficacy and safety data are limited and are focused on results from academic medical centers rather than private settings where most patients receive care. Medical records of 165 patients who received FMTs for CDI were reviewed from an academic medical center and an adjacent, unaffiliated private practice. Of these patients, 68 also completed a survey regarding their long-term disease course and interval health. CDI resolution occurred in 81.3% (100/123) at the academic center and 95.2% (40/42) in the private setting. Private practice patients were more likely to present with recurrent, rather than refractory, CDI (92.9% vs. 66.7% P <0.001). Those from the academic center were more likely to have comorbid IBD, recent hospitalization, recent proton pump inhibitor use, ongoing immunosuppression, and inpatient FMT (all P values <0.05).Among surveyed patients, 29.4% developed interval comorbidities or changes to pre-existing conditions after a median follow-up of 33.7 months (IQR 13.2 to 44.3mo). Of 30 patients requiring subsequent antibiotics, 13.3% suffered CDI relapse. All subjects who had initially responded to FMT but had a subsequent CDI (17.9%, 10/56) responded to another FMT. In a real-world setting, patients who underwent FMT at academic centers differed significantly in clinical characteristics from those treated at a private practice. In both settings, FMT is an effective treatment for CDI not responding to standard therapies, even after subsequent antibiotic use. New diagnoses following FMT, however, are common and merit further exploration.

The Prevalence of Multidrug-Resistant Organisms in Patients with Surgical Site Infections in Riyadh, Saudi Arabia: A Cross-sectional Study at a Tertiary Care Hospital

Background: Multidrug-resistant (MDR) infections are a threat in patients undergoing surgery. This study was undertaken to determine the prevalence and possible predictors of MDR infections over a two-year period in patients with surgical site infection (SSI) at a tertiary care hospital in Riyadh, Saudi Arabia. Methods: We conducted a cross-sectional study from April 2016 to April 2018 by reviewing hospital records of patients with a diagnosis of SSI based on a physician report and laboratory findings. The isolation of MDR organisms (MDRO) from SSI was the primary outcome variable as well as other risk factors. Results: SSI was diagnosed in 55 out of 77 patients under study, with MDRO prevalence rate of 44%. Previous antibiotic use and hospitalization in the last 90 days were strongly associated with developing MDRO infection often due to ESBL producing Gram-negative bacterial pathogens. Superficial and deep incisional SSI were more frequent in patients compared to organ/space SSI. History of diabetes mellitus, duration of surgery and bacterial colonization at other body site also increased the likelihood of MDRO. Factors such as trauma, obesity, general anesthesia, and wound types were not found to increase the risk for MDRO. Conclusions: Our study identified recent antibiotic use and hospitalization as major risk factors for MDRO surgical site infections. Other predisposing factors include diabetes mellitus, duration of surgery and bacterial colonization. MDRO isolated include E. coli and Pseudomonas aeruginosa. Bacterial pathogens harboring multiple resistant mechanisms can complicate SSI adversely affecting clinical outcomes following routine surgical procedures.

Combined telemonitoring and telecoaching for heart failure improves outcome

Telemedicine has been shown to improve the outcome of heart failure (HF) patients in addition to medical and device therapy. We investigate the effectiveness of a comprehensive telehealth programme in patients with recent hospitalisation for HF on subsequent HF hospitalisations and mortality compared to usual care in a real-world setting. The telehealth programme consists of daily remote telemonitoring of HF signs/symptoms and regular individualised telecoaching sessions. Between January 2018 and September 2020, 119,715 patients of a German health insurer were hospitalised for HF and were eligible for participation in the programme. Finally, 6065 HF patients at high risk for re-hospitalisation were enroled. Participants were retrospectively compared to a propensity score matched usual care group (n = 6065). Median follow-up was 442 days (IQR 309–681). Data from the health insurer was used to evaluate outcomes. After one year, the number of hospitalisations for HF (17.9 vs. 21.8 per 100 patient years, p < 0.001), all-cause hospitalisations (129.0 vs. 133.2 per 100 patient years, p = 0.015), and the respective days spent in hospital (2.0 vs. 2.6 days per year, p < 0.001, and 12.0 vs. 13.4, p < 0.001, respectively) were significantly lower in the telehealth than in the usual care group. Moreover, participation in the telehealth programme was related to a significant reduction in all-cause mortality compared to usual care (5.8 vs. 11.0 %, p < 0.001). In a real-life setting of ambulatory HF patients at high risk for re-hospitalisation, participation in a comprehensive telehealth programme was related to a reduction of HF hospitalisations and all-cause mortality compared to usual care.

Impact of diabetes on healthcare utilization and expenditure among older adults in India.

The present study aims to investigate the disparities in healthcare utilization and healthcare burden among individuals with and without diabetes. The prevalence of diabetes is more pronounced among older adults, which can detrimentally influence their health and quality of life while also restricting their capacity to self-manage and giving rise to competing healthcare demands. Thus, it is crucial to understand the implications of diabetes on healthcare demands and expenditures to mitigate its detrimental consequences. Data was used from the initial round of the Longitudinal Aging Study in India (LASI), conducted in 2017-18. The analytical sample included 65,562 individuals aged 45 or above, and 8429 individuals were identified as having diabetes. The primary outcome variable was the out-of-pocket expenditure (OOPE) in the most recent hospitalization. Descriptive statistics and logistic regression are used to find the trend in the prevalence of morbidities both in diabetic and nondiabetic groups. Additionally, quantile regression was used to study the association between the presence of diabetes and the risk of excess healthcare expenditure calculated through out-of-pocket expenditure for hospitalization and expenditure on medicines. 16% of people with diabetes were hospitalized in the past year, compared to 9% without diabetes. The mean hospitalization length for diabetics was 13.6days, compared to 6.5 for nondiabetics. Diabetes is significantly associated with higher OOPE for hospitalization across all quintiles, and its effect on hospitalization is weakest in the highest quintile. Having diabetes is also found to be significantly associated with the expenditure on medicines across all quintiles. The study highlights the need for diabetes awareness programs and interventions integrated into national health policies. The quantile regression model provides crucial insights into the association between diabetes and OOPE for hospitalization and medicine The increase of OOPE for hospitalisation and medicine due to the presence of diabetes emphasizes the need to address the financial burden faced by people with diabetes, highlighting the urgency of prioritizing measures to improve access to affordable care. The online version contains supplementary material available at 10.1007/s40200-023-01319-w.

SAT248 A Case Report Of Hypercalcemia Secondary To Calcium Sulfate Antibiotic Beads

Abstract Disclosure: R. Habibi: None. G. Vahdani: None. N. Ebrahimi: None. Introduction: Periprosthetic joint infections are a rare and uncommon complication in arthroplasties of the hip or knee, happening in ∼0.7% of these procedures. Placement of antibiotic eluting beads, sometimes referred to as calcium sulfate beads (CSB), which are bio-compatible hydrophilic crystals used to deliver antibiotics locally, are one solution to prevent such complications. Hypercalcemia post-CSB placement is a very uncommon, rare and unusual complication that has only been presented in the literature a handful of times. Below, we report on a such a patient, illustrating the importance of surgical history in investigating the cause of hypercalcemia. Presentation: 63yo F with PMH of HTN, HLD, Crohn’s, T2DM, CKD3 who had a recent hospital admission 2 weeks prior for new arthritis secondary to pseudogout crystals, s/p bilateral synovectomy and CSB placement by orthopedics. She was subsequently discharged to nursing facility and re-presented to hospital for increasing AMS and worsening knee pain. Labs showed evidence of AKI with creatinine 1.9, severe hypercalcemia at 17.5 mg/dl with concomitant hypophosphatemia at 1.1 mg/dl. PTHrP WNL &amp; PTH low at 7pg/ml and histo antigen neg, suggesting this was not related to PTH. Malignancy ruled out based on past imaging that was done in 2 months prior. MM ruled out since normal SPEP, UPEP, and kappa:lambda. Unlikely that this was milk alkali as patient did not have alkalosis. Vitamin 1,25 low at 10pg/ml ruling out sarcoidosis. Vitamin 25 WNL. Urine Ca 24hr WNL suggesting no FHH. Ca levels returned to normal after pamidronate, IV fluids and calcitonin. Chart review suggested that CSB implanted in her knees as the likely cause of her hypercalcemia. Discussion: It is important to bring awareness that one of the causes of severe hypercalcemia is post CSB placement. Vigilant monitoring of calcium levels pre and post operation after CSB placement is indicated, particularly in patients with a previous history of CKD. It has been hypothesized that there is a dose-dependent relationship between CSB volume and hypercalcemia, with suggestions that limiting CSB to less than 40ml per operation may be beneficial. A 10ml pack of CSB contains 5.73 grams of elemental calcium which is subsequently released over a 30-60-day interval. There is limited information on the mechanism of hypercalcemia secondary to CSB use, so further studies need to be implemented. Ultimately, it is crucial for physicians to have a high suspicion for CSB induced hypercalcemia post-arthroplasty as CSB use expands. Presentation: Saturday, June 17, 2023

Changes in Prognostic Beliefs of Patients With Metastatic Cancer and Their Association With Changing Health Status.

Patients' prognostic beliefs are known to influence treatment decisions. However, the evolution of these beliefs over an extended period in patients with metastatic cancer is understudied. We assessed longitudinal changes in prognostic beliefs and investigated their association with patients' changing health status. We surveyed a cohort of 600 patients with solid metastatic cancer every 9 months, up to 54 months. At each time point, we assessed whether patients believed their current treatments would cure them (responses classified as accurate, inaccurate, or uncertain belief) and tested the association of their response with symptom burden and recent unplanned hospital admission. Only 29% of patients had accurate prognostic belief at baseline, and 24% of patients changed from having accurate to uncertain/inaccurate belief at some point during follow-up. Patients who experienced greater symptom burden were less likely to report inaccurate (relative risk ratio [RRR], 0.87; 95% CI, 0.84-0.90) or uncertain prognostic belief (RRR, 0.90; 95% CI, 0.87-0.92), whereas those with a recent unplanned hospital admission were more likely to report inaccurate (RRR, 2.71; 95% CI, 1.48-4.94) or uncertain belief (RRR, 2.34; 95% CI, 1.34-4.07) compared with accurate belief. An increase in symptom burden was associated with change toward accurate belief (RRR, 1.75; 95% CI, 1.33-2.31) as opposed to no change. In our study of long-term changes in prognostic beliefs among patients with metastatic cancer, reported prognostic beliefs were unstable, changed from accurate to inaccurate/uncertain and vice versa, and were associated with their changing health status. Our findings imply that conversations about goals of care must occur regularly to factor in these changes.