Download Circulation: Heart Failure Topic Review

Circulation: Heart Failure Topic Review
Circulation: Heart Failure Editors’ Picks
Most Important Articles in Readmissions
Robb D. Kociol, MD
The following are highlights from the series, Circulation: Heart Failure Topic Review. This series summarizes the most important articles, as
selected by the editors, that have been published in the Circulation portfolio. The studies included in this article represent the most noteworthy research in readmissions. (Circ Heart Fail. 2013;6:e48-e54.)
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Rates and Predictors of 30-Day Readmission
Among Commercially Insured and MedicaidEnrolled Patients Hospitalized With Systolic
Heart Failure
survival over extended follow-up among patients with HF who were
newly discharged. Among 8543 patients followed for 22 567 personyears, 60.7% had HF of ischemic etiology and HF with reduced ejection
fraction (left ventricular ejection fraction ≤45% versus >45% [HF with
preserved ejection fraction]) was present in 67.3%. During the 10-year
follow-up period, 98.8% of the cohort died, and 35 966 hospital readmissions occurred. Cardiovascular readmissions occurred frequently
and were largely due to episodes of recurrent HF. Within the first year
postdischarge, 66.5% of patients were rehospitalized for cardiovascular
disease, and 61.3% were readmitted for HF. There was a preponderance
of readmissions in the months comprising the initial and final deciles of
the lifespan of the cohort. Of all recurrent HF hospitalizations, 26.8%
occurred in the first and 39.8% in the last deciles of cohort survival
duration. Similarly, 29.7% and 52.3% of all cardiovascular readmissions occurred in the first and last deciles of the cohort survival duration,
respectively. The presence of ischemic HF etiology was a ubiquitous
predictor of the first cardiovascular readmission, recurrent hospitalizations for cardiovascular, HF, and coronary heart disease on repeatedevents analysis. Although presence of HF with reduced ejection fraction
was associated with a shorter time to first recurrent HF or coronary heart
disease readmission, it was not a predictor of repeat hospitalizations.
Summary: Medicare’s introduction of public reporting and value-based
purchasing centered on 30-day risk-adjusted readmission rates after
hospital discharge for heart failure (HF) has helped to heighten interest
among state governments and commercial payers in HF readmissions.
As all potentially avoidable HF readmissions represent an opportunity
to improve healthcare quality and efficiency, understanding the rates and
predictors in non-Medicare populations is important. This is particularly
true among patients with systolic dysfunction, for whom most HF-specific
therapies are targeted. Using claims-based administrative data, we evaluated 1198 Medicaid and 3350 commercially insured unique systolic HF
index admissions. All patients were <65 years of age, with a mean age of
55 years. Unadjusted all-cause 30-day readmission rates were 17.4% for
Medicaid enrollees and 11.8% for commercially insured patients. After
adjustment for differences in case mix, the odds of all-cause readmission
were 32% higher among Medicaid than commercially insured patients,
and 68% higher when only HF-related readmissions were considered.
No significant differences in readmission rates were seen for managed
care versus fee-for-service or capitated versus noncapitated plan types.
These results suggest that socioeconomically disadvantaged populations,
as indicated by Medicaid insurer status, represent a high-risk population
potentially warranting specific interventions.
Conclusions: Among newly discharged patients with HF, cardiovascular events were clustered at early postdischarge and prefatal time
periods, and were increased among those with ischemic etiology.2
Socioeconomic Status, Medicaid Coverage,
Clinical Comorbidity, and Rehospitalization
or Death After an Incident Heart Failure
Hospitalization: Atherosclerosis Risk in
Communities Cohort (1987 to 2004)
Conclusions: Compared with commonly cited Medicare HF readmission rates of 20% to 25%, Medicaid patients with systolic HF had
lower 30-day readmission rates, and commercially insured patients
had even lower rates. Even after adjustment for case mix, Medicaid
patients were more likely to be readmitted than commercially insured
patients, suggesting that more attention should be focused on readmissions among socioeconomically disadvantaged populations.1
Summary: Hospital discharges for heart failure (HF) continue to rise.
Chronic conditions such as hypertension, diabetes, and obesity are risk
factors for the development of HF, and the burden of rehospitalization
increases with increasing comorbidity. However, variations in HF morbidity are not completely explained by clinical features of the disease,
suggesting the need to explore understudied domains, such as the influence of the socioeconomic context. The authors assessed the association of neighborhood median household income (nINC) and receipt of
Medicaid with rehospitalization or death in the Atherosclerosis Risk in
Communities cohort study (1987 to 2004) after an incident HF hospitalization (n=1342) in the context of individual socioeconomic status.
Participants who lived in low-nINC areas at baseline and had multiple
comorbidities were rehospitalized faster and more often compared with
Lifetime Analysis of Hospitalizations and
Survival of Patients Newly Admitted With
Heart Failure
Summary: Hospital readmissions for heart failure (HF) contribute to
increased morbidity and resource burden. However, the predictors of
hospitalization and patterns of cardiovascular events during the lifetime of patients with HF have not been elucidated. In this study, the
authors examined recurrent hospitalizations, cardiovascular events, and
Correspondence to The Editors, Circulation: Heart Failure Editorial Office, 560 Harrison Ave, Suite 502, Boston, MA 02118. E-mail
[email protected]
© 2013 American Heart Association, Inc.
Circ Heart Fail is available at http://circheartfailure.ahajournals.org
e48
DOI: 10.1161/CIRCHEARTFAILURE.113.000572
The Editors Circulation: Heart Failure Topic Review e49
participants living in high-nINC areas with multiple comorbidities.
Medicaid recipients with a low level of comorbidity were rehospitalized
faster and more often compared with non-Medicaid recipients. In the
context of increasing hospital discharges for HF, it is critical to identify
social and economic neighborhood forces that affect HF rehospitalization. The observed differences by nINC may have important implications for the management and treatment of patients with HF. It is likely
that nINC determines, in part, the availability of healthcare resources
in a community, such as the proximity of neighborhood health clinics.
Outpatient care is very important to the out-of-hospital monitoring of
patients with HF and if less available in low-nINC areas, may adversely
affect the progression of HF among patients in these communities.
Conclusions: Comorbidity burden seems to influence the association
among nINC, Medicaid status, and rehospitalization and death in
patients with HF.3
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National Survey of Hospital Strategies to
Reduce Heart Failure Readmissions:
Findings From the Get With The GuidelinesHeart Failure Registry
Summary: Reducing 30-day heart failure readmissions has become
a national priority, yet which hospital-level processes of care might
effectively accomplish this goal are unknown. To better understand
those care processes currently being used by hospitals in the United
States to lower 30-day readmission rates, the authors created a survey
instrument administered to 100 randomly selected sites participating
in the American Heart Association’s Get With the Guidelines-Heart
Failure quality improvement initiative. The survey explored care processes related to 3 domains: inpatient care, discharge and transitional
care, and general quality improvement. Individual care processes and
domain-level scores were described and tested to ascertain associations with hospital-level 30-day readmission rates. The authors found
a wide variety of care processes used among various institutions.
No individual care processes were reliably associated with reduced
30-day readmission rates. Among the 3 overall domains, only scores
in the discharge and transitional care domain were modestly associated with 30-day readmission rates. The authors conclude that substantial variation in processes to reduce 30-day readmissions among
hospitals reflects widespread uncertainty about how to achieve these
goals. Whether increased attention to discharge and transitional care
processes might result in reduced readmissions requires further study.
Conclusions: A variety of strategies are used by hospitals in an attempt
to improve 30-day readmission rates for patients hospitalized with heart
failure. Although more complete discharge and transitional care processes may be modestly associated with lower 30-day readmission rates,
most current strategies are not associated with lower readmission rates.4
Mode of Action and Effects of Standardized
Collaborative Disease Management on
Mortality and Morbidity in Patients With
Systolic Heart Failure: The Interdisciplinary
Network for Heart Failure (INH) Study
Summary: The present study developed a nurse-coordinated health
care program (HeartNetCare-HF), which pursued telephone-based
monitoring and education in a collaboration between skilled nurses,
general practitioners, and specialists; responded to questions raised by
patients; and provided supervision for caregivers. The program was
evaluated versus usual care in a prospective, randomized, controlled
trial in 715 patients after discharge from hospitalization for cardiac
decompensation. Nurses were asked to document prospectively all
modules executed during contacts, issues requiring counseling, and
subsequent actions taken. The authors hypothesized (1) that the program would have a favorable impact on time to death or rehospitalization (composite primary end point) and improve further secondary
outcomes, including quality of life, and (2) that the study would elucidate the mode of action of the program in individual subjects and
thus help to identify the most important components regarding outcome. Patient compliance with the program was satisfactory. After
180 days, the primary composite end point was neutral. However,
all-cause mortality risk and important surrogates of patient well-being
including quality of life were improved. Application flow in individual
subjects indicated a broad spectrum of patient needs and highlighted
in particular the importance of noncardiac problems in this elderly and
multimorbid population. The findings encourage a multidisciplinary
collaborative approach to comprehensive healthcare strategies that
combine modules selected according to individual patient requirements and risk profile and integrate monitoring technologies with
tailored care for both cardiac and noncardiac problems to achieve sustainable improvement of heart failure outcomes.
Conclusions: The primary end point of this study was neutral.
However, mortality risk and surrogates of well-being improved significantly. Quantitative assessment of patient requirements suggested
that besides (tele)monitoring individualized care considering also
noncardiac problems should be integrated in efforts to achieve more
sustainable improvement in heart failure outcomes.5
Characteristics and Outcome After
Hospitalization for Acute Right Heart Failure in
Patients With Pulmonary Arterial Hypertension
Summary: Although much is known about risk factors for poor outcome
in patients hospitalized with acute left heart failure, much less is known
about the syndrome of acute right heart failure. By using a retrospective
study design, the authors analyzed the characteristics and predictors of
outcome of patients with pulmonary arterial hypertension (PAH) hospitalized with acute right heart failure at Stanford Hospital between June
1999 and September 2009. They found that acute heart failure in patients
with PAH is associated with a significant burden of disease, with a 90-day
mortality or urgent transplantation rate of 18%. Adverse outcomes
occurred during the hospital stay and in the early postdischarge period.
Independent factors strongly associated with an increased likelihood of
mortality or urgent transplantation at 90 days included higher respiratory
rate on admission, renal dysfunction, hyponatremia, and severe tricuspid
regurgitation. These findings have 3 major clinical implications. First,
identification of predictors of poor outcome may guide tailored inotropic
or prostanoid therapy or early referral for lung transplantation. Second,
close follow-up after hospitalization for acute right heart failure would
be recommended because this represents a highly vulnerable period.
Finally, new approaches to management of acute right heart failure in
PAH are needed to reduce the mortality associated with the syndrome.
Conclusions: These results highlight the high mortality after hospitalizations for acute right heart failure in patients with PAH. Factors identifiable within hours of hospitalization may help predict the likelihood
of death or the need for urgent transplantation in patients with PAH.6
Characteristics and Outcomes of Very
Elderly Patients After First Hospitalization
for Heart Failure
Summary: Heart failure is the most common reason for hospitalization among older patients. With the aging population, the number of
older patients hospitalized for heart failure will grow severalfold in
the coming years. Currently, the very elderly—individuals 80 years
and older—represent the fastest-growing segment of the older population. Their numbers are expected to grow to 21 million during the
e50 Circ Heart Fail July 2013
next 40 years. Data on survival and readmission rates after a first heart
failure hospitalization are limited in this segment of the population.
The authors examined trends in mortality rates and heart failure readmissions rates of a national population of veterans 80 years and older
from 1999 to 2008 and found substantial improvement in 30-day and
1-year mortality rates, with the most impressive decreases observed
among those 90 years and older. Although older patients had significantly fewer readmissions for heart failure over time, they continued
to be readmitted frequently for other conditions after their index hospitalization for heart failure. Identifying predictors for readmissions
among the very elderly population will be crucial to treat this rapidly
growing segment of heart failure patients more effectively.
Conclusions: Mortality for very elderly HF patients has improved
over time, but 30-day readmissions remain frequent. Future studies
should identify interventions to reduce cardiac and noncardiac rehospitalization of very elderly HF patients.7
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Care and Outcomes of Hispanic Patients
Admitted With Heart Failure With Preserved or
Reduced Ejection Fraction: Findings From Get
With The Guidelines–Heart Failure
Summary: Although Hispanics comprise the largest ethnic group
in the United States, data on differences between Hispanic patients
with heart failure (HF) with preserved ejection fraction (PEF) and
those with reduced EF (REF) are limited. Using the Get With The
Guidelines database, the present study aimed to compare clinical
characteristics, quality of care, and outcomes between Hispanic and
non-Hispanic whites hospitalized for HF stratified by EF. The authors
also evaluated temporal trends in adherence to process-of-care measures for both groups. From 247 participating hospitals from 2005–
2009, 6117 Hispanics were compared with 71 859 non-Hispanic
whites. Forty-six percent of Hispanics had PEF (EF ≥40%) and 54%
had REF (EF <40%); 55% and 45% of non-Hispanic whites had PEF
and REF, respectively. Relative to non-Hispanic whites, Hispanics
with PEF or REF were more likely to be younger and to have more
cardiometabolic risk factors. Hispanics with PEF were more likely
to have nonischemic cardiomyopathy, whereas those with REF were
more likely to have an ischemic cause. In multivariate analysis, a
lower mortality risk was observed among Hispanics with PEF but
not in Hispanics with REF, compared with non-Hispanic whites. In
all groups, composite performance improved within the 5-year study
period. These findings show that Hispanics with PEF but not those
with REF had better in-hospital survival than non-Hispanic whites,
even after adjusting for age differences. Quality of HF care was similar and improved progressively through time, underscoring the potential benefit of a process-of-care improvement program in advancing
health care delivery, irrespective of race/ethnicity or EF.
Conclusions: Hispanic HF patients with PEF had better in-hospital survival than non-Hispanic whites with PEF. Inpatient mortality was similar between groups with REF. Quality of care was similar and improved
over time irrespective of ethnicity, highlighting the potential benefit of
performance improvement programs in promoting equitable care.8
Admission, Discharge, or Change in B-Type
Natriuretic Peptide and Long-Term Outcomes:
Data From Organized Program to Initiate
Lifesaving Treatment in Hospitalized Patients
With Heart Failure (OPTIMIZE-HF) Linked to
Medicare Claims
Summary: B-type natriuretic peptide (BNP) is associated with
short- and long-term prognosis among patients hospitalized with
decompensated heart failure (HF). It is not known which measure
of BNP (admission, discharge, or the change from admission to discharge) best predicts postdischarge outcomes. The authors analyzed
data from the Organized Program to Initiate Lifesaving Treatment
in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry linked to Medicare claims. The analysis included 7039 patients
≥65 years of age admitted to the hospital with a HF diagnosis, surviving to hospital discharge, with admission and discharge BNP
levels recorded. Observed 1-year mortality and 1-year mortality or
rehospitalization were 35.2% and 79.4%, respectively. The analysis
found that after adjustment for patient characteristics, the model
containing discharge level of BNP performed best to predict 1-year
mortality (c-index, 0.693) and 1-year mortality or rehospitalization
(c-index, 0.606). Moreover, these models can be used to improve
risk classification and model discrimination over models using
only clinical variables (1-year mortality net reclassification index,
5.5%, P<0.0001; integrated discrimination improvement, 0.023,
P<0.0001) and (1-year mortality or rehospitalization net reclassification index, 4.2%, P<0.0001; integrated discrimination improvement, 0.010, P<0.0001). These results suggest potential methods
using BNP to improve risk stratification among HF patients at the
time of hospital discharge and may be useful for identifying those
who would benefit from higher intensity outpatient interventions.
Further research is needed to determine if BNP may also be useful
to guide treatment.
Conclusions: Discharge BNP best predicts 1-year mortality
and/or rehospitalization among older patients hospitalized with
heart failure. Discharge BNP plus clinical variables modestly
improves risk classification and model discrimination for longterm outcomes.9
Predictive Value of Low Relative Lymphocyte
Count in Patients Hospitalized for Heart Failure
With Reduced Ejection Fraction: Insights From
the EVEREST Trial
Summary: The immunological axis is becoming increasingly recognized in the pathophysiology of heart failure (HF). Low lymphocyte counts are known to be predictive of cardiovascular outcomes
in chronic HF, but its prognostic significance in patients hospitalized for HF is presently unclear. In this post hoc analysis of the
Efficacy of Vasopressin Antagonism in Heart Failure Outcome
Study with Tolvaptan (EVEREST) trial, the authors evaluated
3717 patients hospitalized for HF and reduced ejection fraction
with available relative lymphocyte counts at the time of enrollment. Lymphopenia was associated with an overall adverse clinical
profile including older age, higher rates of medical comorbidities, lower use of evidence-based HF therapies, higher natriuretic
peptides and lower ejection fraction, blood pressure, and serum
sodium. However, even after accounting for 22 known clinical risk
factors, lower lymphocyte counts were highly predictive of allcause mortality and composite cardiovascular mortality and HF
hospitalization in the first 100 days postdischarge. Lymphocytes
represent a simple, inexpensive and widely available measure that
may assist clinicians in identifying high-risk patients early during
HF hospitalization. This study adds to the growing body of evidence supporting an interconnection between the immune system
and HF. Future prospective investigations are required to determine
whether lymphocytes represent a marker of disease severity or a
potential target for therapy.
Conclusions: Low relative lymphocyte count during hospitalization for HF is an independent predictor of poor outcomes in
the early postdischarge period, beyond traditional prognostic
indicators.10
The Editors Circulation: Heart Failure Topic Review e51
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Discharge to a Skilled Nursing Facility and
Subsequent Clinical Outcomes Among Older
Patients Hospitalized for Heart Failure
Evaluating Treatment Efficacy by Multiple End
Points in Phase II Acute Heart Failure Clinical
Trials: Analyzing Data Using a Global Method
Summary: After acute hospitalization, many older patients in the
United States are discharged to skilled nursing facilities (SNF).
Medicare benefits cover up to 100 days of SNF care for patients hospitalized for at least 3 days who also have a skilled need. Although
heart failure (HF) is the leading cause of hospitalization and rehospitalization for Medicare patients, subsequent discharge to SNF is
not well described. Therefore, the authors evaluated 15 459 Medicare
beneficiaries also enrolled in the Get With The Guidelines Program
who were ≥65 years of age and discharged to home or SNF after ≥3day hospitalization for HF. They found that 24% were discharged to
an SNF, 22% to home with home health service, and 54% to home
with self-care. SNF use varied widely among hospitals (more than
3-fold difference from 10th to 90th percentile), with rates highest
in the Northeast. Patient factors associated with discharge to SNF
included longer length of stay, advanced age, female sex, higher
ejection fraction, absence of ischemic heart disease, and a variety
of comorbidities. Performance measures were modestly lower for
patients discharged to SNF. Discharge to SNF was associated with
substantial risk for adverse events, with more than half of these
patients dead within 1 year. These findings highlight the need to
better characterize this unique population, understand the SNF care
they receive, and consider whether a different set of quality measures
should be applied to these patients.
Summary: Few new therapies for acute heart failure (AHF) have
been approved since the introduction of furosemide in the late 1960s.
This may be attributed at least in part to challenges in the design and
selection of interventions and doses in phase II AHF studies. Because
only a limited number of patients can be enrolled in phase II clinical
studies, surrogate measures such as wedge pressure, remodeling, or
biomarkers have been used to identify potentially effective therapies.
However, several new drugs with promising results on such surrogate
measures in phase II failed to demonstrate positive effects on clinical outcomes in phase III, mostly because surrogate measures are not
universally correlated with clinical benefit in AHF. Combining clinical
outcomes into a composite in phase II allows simultaneous evaluation
of an intervention’s effect on multiple aspects of the AHF disease process, and might allow identification of therapies that will demonstrate
concordant effects on component outcomes in phase III. The authors
have explored several methods of combining such end points. Because
most clinical outcomes in AHF are only slightly correlated, such a
combined end point approach increases the ability to identify interventions that potentially affect multiple clinical facets of AHF rather than
surrogates. Among the composite approaches evaluated, transforming the end points to a common metric—the z score—and averaging
seems to provide the highest power. The average Z approach allows a
quantitative test of the overall effect on multiple outcomes, potentially
allowing identification of new therapies with beneficial clinical effects
in phase II that can be confirmed in phase III trials.
Conclusions: Discharge to SNF is common among Medicare patients
hospitalized for HF, and these patients face substantial risk for adverse
events, with more than half dead within 1 year. These findings highlight the need to better characterize this unique patient population and
understand the SNF care they receive.11
Outcomes of Children Following a First
Hospitalization for Dilated Cardiomyopathy
Conclusions: Assessing the effects of new therapies on multiple clinical end points using the average Z score enables detection of therapeutic efficacy using sample sizes of 100 to 150 patients per group,
approximately double the power achievable assessing the effects on
dyspnea alone.13
Comparison of Composite Measure
Methodologies for Rewarding Quality of
Care: An Analysis From the American Heart
Association’s Get With The Guidelines Program
Summary: Dilated cardiomyopathy (DCM) in children is a heterogeneous disease with a variable clinical course. Whereas some patients
with DCM can remain relatively clinically stable for several years,
others show a more precipitous decline, leading to death or requiring heart transplantation within 1 to 2 years following diagnosis. The
authors hypothesized that the first hospitalization for DCM represents an inflection point in a patient’s disease trajectory for which
death or the need for cardiac transplantation within 1 year was likely.
Furthermore, the authors hypothesized that certain clinical, laboratory, and echocardiographic findings present at the time of first hospital admission were predictive of hospital and 1-year outcomes.
The results of this study demonstrate that the first hospitalization for
DCM marks a period of high risk for clinical decline, end stage heart
failure, and the need for cardiac transplantation when compared with
studies of pediatric patients with DCM using time of diagnosis as
the study entry point, and that fractional shortening, left ventricular
ejection fraction, uric acid, mixed venous saturation, and atrial filling
pressures may aid in predicting outcomes. The results of this study
may aid practitioners to identify at-risk patients who may benefit
from closer outpatient observation, and, perhaps, earlier consideration for cardiac transplantation.
Summary: Composite performance measures are used to aggregate
multiple discrete metrics into a comprehensive assessment of quality
of care. Although there are multiple approaches to aggregating measures of quality, little is known about the influence of different composite scoring methods on hospital rankings for the care of patients
with acute myocardial infarction. The two principal methods—the
opportunity-based score and the all-or-none approach—generate
highly correlated scores for hospitals caring for patients with acute
myocardial infarction. Although the all-or-none approach yields a
greater dispersion in scores, it is similar to the opportunity-based
method in ranking hospitals. Neither composite scoring method has
a strong correlation with the outcomes of 30-day risk-standardized
mortality or readmission.
Conclusions: The first hospitalization for dilated cardiomyopathy
marks a period of high risk for clinical decline, end stage heart failure, and the need for cardiac transplantation. Echocardiographic
function and hemodynamic and serum measurements may aid in predicting outcomes. Despite medical management, most patients will
be rehospitalized and/or require cardiac transplantation within 1 year
of admission.12
Depression and Rehospitalization Following
Acute Myocardial Infarction
Conclusions: The opportunity-based and all-or-none coronary artery
disease composite indices are highly correlated and yield similar
ranking of the top and bottom quintiles of hospitals. The two methods
provide similarly modest correlations with 30-day mortality, but not
readmission.14
Summary: Depression is associated with adverse outcomes in
patients with coronary artery disease. Whether Diagnostic and
e52 Circ Heart Fail July 2013
Statistical Manual for Mental Disorders, Fourth Edition, depressive
disorders (minor or major depression) predict rehospitalization after
acute myocardial infarction is unknown. Minor and major depression
increase the risk of rehospitalization and emergency department visits
after acute myocardial infarction. This result is consistent whether
depression is assessed by symptom questionnaire or by a diagnostic
interview. Multivariable models that predict the risk of rehospitalization after acute myocardial infarction should include depression.
Conclusions: Depressive disorders increase the risk of rehospitalization after AMI. Future work should focus on developing multivariable
models to predict risk of rehospitalization after AMI, and depression
should be included in these.15
Identifying Patients Hospitalized With Heart
Failure at Risk for Unfavorable Future Quality
of Life
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Summary: Communicating expectations for the future to enable
shared decision-making is desired by patients with heart failure and
is endorsed by heart failure practice guidelines. Whereas multiple risk
models exist for survival after heart failure hospitalization, no similar
models exist that also estimate future quality of life, despite its importance to patients with symptomatic heart failure. Readily available
clinical characteristics known at the time of hospital discharge can
help identify patients at high risk for persistently unfavorable health
status or death during the next 6 months. Traditional predictors of
death and hospital readmission (particularly natriuretic peptide levels) are less strongly associated with future health status; baseline
health status is the strongest predictor of future health status.
Conclusions: At the time of hospital discharge, readily available
clinical characteristics are associated with HF patients at high risk
for persistently unfavorable QoL or death during the next 6 months.
Such information can target patients for whom aggressive treatment
options (eg, devices or transplantation) and/or end-of-life discussions
should be strongly considered before hospital discharge.16
Who Has Higher Readmission Rates for Heart
Failure, and Why?: Implications for Efforts to
Improve Care Using Financial Incentives
Summary: Decreasing readmissions is seen as having the potential
to lower costs and improve quality simultaneously and therefore has
become an important target for policymakers. There is significant variability in hospitals’ performance on readmission rates across the nation;
little is known about why some hospitals perform well, whereas others
perform poorly. Legislative efforts in this area, including the recently
passed Patient Protection and Affordable Care Act, focus on reducing
payments to those with the highest readmission rates; if poorly performing hospitals are also resource-poor, either financially or clinically,
these payment reductions could lead to an increase in existing gaps in
performance. Hospitals with limited resources, either financial, clinical,
or both, namely publicly owned hospitals, hospitals located in counties
with low median income, hospitals with fewer cardiac capabilities or
lower nurse staffing levels, and small hospitals, had higher readmission
rates for heart failure. Thus, because some of the most financially and
clinically resource-poor hospitals in the country are among the worst
performers for heart failure readmissions, quality improvement efforts
that rely on penalties and rewards may further widen the quality gap.
Conclusions: Given that many poor-performing hospitals also have
fewer resources, they may suffer disproportionately from financial
penalties for high readmission rates. As we seek to improve care for
patients with heart failure, we should ensure that penalties for poor
performance do not worsen disparities in quality of care.17
Incremental Value of Clinical Data Beyond
Claims Data in Predicting 30-Day Outcomes
After Heart Failure Hospitalization
Summary: Risk-adjustment models currently used by the Centers for
Medicare and Medicaid Services incorporate data exclusively from
administrative claims. Results from these models are used for hospital profiling and public reporting efforts. Given recent attention on
electronic health records, it may soon be possible to incorporate clinical data into claims-only models if the incremental values of these
data are warranted.
Conclusions: Adding clinical data to claims data for heart failure
hospitalizations significantly improved prediction of mortality, and
shifted mortality performance rankings for a substantial proportion of
hospitals. Clinical data did not meaningfully improve the discrimination of the readmission model, and had little effect on performance
rankings.18
Get With The Guidelines Program Participation,
Process of Care, and Outcome for Medicare
Patients Hospitalized With Heart Failure
Summary: There is variation in process of care and outcome (30day readmission and mortality) among US hospitals after a hospitalization for heart failure. The Centers for Medicare and Medicaid
Services (CMS) publicly reports process of care and outcome of
Medicare beneficiaries for individual US hospitals. The AHA has
created a quality improvement program for hospitals called Get With
The Guidelines. Hospitals participating in Get With The Guidelines
had better process of care, as defined by CMS, when compared with
hospitals not participating in the program. Readmission rates may
be slightly lower among hospitals participating in Get With The
Guidelines compared with nonparticipating hospitals.
Conclusions: Although there was evidence that hospitals enrolled
in the GTWG-HF program demonstrated better processes of care
than other hospitals, there were few clinically important differences in outcomes. Further identification of opportunities to
improve outcomes, and inclusion of these metrics in GTWG-HF,
may further support the value of GTWG-HF in improving care for
patients with HF.19
Introduction of the Tools for Economic Analysis
of Patient Management Interventions in
Heart Failure Costing Tool: A User-Friendly
Spreadsheet Program to Estimate Costs of
Providing Patient-Centered Interventions
Summary: Published economic evaluations of disease management
programs apply a variety of approaches to cost estimation, making
comparisons across studies difficult. High-quality, comprehensive
cost estimates are essential for informed decision making about
program budgeting, negotiating payments for services, and conducting cost-effectiveness analyses to evaluate the value of patient-centered interventions. The authors developed the Tools for Economic
Analysis of Patient Management Interventions in Heart Failure
Costing Tool for use by research groups and healthcare managers
to estimate costs of patient-focused programs. The tool facilitates
data collection and cost estimation for personnel, facilities, equipment, supplies, patient incentives, miscellaneous items, and start-up
activities. Adoption of the tool and systematic reporting of resulting cost estimates would lead to the availability of standardized cost
estimates across different types of patient-focused interventions for
heart failure or other conditions.
The Editors Circulation: Heart Failure Topic Review e53
Conclusions: The TEAM-HF Costing Tool could prove to be a valuable resource for researchers and healthcare managers to generate
comprehensive cost estimates of patient-centered interventions in
heart failure or other conditions for conducting high-quality economic evaluations and making well-informed healthcare management decisions.20
Mortality and Readmission of Patients With
Heart Failure, Atrial Fibrillation, or Coronary
Artery Disease Undergoing Noncardiac Surgery:
An Analysis of 38 047 Patients
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Summary: Heart failure (HF), coronary artery disease (CAD) and
atrial fibrillation (AF) are the 3 most common chronic cardiovascular conditions, affecting a broad cross-section of the population. An
increasing number of patients with HF, CAD, and AF survive longer
and undergo noncardiac surgery. Although the perioperative risk for
the patients with CAD has been well described, the risk for patients
with HF or AF is less well defined. Using a cohort of >37 000 patients
with HF, CAD, or AF from Alberta, Canada, the authors found that
the risk for 30-day postoperative mortality was 3 times higher for
those with HF compared with those with CAD, and nearly twice as
high for AF compared with CAD. This difference persisted even after
adjustment for patient and hospital variables.
Conclusions: Although current perioperative risk prediction models
place greater emphasis on CAD than HF or AF, patients with HF or
AF have a significantly higher risk of postoperative mortality than
patients with CAD, and even minor procedures carry a risk higher
than previously appreciated.21
The Need for Multiple Measures of Hospital
Quality: Results From the Get With The
Guidelines–Heart Failure Registry of the
American Heart Association
Summary: Attention to the quality and value of health care has
increased significantly in the United States with the passage of the
Affordable Care Act. Heart failure is one of the main areas targeted
for improvement in quality and costs nationally. Prior studies have
shown major gaps in the use of best therapies and outcomes are poor.
Although there is attention to improving processes of care and outcomes, it is unclear how these metrics of quality correlate with one
another or whether hospitals should focus on one area to improve
overall quality. This uncertainity also presents challenges to the
public, hospitals, and policy makers in designing and participating
in pay-for-performance health policies. By using data from the Get
With The Guidelines–Heart Failure (GWTG-HF) registry linked with
Medicare claims, the authors examined how profiling of hospitals is
affected by different measures of quality of care.
Conclusions: Agreement between different methods of ranking hospital-based quality of care and 30-day mortality or readmission rankings was poor. Profiling quality of care will require multidimensional
ranking methods and/or additional measures.22
Multisite Randomized Trial of a Single-Session
Versus Multisession Literacy-Sensitive SelfCare Intervention for Patients With Heart Failure
Summary: This article describes the comparative effectiveness of
2 types of a heart failure self-care training program: single-session
training versus multisession training. In a diverse population across
4 clinical sites, there was no difference in rate of hospitalization or
death between the interventions. However, patient literacy was an
important factor in the effect of the intervention. Patients with low
literacy seemed to benefit from the multisession intervention compared with the single-session intervention, but patients with higher
literacy did not benefit. Although self-care training for heart failure
is an important component of guideline-based care for all patients, it
may be important to focus our most intensive resources via ongoing
training for patients with low literacy skills.
Conclusions: Overall, an intensive multisession intervention did not
change clinical outcomes compared with a single-session intervention. People with low literacy seem to benefit more from multisession
interventions than people with higher literacy.23
Outcomes of Medicare Beneficiaries
Undergoing Catheter Ablation for Atrial
Fibrillation
Summary: Catheter ablation is increasingly used in older patients
with atrial fibrillation for whom medical therapy has failed. However,
clinical trials of catheter ablation have enrolled relatively young
patients with limited comorbidity. To describe the use of catheter
ablation and associated outcomes in older persons with atrial fibrillation, the authors conducted a retrospective cohort study of 15 423
Medicare beneficiaries who underwent catheter ablation for atrial
fibrillation between July 2007 and December 2009. For every 1000
procedures, there were 17 cases of hemopericardium requiring intervention, 8 cases of stroke, and 8 deaths within 30 days. More than
40% of patients required hospitalization within 1 year; however,
atrial fibrillation or atrial flutter was the primary discharge diagnosis
in only 38.4% of cases. Eleven percent of patients underwent repeat
ablation within 1 year. Renal impairment, age ≥80 years, and heart
failure were major risk factors for mortality within 1 year after catheter ablation. Whereas major complications after catheter ablation
were associated with advanced age, they were fairly infrequent, and
few patients underwent repeat ablation. Randomized trials are needed
to assess the efficacy of catheter ablation in older adults and to better
inform risk-benefit calculations for older patients with drug-refractory, symptomatic atrial fibrillation.
Conclusions: Major complications after catheter ablation for atrial
fibrillation were associated with advanced age but were fairly infrequent. Few patients underwent repeat ablation. Randomized trials
are needed to inform risk-benefit calculations for older persons with
drug-refractory, symptomatic atrial fibrillation.24
Echocardiographic Variables After Left
Ventricular Assist Device Implantation
Associated With Adverse Outcome
Summary: A successful acute outcome after left ventricular assist
device (LVAD) implantation depends on patient selection and the
technical difficulty of surgery. However, how we treat our patients
and LVAD settings may affect the patient outcome beyond the postsurgical period. In the present study, the authors retrospectively analyzed several variables in echocardiographic examinations performed
30 days after LVAD implant for their association with a compound
end point (90-day mortality, readmission for heart failure, or New
York Heart Association class III or higher at the end of the 90-day
period). They found that mortality and persistent heart failure after
LVAD surgery are predominantly associated with echocardiographic
variables assessing the efficiency of unloading of the left ventricle
and atrium, and those assessing right ventricular function. The only
right ventricular variable significantly associated with adverse outcome was a decreased tissue Doppler velocity of the lateral tricuspid annulus. The variables assessing LV unloading, associated with
adverse outcome were a high estimated left atrial pressure (>15
e54 Circ Heart Fail July 2013
mm Hg) and a short mitral inflow deceleration time divided by the
E wave velocity (<2 ms/[cm/s]). An interventricular septum deviated
to the left was associated with worse outcome as well. In conclusion,
echocardiographic variables suggestive of efficient but not excessive
LV unloading are associated with favorable mid and long-term outcome after LVAD surgery.
Conclusions: Mortality and heart failure after LVAD surgery seem
to be predominantly determined by echocardiographic evidence of
inefficient unloading of the left ventricle and persistence of right ventricular dysfunction. Increased estimated LA pressure and short MDI
are associated with worse mid term outcome. Leftward deviation of
the septum is associated with worse outcome as well.25
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Circulation: Heart Failure Editors' Picks: Most Important Articles in Readmissions
Robb D. Kociol
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Circ Heart Fail. 2013;6:e48-e54
doi: 10.1161/CIRCHEARTFAILURE.113.000572
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