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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.) Downloaded from http://circheartfailure.ahajournals.org/ by guest on May 2, 2017 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 Downloaded from http://circheartfailure.ahajournals.org/ by guest on May 2, 2017 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 Downloaded from http://circheartfailure.ahajournals.org/ by guest on May 2, 2017 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 Downloaded from http://circheartfailure.ahajournals.org/ by guest on May 2, 2017 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 Downloaded from http://circheartfailure.ahajournals.org/ by guest on May 2, 2017 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 Downloaded from http://circheartfailure.ahajournals.org/ by guest on May 2, 2017 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 References Downloaded from http://circheartfailure.ahajournals.org/ by guest on May 2, 2017 1. Allen LA, Smoyer Tomic KE, Smith DM, Wilson KL, Agodoa I. Rates and predictors of 30-day readmission among commercially insured and Medicaid-enrolled patients hospitalized with systolic heart failure. Circ Heart Fail. 2012;5:672–679. 2. 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Circulation: Heart Failure Editors' Picks: Most Important Articles in Readmissions Robb D. Kociol Downloaded from http://circheartfailure.ahajournals.org/ by guest on May 2, 2017 Circ Heart Fail. 2013;6:e48-e54 doi: 10.1161/CIRCHEARTFAILURE.113.000572 Circulation: Heart Failure is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2013 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-3289. Online ISSN: 1941-3297 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circheartfailure.ahajournals.org/content/6/4/e48 Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation: Heart Failure can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. 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