Background:
Patients hospitalized with heart failure (HF) are often treated for concomitant respiratory disease due to diagnostic uncertainty or coexisting conditions. Testing with natriuretic peptides, chest radiograph (CXR), and transthoracic echocardiogram (TTE) is common and may influence these treatment decisions. We examined hospital variation in diagnostic testing among inpatients with HF and how testing relates to additional treatment for coexisting respiratory conditions.
Methods:
We identified hospitalizations with a principal discharge diagnosis of HF from 2009-2010 Premier, Inc. hospitals and age>18y, known admission source, non-pediatric attending physician, receipt of HF treatment (loop diuretics, inotropes, or IV vasodilators), and >2 day hospital stay. We excluded hospitalizations with present-on-admission codes for infections besides pneumonia or inflammatory, allergic, or autoimmune conditions besides COPD. For hospital days 1-2, we calculated each hospital’s proportion of admissions receiving selected diagnostic tests (natriuretic peptides, CXR, TTE) and respiratory treatments (short-acting inhaled bronchodilators, antibiotics, high-dose steroids). Treatment categories were mutually exclusive. The proportion of admissions receiving diagnostic testing and respiratory treatments was calculated for each hospital, and summary statistics were reported across hospitals.
Results:
We identified 164,494 HF hospitalizations among 368 hospitals. Natriuretic peptide testing across hospitals was done in 81% to 92% (IQR; median 87%) of HF admissions, CXR testing was done in 87% to 94% (IQR; median 91%), and TTE testing was done in 39% to 56% (IQR; median 48%). The median proportion of hospitalizations receiving diagnostic testing at the hospital level was similar among patients treated only for HF and those also treated with at least one respiratory therapy (respectively, 88% vs. 90% for natriuretic peptides, 90% vs. 93% for CXR, and 51% vs. 49% for TTE). Detailed description of diagnostic testing among each treatment group at the hospital level is provided in the accompanying table.
Conclusion:
Hospital use of relatively inexpensive diagnostic tests among HF inpatients including natriuretic peptides and CXR is frequent with little inter-hospital variation. In contrast, more expensive testing with TTE is less common though more variable across hospitals. Although often ordered, natriuretic peptides, CXR, and TTE do not appear to influence physicians’ decisions to treat only for heart failure or also for potential coexisting respiratory conditions.
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