Abstract 109: In-Hospital Worsening Heart Failure is Associated With Poor Patient Outcomes and Increased Health Care Utilization

Background: A subset of patients hospitalized with acute heart failure (AHF) experiences worsening clinical status while hospitalized and require escalation of therapy. This phenomenon, termed in-hospital worsening heart failure (WHF), is an endpoint for many clinical trials but limited data exist on the prevalence of WHF in clinical practice and associated outcomes. Methods: We analyzed inpatient data from Acute Decompensated Heart Failure National Registry (ADHERE) linked to Medicare claims data to describe outcomes and health care utilization of patients that developed WHF. In-hospital WHF was defined by any of the following: use of inotropes or intravenous vasodilators >12 hours after admission; initiation of mechanical circulatory support, hemodialysis, or ventilation after the first inpatient day; or transfer to the ICU after initial admission to a regular hospital ward. Patients with WHF were compared to those with an uncomplicated hospital course and those that had a complicated hospital presentation, defined as requiring the above advanced therapies on arrival. Results: The study population consisted of 63,727 patients hospitalized between 01/2001 and 12/2004. Of these, WHF developed in 7032 (11%), 15,361 (24%) presented with a complicated presentation and 41,334 (65%) with an uncomplicated hospital course. Observed mean length of stay was longest in the WHF cohort (10.0 days) followed by complicated presentation (6.3 days) and uncomplicated course (4.8 days). Patients with WHF also had higher observed rates of mortality and all-cause readmission at 30 days and 1 year after discharge (P<0.001; Figure). The adjusted hazard ratio for 30-day mortality was 2.56 (99% CI 2.34-2.80) for WHF compared to an uncomplicated hospital course and 1.29 (1.17-1.42) compared to a complicated presentation. Medicare payments were also higher for patients with WHF with an adjusted cost ratio at 30 days of 1.35 (99% CI 1.24-1.46) for WHF compared to an uncomplicated hospital course and 1.11 (1.02-1.22) compared to a complicated presentation. Conclusion: In a large, multicenter registry, in-hospital WHF was common and associated with higher rates of mortality, all-cause readmission, and Medicare payments. Preventing and treating WHF represents an important therapeutic target among patients hospitalized with AHF.

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The Effect of Noninvasive Telemonitoring for Chronic Heart Failure on Health Care Utilization: Systematic Review (Preprint)

10.2196/preprints.26744 ◽

2020 ◽

Author(s):

Stefan L Auener ◽

Toine E P Remers ◽

Simone A van Dulmen ◽

Gert P Westert ◽

Rudolf B Kool ◽

...

Keyword(s):

Heart Failure ◽

Health Care ◽

Chronic Heart Failure ◽

Health Care Utilization ◽

Health Care Costs ◽

Emergency Department Visits ◽

Care Utilization ◽

Controlled Trials ◽

Randomized Controlled ◽

Care Costs

BACKGROUND Chronic heart failure accounts for approximately 1%-2% of health care expenditures in most developed countries. These costs are primarily driven by hospitalizations and comorbidities. Telemonitoring has been proposed to reduce the number of hospitalizations and decrease the cost of treatment for patients with heart failure. However, the effects of telemonitoring on health care utilization remain unclear. OBJECTIVE This systematic review aims to study the effect of telemonitoring programs on health care utilization and costs in patients with chronic heart failure. We assess the effect of telemonitoring on hospitalizations, emergency department visits, length of stay, hospital days, nonemergency department visits, and health care costs. METHODS We searched PubMed, Embase, and Web of Science for randomized controlled trials and nonrandomized studies on noninvasive telemonitoring and health care utilization. We included studies published between January 2010 and August 2020. For each study, we extracted the reported data on the effect of telemonitoring on health care utilization. We used <i>P</i><.05 and CIs not including 1.00 to determine whether the effect was statistically significant. RESULTS We included 16 randomized controlled trials and 13 nonrandomized studies. Inclusion criteria, population characteristics, and outcome measures differed among the included studies. Most studies showed no effect of telemonitoring on health care utilization. The number of hospitalizations was significantly reduced in 38% (9/24) of studies, whereas emergency department visits were reduced in 13% (1/8) of studies. An increase in nonemergency department visits (6/9, 67% of studies) was reported. Health care costs showed ambiguous results, with 3 studies reporting an increase in health care costs, 3 studies reporting a reduction, and 4 studies reporting no significant differences. Health care cost reductions were realized through a reduction in hospitalizations, whereas increases were caused by the high costs of the telemonitoring program or increased health care utilization. CONCLUSIONS Most telemonitoring programs do not show clear effects on health care utilization measures, except for an increase in nonemergency outpatient department visits. This may be an unwarranted side effect rather than a prerequisite for effective telemonitoring. The consequences of telemonitoring on nonemergency outpatient visits should receive more attention from regulators, payers, and providers. This review further demonstrates the high clinical and methodological heterogeneity of telemonitoring programs. This should be taken into account in future meta-analyses aimed at identifying the effective components of telemonitoring programs.

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Validation of the “Doorbell Test”: A Novel Functional Test of Frailty and Clinical Status After Acute Decompensated Heart Failure

Heart Lung and Circulation ◽

10.1016/j.hlc.2019.08.010 ◽

2020 ◽

Vol 29 (7) ◽

pp. 1054-1062

Author(s):

James E. Gunton ◽

Savvy Nandal ◽

Julieanne Jones ◽

Derek P. Chew ◽

Thomas H. Marwick ◽

...

Keyword(s):

Heart Failure ◽

Acute Decompensated Heart Failure ◽

Clinical Status ◽

Decompensated Heart Failure ◽

Functional Test

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Health-Care Utilization After Hospice Enrollment in Patients With Heart Failure and Cancer

American Journal of Hospice and Palliative Medicine® ◽

10.1177/1049909116688209 ◽

2017 ◽

Vol 35 (2) ◽

pp. 229-235 ◽

Cited By ~ 2

Author(s):

Meredith A. MacKenzie ◽

Alexandra Hanlon

Keyword(s):

Heart Failure ◽

Health Care ◽

Health Care Utilization ◽

Emergency Service ◽

Service Use ◽

Emergency Services ◽

Hospice Care ◽

Care Utilization ◽

Patients With Heart Failure ◽

Utilization Patterns

This study aimed to examine the role of diagnosis in health-care utilization patterns after hospice enrollment. Using 2007 National Home and Hospice Care Survey data from hospice patients with heart failure (n = 311) and cancer (n = 946), we analyzed emergency service use and discharge to hospital via logistic regression pre- and postpropensity score matching. Prematching, patients with heart failure had twice the odds of emergency services use than patients with cancer ( P < .001) and twice the odds of discharge to hospital ( P = .02). Differences were reduced postmatching for emergency service use (odds ratio [OR]: 1.6, P = .05) and eliminated for discharge to hospital (OR: 1.32, P = .45). Health-care utilization correlates included diagnosis, place of care, and advance directives. Attention to the unique needs of patients with heart failure is needed, along with improved advanced care planning.

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The Association Between Life-Space and Health Care Utilization in Older Adults with Heart Failure

The Journals of Gerontology Series A ◽

10.1093/gerona/glv076 ◽

2015 ◽

Vol 70 (11) ◽

pp. 1442-1447 ◽

Cited By ~ 9

Author(s):

Alexander X. Lo ◽

Kellie L. Flood ◽

Richard E. Kennedy ◽

Vera Bittner ◽

Patricia Sawyer ◽

...

Keyword(s):

Heart Failure ◽

Older Adults ◽

Health Care ◽

Health Care Utilization ◽

Care Utilization ◽

Life Space

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Implementation of a Cardiogenic Shock Team and Clinical Outcomes (INOVA-SHOCK Registry): Observational and Retrospective Study (Preprint)

10.2196/preprints.9761 ◽

2018 ◽

Author(s):

Behnam Tehrani ◽

Alexander Truesdell ◽

Ramesh Singh ◽

Charles Murphy ◽

Patricia Saulino

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Acute Myocardial Infarction ◽

Cardiogenic Shock ◽

Clinical Outcomes ◽

Mechanical Circulatory Support ◽

Acute Decompensated Heart Failure ◽

Survival Rates ◽

Decompensated Heart Failure ◽

Circulatory Support

BACKGROUND The development and implementation of a Cardiogenic Shock initiative focused on increased disease awareness, early multidisciplinary team activation, rapid initiation of mechanical circulatory support, and hemodynamic-guided management and improvement of outcomes in cardiogenic shock. OBJECTIVE The objectives of this study are (1) to collect retrospective clinical outcomes for acute decompensated heart failure cardiogenic shock and acute myocardial infarction cardiogenic shock, and compare current versus historical survival rates and clinical outcomes; (2) to evaluate Inova Heart and Vascular Institute site specific outcomes before and after initiation of the Cardiogenic Shock team on January 1, 2017; (3) to compare outcomes related to early implementation of mechanical circulatory support and hemodynamic-guided management versus historical controls; (4) to assess survival to discharge rate in patients receiving intervention from the designated shock team and (5) create a clinical archive of Cardiogenic Shock patient characteristics for future analysis and the support of translational research studies. METHODS This is an observational, retrospective, single center study. Retrospective and prospective data will be collected in patients treated at the Inova Heart and Vascular Institute with documented cardiogenic shock as a result of acute decompensated heart failure or acute myocardial infarction. This registry will include data from patients prior to and after the initiation of the multidisciplinary Cardiogenic Shock team on January 1, 2017. Clinical outcomes associated with early multidisciplinary team intervention will be analyzed. In the study group, all patients evaluated for documented cardiogenic shock (acute decompensated heart failure cardiogenic shock, acute myocardial infarction cardiogenic shock) treated at the Inova Heart and Vascular Institute by the Cardiogenic Shock team will be included. An additional historical Inova Heart and Vascular Institute control group will be analyzed as a comparator. Means with standard deviations will be reported for outcomes. For categorical variables, frequencies and percentages will be presented. For continuous variables, the number of subjects, mean, standard deviation, minimum, 25th percentile, median, 75th percentile and maximum will be reported. Reported differences will include standard errors and 95% CI. RESULTS Preliminary data analysis for the year 2017 has been completed. Compared to a baseline 2016 survival rate of 47.0%, from 2017 to 2018, CS survival rates were increased to 57.9% (58/110) and 81.3% (81/140), respectively (P=.01 for both). Study data will continue to be collected until December 31, 2018. CONCLUSIONS The preliminary results of this study demonstrate that the INOVA SHOCK team approach to the treatment of Cardiogenic Shock with early team activation, rapid initiation of mechanical circulatory support, hemodynamic-guided management, and strict protocol adherence is associated with superior clinical outcomes: survival to discharge and overall survival when compared to 2015 and 2016 outcomes prior to Shock team initiation. What may limit the generalization of these results of this study to other populations are site specific; expertise of the team, strict algorithm adherence based on the INOVA SHOCK protocol, and staff commitment to timely team activation. Retrospective clinical outcomes (acute decompensated heart failure cardiogenic shock, acute myocardial infarction cardiogenic shock) demonstrated an increase in current survival rates when compared to pre-Cardiogenic Shock team initiation, rapid team activation and diagnosis and timely utilization of mechanical circulatory support. CLINICALTRIAL ClinicalTrials.gov NCT03378739; https://clinicaltrials.gov/ct2/show/NCT03378739 (Archived by WebCite at http://www.webcitation.org/701vstDGd)

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The Effect of Noninvasive Telemonitoring for Chronic Heart Failure on Health Care Utilization: Systematic Review

Journal of Medical Internet Research ◽

10.2196/26744 ◽

2021 ◽

Vol 23 (9) ◽

pp. e26744

Author(s):

Stefan L Auener ◽

Toine E P Remers ◽

Simone A van Dulmen ◽

Gert P Westert ◽

Rudolf B Kool ◽

...

Keyword(s):

Heart Failure ◽

Health Care ◽

Chronic Heart Failure ◽

Health Care Utilization ◽

Health Care Costs ◽

Emergency Department Visits ◽

Care Utilization ◽

Controlled Trials ◽

Randomized Controlled ◽

Care Costs

Background Chronic heart failure accounts for approximately 1%-2% of health care expenditures in most developed countries. These costs are primarily driven by hospitalizations and comorbidities. Telemonitoring has been proposed to reduce the number of hospitalizations and decrease the cost of treatment for patients with heart failure. However, the effects of telemonitoring on health care utilization remain unclear. Objective This systematic review aims to study the effect of telemonitoring programs on health care utilization and costs in patients with chronic heart failure. We assess the effect of telemonitoring on hospitalizations, emergency department visits, length of stay, hospital days, nonemergency department visits, and health care costs. Methods We searched PubMed, Embase, and Web of Science for randomized controlled trials and nonrandomized studies on noninvasive telemonitoring and health care utilization. We included studies published between January 2010 and August 2020. For each study, we extracted the reported data on the effect of telemonitoring on health care utilization. We used P<.05 and CIs not including 1.00 to determine whether the effect was statistically significant. Results We included 16 randomized controlled trials and 13 nonrandomized studies. Inclusion criteria, population characteristics, and outcome measures differed among the included studies. Most studies showed no effect of telemonitoring on health care utilization. The number of hospitalizations was significantly reduced in 38% (9/24) of studies, whereas emergency department visits were reduced in 13% (1/8) of studies. An increase in nonemergency department visits (6/9, 67% of studies) was reported. Health care costs showed ambiguous results, with 3 studies reporting an increase in health care costs, 3 studies reporting a reduction, and 4 studies reporting no significant differences. Health care cost reductions were realized through a reduction in hospitalizations, whereas increases were caused by the high costs of the telemonitoring program or increased health care utilization. Conclusions Most telemonitoring programs do not show clear effects on health care utilization measures, except for an increase in nonemergency outpatient department visits. This may be an unwarranted side effect rather than a prerequisite for effective telemonitoring. The consequences of telemonitoring on nonemergency outpatient visits should receive more attention from regulators, payers, and providers. This review further demonstrates the high clinical and methodological heterogeneity of telemonitoring programs. This should be taken into account in future meta-analyses aimed at identifying the effective components of telemonitoring programs.

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A role for the Reitan catheter pump for percutaneous cardiac circulatory support of patients presenting acute congestive heart failure with low output and renal dysfunction?

Future Cardiology ◽

10.2217/fca-2019-0080 ◽

2020 ◽

Vol 16 (3) ◽

pp. 159-164

Author(s):

Julien Regamey ◽

Nicolas Barras ◽

Marco Rusca ◽

Roger Hullin

Keyword(s):

Heart Failure ◽

Congestive Heart Failure ◽

Renal Function ◽

Renal Dysfunction ◽

Impaired Renal Function ◽

Acute Decompensated Heart Failure ◽

Vascular Complications ◽

Decompensated Heart Failure ◽

Circulatory Support ◽

Heart Failure Patients

Outcomes in acute decompensated heart failure remain poor, in particular when patients present with impaired renal function. Recent results indicate that treatment of acute decompensated heart failure patients with the Reitan catheter pump not only increases cardiac index, but also improves renal function resulting in maintained increase of diuresis. These favorable effects were achieved without significant hemolysis, bleeding or vascular complications suggesting that Reitan catheter pump treatment has the potential to facilitate recovery from acute decompensated heart failure with low output and complicated by renal dysfunction.

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Receiving care according to national heart failure guidelines is associated with lower total costs: an observational study in Region Halland, Sweden

European Heart Journal - Quality of Care and Clinical Outcomes ◽

10.1093/ehjqcco/qcaa020 ◽

2020 ◽

Author(s):

Zayed M Yasin ◽

Philip D Anderson ◽

Markus Lingman ◽

Japneet Kwatra ◽

Awais Ashfaq ◽

...

Keyword(s):

Heart Failure ◽

Health Care ◽

Observational Study ◽

Health Care Utilization ◽

Inpatient Care ◽

Quality Care ◽

Prescribing Patterns ◽

Care Utilization ◽

Chronic Obstructive ◽

Obstructive Pulmonary Disease

Abstract Aims Patients with heart failure (HF) have high costs, morbidity, and mortality, but it is not known if appropriate pharmacotherapy (AP), defined as compliance with international evidence-based guidelines, is associated with improved costs and outcomes. The purpose of this study was to evaluate HF patients’ health care utilization, cost and outcomes in Region Halland (RH), Sweden, and if AP was associated with lower costs. Methods and results A total of 5987 residents of RH in 2016 carried HF diagnoses. Costs were assigned to all health care utilization (inpatient, outpatient, emergency department, primary health care, and medications) using a Patient Encounter Costing methodology. Care of HF patients cost €58.6 M, (€9790/patient) representing 8.7% of RH’s total visit expenses and 14.9% of inpatient care (IPC) expenses. Inpatient care represented 57.2% of this expenditure, totalling €33.5 M (€5601/patient). Receiving AP was associated with significantly lower costs, by €1130 per patient (P < 0.001, 95% confidence interval 574–1687). Comorbidities such as renal failure, diabetes, chronic obstructive pulmonary disease, and cancer were significantly associated with higher costs. Conclusion Heart failure patients are heavy users of health care, particularly IPC. Receiving AP is associated with lower costs even adjusting for comorbidities, although causality cannot be proven from an observational study. There may be an opportunity to decrease overall costs and improve outcomes by improving prescribing patterns and associated high-quality care.

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Heart Failure

10.2310/fm.1409 ◽

2020 ◽

Author(s):

Sachin P Shah ◽

Mandeep R. Mehra

Keyword(s):

Heart Failure ◽

Chronic Heart Failure ◽

Ejection Fraction ◽

Acute Decompensated Heart Failure ◽

Heart Association ◽

Decompensated Heart Failure ◽

Advanced Heart Failure ◽

Circulatory Support ◽

Preserved Ejection Fraction ◽

Reduced Ejection Fraction

Heart failure is a syndrome related to abnormal cardiac performance with a consequence of impaired cardiac output at rest or with exertion and/or congestion, which usually leads to symptoms of fatigue, dyspnea, and edema. The syndrome is characterized by various phenotypes related to a vast array of etiologies with diverse management targets. The current broad categorization of heart failure separates patients based on ejection fraction. Further description of the phenotype beyond ejection fraction is imperative to correctly identify the etiology of heart failure and, ultimately, to choose medical, device, and surgical therapies appropriately. This review covers the epidemiology of heart failure, defining the phenotype and etiology of heart failure, recognition and management of acute decompensated heart failure, management of chronic heart failure with a reduced ejection fraction, implantable cardioverter-defibrillators in heart failure with a reduced ejection fraction, management of heart failure with a preserved ejection fraction, and advanced heart failure. Figures show the evolution of therapy in chronic heart failure from the symptom-directed model, the complex pathophysiology and principal aberrations underlying heart failure with preserved ejection fraction, and concepts underlying surgical therapy in advanced heart failure using Laplace’s law. Tables list various etiologies of heart failure; sensitivity and specificity of clinical, biomarker, and radiographic data in the diagnosis of acute decompensated heart failure; drugs and devices with a demonstrated survival benefit in heart failure with a reduced ejection fraction; neurohormonal antagonist dosing in heart failure with a reduced ejection fraction; randomized, placebo-controlled trials in heart failure with a preserved ejection fraction; categorization of heart failure according to American Heart Association/American College of Cardiology heart failure stage, New York Heart Association functional class, and Interagency Registry for Mechanically Assisted Circulatory Support level; and poor prognostic indicators in heart failure. This review contains 4 highly rendered figures, 8 tables, and 114 references.

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Heart Failure

10.2310/tywc.1409 ◽

2018 ◽

Author(s):

Sachin P Shah ◽

Mandeep R. Mehra

Keyword(s):

Heart Failure ◽

Chronic Heart Failure ◽

Ejection Fraction ◽

Acute Decompensated Heart Failure ◽

Heart Association ◽

Decompensated Heart Failure ◽

Advanced Heart Failure ◽

Circulatory Support ◽

Preserved Ejection Fraction ◽

Reduced Ejection Fraction

Heart failure is a syndrome related to abnormal cardiac performance with a consequence of impaired cardiac output at rest or with exertion and/or congestion, which usually leads to symptoms of fatigue, dyspnea, and edema. The syndrome is characterized by various phenotypes related to a vast array of etiologies with diverse management targets. The current broad categorization of heart failure separates patients based on ejection fraction. Further description of the phenotype beyond ejection fraction is imperative to correctly identify the etiology of heart failure and, ultimately, to choose medical, device, and surgical therapies appropriately. This review covers the epidemiology of heart failure, defining the phenotype and etiology of heart failure, recognition and management of acute decompensated heart failure, management of chronic heart failure with a reduced ejection fraction, implantable cardioverter-defibrillators in heart failure with a reduced ejection fraction, management of heart failure with a preserved ejection fraction, and advanced heart failure. Figures show the evolution of therapy in chronic heart failure from the symptom-directed model, the complex pathophysiology and principal aberrations underlying heart failure with preserved ejection fraction, and concepts underlying surgical therapy in advanced heart failure using Laplace’s law. Tables list various etiologies of heart failure; sensitivity and specificity of clinical, biomarker, and radiographic data in the diagnosis of acute decompensated heart failure; drugs and devices with a demonstrated survival benefit in heart failure with a reduced ejection fraction; neurohormonal antagonist dosing in heart failure with a reduced ejection fraction; randomized, placebo-controlled trials in heart failure with a preserved ejection fraction; categorization of heart failure according to American Heart Association/American College of Cardiology heart failure stage, New York Heart Association functional class, and Interagency Registry for Mechanically Assisted Circulatory Support level; and poor prognostic indicators in heart failure. This review contains 3 highly rendered figures, 7 tables, and 113 references.

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