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Introduction: While multimorbidity (having ≥2 chronic conditions) is associated with inadequate higher intensity exercise, less is known about how multimorbidity relates to total movement accumulated throughout the day. We tested the hypothesis that multimorbidity is associated with lower 24-hr movement in a population-based study. Methods: We analyzed data from 2011-2014 National Health and Nutrition Examination Survey. A wrist-worn device (ActiGraph GT3X) captured movement over 24 hours in Monitor-Independent Movement Summary units (MIMS-units). Multimorbidity was quantified using 13 chronic conditions included in the CDC recommendations via self-report or clinical thresholds. We conducted multivariable linear regressions analyses to examine the association of each chronic condition and number of conditions with total daily MIMS-units. Models were adjusted for age, sex, race/ethnicity, education, and smoking, as well as the other chronic conditions in the model by condition type, per convention. Results: The sample included 7013 US adults aged 30+ (mean (± SE) age 53.2 ± 0.3 years, 53% female, 30% non-White). On average, participants had 2.4 (range 0-11) chronic conditions with 62% having ≥2. Those with ≥2 conditions had -1183.6 (95% CI: -1401.0, -966.2) lower daily MIMS-units. On a continuous scale, for each additional condition, movement was lower by -504.2 (95% CI: -580.4, -427.9) MIMS-units. Compared to those with 0 conditions, there was a dose-response reduction in movement with multimorbidity ( Figure ). Presence (vs absence) of obesity, diabetes, stroke, chronic kidney disease, cancer, depression, and memory problems were each associated with lower 24-hr movement activity. Conclusions: Multimorbidity is highly prevalent in US adults and associated with lower 24-hr movement. Intervention strategies focused on promotion of daily lifestyle movement may attenuate population-level multimorbidity burden. Future research should examine which co-occurring conditions contribute to low movement.

Introduction: While there are data demonstrating poor outcomes associated with discontinuation of renin-angiotensin system inhibitors (RASI) after hospitalization for heart failure with reduced ejection fraction (HFrEF), less is known about the prevalence and outcomes of RASI dose reduction. Objective: To determine the proportion of older US adults with HFrEF who had RASI down-titration after hospitalization and identify characteristics associated with RASI down-titration. Methods: This study included US Medicare beneficiaries age > 65 years with fee-for-service coverage hospitalized with HFrEF in 2007-2017 who filled a prescription for a RASI in the 90 days prior to hospitalization. We compared dosages of RASI prescription fills prior to and up to 1 year after hospitalization. Diagnoses of conditions that can reduce RASI tolerance (hypotension, acute kidney injury, hyperkalemia, angioedema, syncope, fall-related injuries) were identified during the hospitalization. We used modified Poisson models to calculate prevalence ratios and 95% CIs. Results: Among 35,047 Medicare beneficiaries hospitalized with HFrEF, the average age was 78.5 (SD 8.0) years, 82.3% were white, and 50.8% were women. After hospitalization, 61.9% filled a prescription for the same or higher dose, 15.6% filled a lower dose, and 22.6% did not fill a prescription for a RASI. Among the beneficiaries who filled a prescription for a RASI after hospitalization, hypotension, acute kidney injury, and hyperkalemia were associated with a higher prevalence of RASI down-titration (Table). Conclusion: Down-titration of RASIs is common among older adults with HFrEF following hospitalization and is more frequent among individuals with hypotension, acute kidney injury, or hyperkalemia during hospitalization. Down-titration may reduce risks of adverse events during periods of reduced medication tolerance after hospitalization, but could also lead to sustained suboptimal treatment.

Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Although self-reported prior diagnosis is a widely used method for ascertainment of AF in population studies, recall bias may impact the accuracy of this method. Objective: To examine the consistency of self-reported AF as compared to diagnoses recorded in Medicare claims. Methods: Among 30,239 black and white adults aged 45 years and older who enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, 8,588 participants aged 65 years and older with a minimum of 6 months of Medicare fee-for-service coverage at the time of enrollment were included in this analysis. Using AF diagnosis codes from Medicare claims as the “gold standard”, we calculated sensitivity, specificity, positive predictive value (PPV), and negative predicted value (NPV) of self-reported prior diagnosis of AF by a physician or other health professional. Results: The average age of the study population was 73.4 years, 50.5% were women, 31.6% were black, and 10.1% reported a prior diagnosis of AF. The prevalence of Medicare claims diagnoses for AF ranged from 28.6% to 32.5% depending on definition ( Table ). Compared to Medicare claims, self-reported prior diagnosis of AF had 22.4-24.5% sensitivity, 95.6-95.7% specificity, 68.8-71.5% PPV, and 71.9-76.0% NPV. Results were consistent across strata defined by age, gender, race, and cognitive status. Conclusion: Compared to Medicare claims, self-reported prior diagnosis by a physician or other health professional had low sensitivity but high specificity to detect AF. This suggests that an approach utilizing only self-report to detect AF would not be ideal. However, most participants who reported a prior diagnosis of AF had Medicare claims supporting this diagnosis.

Introduction: Masked hypertension is defined as having hypertensive blood pressure (BP) outside of the office setting among adults with non-hypertensive BP when measured in the office. Some guidelines recommend defining out-of-office BP using awake measurements while other guidelines recommend using awake and asleep measurements. Hypothesis: We hypothesized that defining masked hypertension using the awake and asleep BP measurements would increase the prevalence of masked hypertension compared to using the awake period alone, and the magnitude of this difference would be greater among non-Hispanic blacks compared with non-Hispanic whites and Hispanics. Methods: We pooled previously collected data from 5 NHLBI-funded population- and community-based studies including the Jackson Heart Study, the Coronary Artery Risk Development in Young Adults Study (total participants: 2,866). All participants had office systolic BP (SBP) Results: The prevalence of masked hypertension increased from 29% to 43% when defined using awake, asleep, or 24-hour BP versus using awake BP alone (Table). This increase was larger in non-Hispanic blacks (31-54%) compared with non-Hispanic whites (28-37%) and Hispanics (17-26%). The adjusted prevalence ratio (95% confidence interval) for having masked hypertension for non-Hispanic blacks compared with Non-Hispanic whites was higher from 1.20(1.05,1.37) to 1.33(1.20,1.47) when defined using awake, asleep and 24-hour BP versus awake BP only. Conclusions: Including asleep BP to define masked hypertension increased the prevalence of masked hypertension to a larger extent among non-Hispanic blacks compared to non-Hispanic whites and Hispanics.

Introduction: Studies of incident heart failure (HF) have provided insights into key risk factors for the disease but have been limited to select populations that often lack geographic, racial, and gender diversity. There is a need to assemble a HF-free cohort using a contemporary, geographically diverse sample. Aim: To develop and validate a strategy for assembling a HF-free cohort from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Methods: To assemble a HF-free cohort, we identified and excluded REGARDS participants who were taking HF-specific medications at baseline including: digoxin without atrial fibrillation, angiotensin converting enzyme inhibitor/angiotensin receptor blocker plus beta-blocker in the absence of hypertension, carvedilol, spironolactone, loop diuretic or a combination of hydralazine and nitrates. We then examined the subgroup of REGARDS participants with at least 6 months of Medicare claims at the time of the baseline assessment; we evaluated diagnostic performance (negative predictive value, positive predictive value, sensitivity and specificity) using three Medicare claims-based definitions of HF as the referent standard: Hospitalization for HF, Principal Diagnosis of HF, and Any Diagnosis of HF. Results: Among 28,884 eligible participants, 3,125 used HF-specific medications at baseline, leaving 25,759 (89%) participants in the proposed HF-free cohort. Participants in the HF-free cohort had a lower prevalence of coronary disease, atrial fibrillation, and diabetes compared to excluded participants. Depending on the Medicare definition used as the referent, the percent of the HF-free cohort without evidence of HF based on Medicare claims (the negative predictive value) ranged from 95.0-99.2% (Table 1). Negative predictive value was stable across age, sex, and race strata. Conclusions: This medication-based strategy to assembling a HF-free cohort in REGARDS can serve as a basis for future studies to examine incident HF in REGARDS and similar studies.

Background: Length of stay (LOS) during heart failure (HF) hospitalizations has decreased, accompanied by recent increases in post-discharge mortality and 30-day readmission rates among these patients. Methods: We conducted a retrospective cohort study of 19,477 Medicare beneficiaries in order to determine whether patients with the longest LOS also had the highest risk of death or readmission. We included patients hospitalized for HF and discharged alive between 2007 and 2011 with documented left ventricular (LV) systolic, diastolic, or combined dysfunction. We estimated the associations of LOS, risk for 30-day mortality, and risk for 30-day readmission with: type of LV dysfunction, HF severity, comorbidity burden, discharge disposition, demographics, nursing home residence, and calendar year. Gamma regression, Poisson regression, and Cox proportional hazards were used to model LOS, 30-day mortality, and 30-day readmission, respectively. Each model included all covariates. Results: The mean (IQR) LOS was 5 (4 - 8) days, 7% of the patients died within 30 days, and 23% of the patients were readmitted within 30 days. Patients with isolated diastolic dysfunction (DD) had 2% shorter LOS than patients with any systolic dysfunction (SD), but had 10% lower 30-day mortality. Comorbidities were associated with a 3% to 10% longer LOS, with the exception of chronic kidney disease (CKD) (16% longer) and malnutrition (30% longer). Only CKD, malnutrition, and chronic obstructive pulmonary disease (COPD) were associated with 30-day mortality (22%, 51%, and 14% higher risk, respectively). Most comorbidities were associated with 10% - 20% higher risk of 30-day readmission. Regarding discharge disposition, patients discharged home had 40% shorter LOS, 78% lower 30-day mortality, and 11% lower risk for 30-day readmission than patients discharged to a skilled nursing facility (SNF). Conclusions: We found no mismatch between LOS and prognosis among Medicare beneficiaries hospitalized for HF.

Introduction: In heart failure (HF) with reduced ejection fraction (HFrEF), there is evidence that the β-blockers metoprolol succinate, bisoprolol and carvedilol improve prognosis. Objective: To examine β-blocker prescriptions and fills after HF hospitalization. Methods: In 2006-2011, we identified 344 HF hospitalizations (147 HFrEF, 152 with preserved ejection fraction, 45 unknown) with linked Medicare claims among 201 participants of the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a cohort of 30,239 black and white adults. Comorbidities and prescriptions were abstracted from medical records. Claims were used to assess prescription fills. Risk ratios (RR) and confidence intervals (CI) for β-blocker prescriptions and fills were calculated using generalized estimating equations adjusted for age, race and sex. Results: Women accounted for 59% of HF hospitalizations and blacks 54%; 90% had prior HF. β-blockers were prescribed for 78% (87% with HFrEF); 58% (74% with HFrEF) of β-blocker prescriptions were metoprolol succinate, bisoprolol or carvedilol. Prescriptions were filled within 30 days of discharge for 46%. There was evidence of β-blocker up-titration for 9% (21% with HFrEF). HFrEF was more strongly associated with prescriptions and fills of metoprolol succinate, bisoprolol or carvedilol (RR 1.82 [95% CI 1.32, 2.53] and 1.73 [95% CI 1.12, 2.68], respectively) than any β-blocker (RR 1.12 [95% CI 0.99, 1.27] and 1.06 [95% CI 0.82, 1.36], respectively). After HFrEF hospitalization, black race and β-blockers at admission were positively associated with β-blocker prescriptions, female sex was positively associated with fills and chronic obstructive pulmonary disease was inversely, but not significantly, associated with prescriptions and fills ( Table ). Conclusions: β-blockers were prescribed at discharge for most HF hospitalizations, but many prescriptions do not appear to have been filled and up-titration was rare.

Introduction: In clinical trial populations with heart failure (HF) and reduced ejection fraction, there is evidence that the β-blockers metoprolol succinate, carvedilol, and bisoprolol reduce mortality and hospitalizations. The short-term impact of β-blockers among typical hospitalized HF patients with heavy comorbidity burdens is less clear. Hypothesis: Filling a β-blocker within 7 days of HF hospitalization is associated with lower rehospitalization risk 8-30 days after discharge. Methods: We identified 76,568 HF hospitalizations in the Medicare national 5% sample among beneficiaries with fee-for-service and medication coverage (20,358 with documented systolic dysfunction). Beneficiary characteristics, β-blocker fills, and rehospitalization for HF, cardiovascular disease (CVD), or any cause were assessed through Medicare claims. We used generalized estimating equations to calculate multivariable-adjusted risk ratios for rehospitalization. Results: The average age was 76 years, 61% were women, and 19% were black. Comorbidities were common (hypertension 85%, coronary heart disease 70%, chronic kidney disease 65%, chronic obstructive pulmonary disease 57%, diabetes 53%, atrial fibrillation 48%, depression 25%, hypotension 21%, valvular or rheumatic heart disease 15%). Almost all had prior diagnoses of HF (99%). Within 7 days of discharge, 25% filled any β-blocker and 17% filled metoprolol succinate, carvedilol, or bisoprolol. In the 8-30 days following discharge, 9% were rehospitalized for HF, 12% for CVD, and 22% for any cause. Filling a β-blocker was associated with a lower risk rehospitalization for HF, CVD, and any cause in both the overall population and the subgroup with documented systolic dysfunction ( Table ). Conclusions: Medicare beneficiaries with HF who filled β-blockers shortly after discharge had better short-term prognosis; however, risk of rehospitalization among those with and without β-blocker fills was high.

Background: Guidelines for treatment of heart failure (HF) with reduced ejection fraction recommend use of β-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), aldosterone antagonists, diuretics, digoxin, and, for blacks, the combination of hydralazine and isosorbide dinitrate. Race-specific treatment guidelines, differences in pathophysiology, comorbidities, and contraindications, and patient and provider preferences may result in differential use of these medications in blacks and whites with HF. Objectives: To examine differences in pre-hospitalization medication use among black and white Medicare beneficiaries hospitalized for HF. Methods: Medicare beneficiaries with fee-for-service and pharmacy coverage who had HF hospitalizations (inpatient claims for ≥1 overnight stay with HF as the primary discharge diagnosis, discharged alive) between 2007 and 2011 were identified in the Medicare national 5% sample. More than 98% of Medicare beneficiaries hospitalized for HF had prior inpatient or outpatient diagnoses of HF. Characteristics and medication use in the year prior to hospitalization were assessed through Medicare data. We compared pre-hospitalization medication use between black and white beneficiaries in the overall population with HF (n = 42,721) and in the subpopulation with documented systolic dysfunction (n = 9,702) with a χ 2 test. Results: Use of β-blockers and aldosterone antagonist was similar between blacks and whites ( Table ). Blacks were more likely to use ACE inhibitors, ARBs, and hydralazine. Whites were more likely to use diuretics and digoxin. Results were consistent when the population was limited to those with documented systolic dysfunction. Conclusions: Blacks were as likely as or more likely than whites to receive pharmacologic heart failure therapies with the exception of diuretics, which were none the less commonly used, and digoxin. Additional research is needed to determine the causes and implications of these differences.

Background: Heart failure (HF) is among the most common reasons for hospitalization in the United States. Hospital length of stay (LOS) is a driver of cost and disease burden. Objectives: To examine factors associated with LOS of HF hospitalizations. Methods: Medicare beneficiaries with fee-for-service and pharmacy coverage who had HF hospitalizations (inpatient claims with ≥1 overnight stay/2 hospital days with HF as the primary discharge diagnosis, discharged alive) between 2007 and 2011 were identified in the Medicare national 5% sample. The median and interquartile range (IQR) LOS was calculated by demographic characteristics, comorbidities, and discharge status based on Medicare claims data with the Kruskal-Wallis test to compare distributions in the overall population with HF (n = 45,584) and in the subpopulation with documented systolic dysfunction (n = 10,256). Results: The median LOS was 5 days (range 2-255, IQR 4-8 days) in the overall HF population and 5 days (range 2-204, IQR 4-8 days) in those with systolic dysfunction. Across most demographic characteristics and comorbidities, the median LOS was 5 days but was higher among nursing home residents and individuals with malnutrition in both groups and with chronic kidney disease in those with systolic dysfunction ( Figure ). All comorbidities were associated with a shift in the distribution toward longer LOS in the population with systolic dysfunction and all but coronary heart disease in the overall population (p < 0.001). HF patients discharged to a skilled nursing facility had longer LOS (median 7 days, IQR 5-10 days) versus other discharge statuses (median 5 days, IQR 3-7 days, p < 0.001) in both populations. Conclusions: In patients hospitalized for HF, the median LOS was 5 days across most comorbidities and other characteristics, but comorbidities were associated with a shift in the upper tail of the distribution toward longer LOS. Worse functional status (nursing residence or discharge to a skilled nursing facility) was associated with a higher median LOS.