Search

Background: Hospitalization and readmission rates have decreased in recent years, with the possible consequence that hospitals are increasingly filled with high-risk patients., Objective: We studied whether readmission reduction has affected the risk profile of hospitalized patients and whether readmission reduction was similarly realized among hospitalizations with low, medium, and high risk of readmissions., Design: Retrospective study of hospitalizations between January 2009 and June 2015., Patients: Hospitalized fee-for-service Medicare beneficiaries, categorized into 1 of 5 specialty cohorts used for the publicly reported hospital-wide readmission measure., Measurements: Each hospitalization was assigned a predicted risk of 30-day, unplanned readmission using a risk-adjusted model similar to publicly reported measures. Trends in monthly mean predicted risk for each cohort and trends in monthly observed to expected readmission for hospitalizations in the lowest 20%, middle 60%, and highest 20% of risk of readmission were assessed using time series models., Results: Of 47,288,961 hospitalizations, 16.2% (n = 7,642,161) were followed by an unplanned readmission within 30 days. We found that predicted risk of readmission increased by 0.24% (P = .03) and 0.13% (P = .004) per year for hospitalizations in the surgery/ gynecology and neurology cohorts, respectively. We found no significant increase in predicted risk for hospitalizations in the medicine (0.12%, P = .12), cardiovascular (0.32%, P = .07), or cardiorespiratory (0.03%, P = .55) cohorts. In each cohort, observed to expected readmission rates steadily declined, and at similar rates for patients at low, medium, and high risk of readmission., Conclusions: Hospitals have been effective at reducing readmissions across a range of patient risk strata and clinical conditions. The risk of readmission for hospitalized patients has increased for 2 of 5 clinical cohorts., (© 2018 Society of Hospital Medicine)

Background: Interventions to reduce readmissions after acute heart failure hospitalization require early identification of patients. The purpose of this study was to develop and test accuracies of various approaches to identify patients with acute decompensated heart failure (ADHF) with the use of data derived from the electronic health record., Methods and Results: We included 37,229 hospitalizations of adult patients at a single hospital during 2013-2015. We developed 4 algorithms to identify hospitalization with a principal discharge diagnosis of ADHF: 1) presence of 1 of 3 clinical characteristics, 2) logistic regression of 31 structured data elements, 3) machine learning with unstructured data, and 4) machine learning with the use of both structured and unstructured data. In data validation, algorithm 1 had a sensitivity of 0.98 and positive predictive value (PPV) of 0.14 for ADHF. Algorithm 2 had an area under the receiver operating characteristic curve (AUC) of 0.96, and both machine learning algorithms had AUCs of 0.99. Based on a brief survey of 3 providers who perform chart review for ADHF, we estimated that providers spent 8.6 minutes per chart review; using this this parameter, we estimated that providers would spend 61.4, 57.3, 28.7, and 25.3 minutes on secondary chart review for each case of ADHF if initial screening were done with algorithms 1, 2, 3, and 4, respectively., Conclusions: Machine learning algorithms with unstructured notes had the best performance for identification of ADHF and can improve provider efficiency for delivery of quality improvement interventions., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Many hospitalized patients have at least 1 chronic disease that is not optimally controlled. The purpose of this study was to explore inpatient provider attitudes about chronic disease management and, in particular, barriers and facilitators of chronic disease management in the hospital., Methods: We conducted a qualitative study of semi-structured interviews of 31 inpatient providers from an academic medical center. We interviewed attending physicians, resident physicians, physician assistants, and nurse practitioners from various specialties about attitudes, experiences with, and barriers and facilitators towards chronic disease management in the hospital. Qualitative data were analyzed using constant comparative analysis., Results: Providers perceived that hospitalizations offer an opportunity to improve chronic disease management, as patients are evaluated by a new care team and observed in a controlled environment. Providers perceived clinical benefits to in-hospital chronic care, including improvements in readmission and length of stay, but expressed concerns for risks related to adverse events and distraction from the acute problem. Barriers included provider lack of comfort with managing chronic diseases, poor communication between inpatient and outpatient providers, and hospital-system focus on patient discharge. A strong relationship with the outpatient provider and involvement of specialists were facilitators of inpatient chronic disease management., Conclusions: Providers perceived benefits to in-hospital chronic disease management for both processes of care and clinical outcomes. Efforts to increase inpatient chronic disease management will need to overcome barriers in multiple domains. Journal of Hospital Medicine 2017;12:162-167., (© 2017 Society of Hospital Medicine)

Objectives: This study sought to determine whether racial and ethnic differences exist among patients with similar access to care. We examined outcomes after heart failure hospitalization within a large municipal health system., Background: Racial and ethnic disparities in heart failure outcomes are present in administrative data, and one explanation is differential access to care., Methods: We performed a retrospective cohort study of 8,532 hospitalizations of adults with heart failure at 11 hospitals in New York City from 2007 to 2010. Primary exposure was ethnicity and race, and outcomes were 30- and 90-day readmission and 30-day and 1-year mortality rates. Generalized estimating equations were used to test for associations between ethnicity and race and outcomes with covariate adjustment., Results: Of the number of hospitalizations included, 4,305 (51%) were for blacks, 2,449 (29%) were for Hispanics, 1,494 (18%) were for whites, and 284 (3%) were for Asians. Compared to whites, blacks and Asians had lower 1-year mortality, with adjusted odds ratios (aORs) of 0.75 (95% confidence interval [CI]: 0.59 to 0.94) and 0.57 (95% CI: 0.38 to 0.85), respectively, and rates for Hispanics were not significantly different (aOR: 0.81; 95% CI: 0.64 to 1.03). Hispanics had higher odds of readmission than whites (aOR: 1.27; 95% CI: 1.03 to 1.57) at 30 (aOR: 1.40; 95% CI: 1.15 to 1.70) and 90 days. Blacks had higher odds of readmission than whites at 90 days (aOR:1.21; 95% CI: 1.01 to 1.47)., Conclusions: Racial and ethnic differences in outcomes after heart failure hospitalization were present within a large municipal health system. Access to a municipal health system may not be sufficient to eliminate disparities in heart failure outcomes., Competing Interests: None of the authors have relevant relationships with industry or conflicts of interest., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Comorbid diabetes is common in heart failure and associated with increased hospitalization and mortality. Nonetheless, the association between glycemic control and outcomes among patients with heart failure and diabetes remains poorly characterized, particularly among low income and minority patients., Methods: We performed a retrospective cohort study of outpatients with heart failure and diabetes in the New York City Health and Hospitals Corporation, the largest municipal health care system in the United States. Cox proportional hazard models were used to measure the association between HbA1c levels and outcomes of all-cause hospitalization, heart failure hospitalization, and mortality., Results: Of 4723 patients with heart failure and diabetes, 42.6 % were black, 30.5 % were Hispanic/Latino, 31.4 % were Medicaid beneficiaries and 22.9 % were uninsured. As compared to patients with an HbA1c of 8.0-8.9 %, patients with an HbA1c of <6.5, 6.5-6.9, 7.0-7.9, and ≥9.0 % had an adjusted hazard ratio (aHR) (95 % CI) for all-cause hospitalization of 1.03 (0.90-1.17), 1.05 (0.91-1.22), 1.03 (0.90-1.17), and 1.13 (1.00-1.28), respectively. An HbA1c ≥ 9.0 % was also associated with an increased risk of heart failure hospitalization (aHR 1.33; 95 % CI 1.11-1.59) and a non-significant increased risk in mortality (aHR 1.20; 95 % CI 0.99-1.45) when compared to HbA1c of 8.0-8.9 %., Conclusions: Among a cohort of primarily minority and low income patients with heart failure and diabetes, an increased risk of hospitalization was observed only for an HbA1c greater than 9 %.

Background: Treatment of acute heart failure in the emergency department (ED) or observation unit is an alternative to hospitalization. Both ED management and observation unit management have been associated with reduced costs and may be used to avoid penalties related to rehospitalizations. The purpose of this study was to examine trends in ED visits for heart failure and disposition following such visits., Methods: We used the National Hospital Ambulatory Medical Care Survey, a representative sample of ED visits in the United States, to estimate rates and characteristics of ED visits for heart failure between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit., Results: The number of ED visits for heart failure remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%, 95% CI -3.7% to +2.5%). Of these visits, 74.2% led to hospitalization, wheras 3.1% led to observation unit admission. The likelihood of hospitalization did not change during the period (adjusted prevalence ratio 1.00, 95% CI 0.99-1.01 for each additional year), whereas admission to the observation unit increased annually (adjusted prevalence ratio 1.12, 95% CI 1.01-1.25). We observed significant regional differences in likelihood of hospitalization and observation admission., Conclusions: The number of ED visits for heart failure and the high proportion of ED visits with subsequent inpatient hospitalization have not changed in the last decade. Opportunities may exist to reduce hospitalizations by increasing short-term management of heart failure in the ED or observation unit., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: Previous studies have suggested that weekend hospital care is inferior to weekday care and that this difference may be related to diminished care intensity. The purpose of this study was to determine whether a metric for measuring intensity of hospital care based on use of the electronic health record was associated with patient-level outcomes., Methods: We performed a cohort study of hospitalizations at an academic medical center. Intensity of care was defined as the hourly number of provider accessions of the electronic health record, termed "electronic health record interactions." Hospitalizations were categorized on the basis of the mean difference in electronic health record interactions between the first Friday and the first Saturday of hospitalization. We used regression models to determine the association of these categories with patient outcomes after adjusting for covariates., Results: Electronic health record interactions decreased from Friday to Saturday in 77% of the 9051 hospitalizations included in the study. Compared with hospitalizations with no change in Friday to Saturday electronic health record interactions, the relative lengths of stay for hospitalizations with a small, moderate, and large decrease in electronic health record interactions were 1.05 (95% confidence interval [CI], 1.00-1.10), 1.11 (95% CI, 1.05-1.17), and 1.25 (95% CI, 1.15-1.35), respectively. Although a large decrease in electronic health record interactions was associated with in-hospital mortality, these findings were not significant after risk adjustment (odds ratio 1.74, 95% CI, 0.93-3.25)., Conclusions: Intensity of inpatient care, measured by electronic health record interactions, significantly diminished from Friday to Saturday, and this decrease was associated with length of stay. Hospitals should consider monitoring and correcting temporal fluctuations in care intensity., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: The study sought to assess the quality of care for heart failure patients who are hospitalized for all causes., Background: Performance measures for heart failure target patients with a principal diagnosis of heart failure. However, patients with heart failure are commonly hospitalized for other causes and may benefit from treatments such as angiotensin-converting enzyme (ACE) inhibitors for left ventricular (LV) systolic dysfunction., Methods: We assessed rates of compliance with care measures for patients hospitalized with acute or chronic heart failure in the ARIC (Atherosclerosis Risk In Communities) study surveillance catchment area from 2005 to 2009. Rates of compliance were compared between patients with a principal discharge diagnosis of heart failure and those with another principal discharge diagnosis., Results: Of 4,345 hospitalizations of heart failure patients, 39.6% carried a principal diagnosis of heart failure. Patients with a principal heart failure diagnosis had higher rates of LV function assessment (89.1% vs. 82.5%; adjusted prevalence ratio [aPR]: 1.07; 95% confidence interval [CI]: 1.04 to 1.10) and discharge ACE inhibitor/angiotensin receptor blocker (ARB) in LV dysfunction (64.1% vs. 56.3%; aPR: 1.11; 95% CI: 1.03 to 1.20) as compared to patients hospitalized for another cause. LV assessment and ACE inhibitor/ARB use were associated with reductions in 1-year post-discharge mortality (adjusted odds ratio: 0.66, 95% CI: 0.51 to 0.85; adjusted odds ratio: 0.72, 95% CI: 0.54 to 0.96, respectively) that did not differ for patients with versus without a principal heart failure diagnosis., Conclusions: Compared with individuals hospitalized with a principal diagnosis of heart failure, heart failure patients hospitalized for other causes were less likely to receive guideline recommended care. Quality initiatives may improve care by targeting hospitalizations with either principal or secondary heart failure diagnoses., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the association between diabetes, glycemic control, and risk of fracture-related hospitalization in the Atherosclerosis Risk in Communities (ARIC) Study., Research Design and Methods: Fracture-related hospitalization was defined using International Classification of Diseases, 9th revision, codes (733.1-733.19, 733.93-733.98, or 800-829). We calculated the incidence rate of fracture-related hospitalization by age and used Cox proportional hazards models to investigate the association of diabetes with risk of fracture after adjustment for demographic, lifestyle, and behavioral risk factors., Results: There were 1,078 incident fracture-related hospitalizations among 15,140 participants during a median of 20 years of follow-up. The overall incidence rate was 4.0 per 1,000 person-years (95% confidence interval [CI], 3.8-4.3). Diagnosed diabetes was significantly and independently associated with an increased risk of fracture (adjusted hazard ratio [HR], 1.74; 95% CI, 1.42-2.14). There also was a significantly increased risk of fracture among persons with diagnosed diabetes who were treated with insulin (HR, 1.87; 95% CI, 1.15-3.05) and among persons with diagnosed diabetes with hemoglobin A1c (HbA1c) ≥8% (1.63; 1.09-2.44) compared with those with HbA1c <8%. Undiagnosed diabetes was not significantly associated with risk of fracture (HR, 1.12; 95% CI, 0.82-1.53)., Conclusions: This study supports recommendations from the American Diabetes Association for assessment of fracture risk and implementation of prevention strategies in persons with type 2 diabetes, particularly those persons with poor glucose control.

Objectives: This study sought to characterize temporal trends in hospitalizations with heart failure as a primary or secondary diagnosis., Background: Heart failure patients are frequently admitted for both heart failure and other causes., Methods: Using the Nationwide Inpatient Sample (NIS), we evaluated trends in heart failure hospitalizations between 2001 and 2009. Hospitalizations were categorized as either primary or secondary heart failure hospitalizations based on the location of heart failure in the discharge diagnosis. National estimates were calculated using the sampling weights of the NIS. Age- and sex-standardized hospitalization rates were determined by dividing the number of hospitalizations by the U.S. population in a given year and using direct standardization., Results: The number of primary heart failure hospitalizations in the United States decreased from 1,137,944 in 2001 to 1,086,685 in 2009, whereas secondary heart failure hospitalizations increased from 2,753,793 to 3,158,179 over the same period. Age- and sex-adjusted rates of primary heart failure hospitalizations decreased steadily from 2001 to 2009, from 566 to 468 per 100,000 people. Rates of secondary heart failure hospitalizations initially increased from 1,370 to 1,476 per 100,000 people from 2001 to 2006, then decreased to 1,359 per 100,000 people in 2009. Common primary diagnoses for secondary heart failure hospitalizations included pulmonary disease, renal failure, and infections., Conclusions: Although primary heart failure hospitalizations declined, rates of hospitalizations with a secondary diagnosis of heart failure were stable in the past decade. Strategies to reduce the high burden of hospitalizations of heart failure patients should include consideration of both cardiac disease and noncardiac conditions.

Background: Diabetes is associated with increased risk of mortality in heart failure. We examined the association of diabetes with expenditures, hospitalizations, and procedures among Medicare beneficiaries with heart failure during the last 6 months of life., Methods and Results: In a 5% national Medicare sample, the prevalence of diabetes was 41.7% among 16,613 beneficiaries who died in 2007 with a diagnosis of heart failure. Diabetes was associated with higher expenditures during the last 6 months of life (mean $39,042 vs $29,003; P < .001), even after adjusting for covariates, including age, sex, race, geographic location, comorbidities, and preceding hospitalizations (cost ratio 1.08, 95% CI 1.05-1.12). For both diabetic and nondiabetic adults, more than one-half of Medicare expenditures were related to hospitalization costs (mean $22,516 vs $15,721; P < .001). Compared with their counterparts without diabetes, beneficiaries with diabetes had higher rates of hospitalization (adjusted incidence rate ratio 1.09, 95% CI 1.05-1.12) and days spent in the intensive care unit., Conclusions: Comorbid diabetes was common in heart failure and associated with higher expenditures, much of which was driven by increased rates of hospitalizations. Programs that focus on prevention of hospitalizations may reduce the substantial costs associated with heart failure near the end of life., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: A substantial portion of the public health burden of heart failure is due to hospitalizations, many of which are for causes other than cardiovascular disease. We assessed whether left ventricular (LV) systolic dysfunction was associated with increased risk of both cardiovascular and noncardiovascular hospitalizations in a community sample of African Americans., Methods: African American participants from the Jackson, MS, site of the Atherosclerosis Risk in Communities (ARIC) study who underwent echocardiography were followed for 12 years. Hospitalization rates among individuals with and without LV systolic dysfunction were compared using negative binomial regression., Results: Among 2,416 participants with echocardiograms, LV systolic dysfunction was found in 61 (2.5%). Participants with LV dysfunction experienced 366 hospitalizations, a rate of 1.27 per person-year, compared with 0.25 per person-year among individuals without LV dysfunction. The incidence rate ratio adjusted for demographics, comorbidities, and other risk factors was 3.11 (95% CI 2.22-4.35). The adjusted rate ratios were 4.76 (95% CI 2.90-7.20) for cardiovascular and 2.67 (95% CI 1.82-3.90) for noncardiovascular diagnoses, with similar findings in the subset of individuals with asymptomatic LV dysfunction. The percentage attributable risks for hospitalizations were 87% and 74% for cardiovascular and noncardiovascular causes (79% and 63% after adjustment)., Conclusions: African American individuals with LV dysfunction are at an increased risk of hospitalization due to a wide range of causes, with noncardiovascular hospitalizations accounting for nearly half the increased risk. To the extent that estimates of risk focus on cardiovascular morbidity, they may underestimate the true health burden of LV dysfunction., (2010 Mosby, Inc. All rights reserved.)

BackgroundMineralocorticoid receptor antagonists (MRA) are an underutilized therapy for heart failure with a reduced ejection fraction (HFrEF), but the current impact of hospitalization on MRA use is not well characterized. The objective of this study was to describe contemporary MRA prescription for heart failure patients before and after the full scope of hospitalizations and the association between MRA discharge prescription and post-hospitalization outcomes.MethodsWe conducted a retrospective cohort study at an academic hospital system in 2013-2016. Among 1500 included hospitalizations of 1009 unique patients with HFrEF and without MRA contraindication, the mean age was 71.9 ± 13.6 years and 443 (29.5%) were female. We compared MRA prescription before and after hospitalizations with McNemar's test and between patients with principal and secondary diagnoses of HFrEF with the chi-square test, and association of MRA discharge prescription with 30-day and 180-day mortality and readmissions using generalized estimating equations.ResultsMRA prescriptions increased from 303 (20.2%) to 375 (25.0%) at discharge (+4.8%, p

Background Evidence regarding the association of anger proneness with incidence of heart failure is lacking. Methods and Results Anger proneness was ascertained among 13,171 black and white participants of the Atherosclerosis Risk in Communities (ARIC) study cohort with the use of the Spielberger Trait Anger Scale. Incident heart failure events, defined as occurrence of ICD-9-CM code 428.x, were ascertained from participants' medical records during follow-up in the years 1990–2010. Relative hazard of heart failure across categories of trait anger was estimated with the use of Cox proportional hazard models. Study participants (mean age 56.9 [SD 5.7] years) experienced 1,985 incident HF events during 18.5 (SD 4.9) years of follow-up. Incidence of HF was greater among those with high, as compared to those with low or moderate trait anger, with higher incidence observed for men than for women. The relative hazard of incident HF was modestly high among those with high trait anger, compared with those with low or moderate trait anger (age-adjusted hazard ratio for men: 1.44 (95% confidence interval [CI] 1.23–1.69). Adjustment for comorbidities and depressive symptoms attenuated the estimated age-adjusted relative hazard in men to 1.26 (95% CI 1.00–1.60). Conclusions Assessment of anger proneness may be necessary in successful prevention and clinical management of heart failure, especially in men. [ABSTRACT FROM AUTHOR]

Background: Some patients with heart failure (HF) will go on to develop advanced HF, characterized by severe HF symptoms despite attempts to optimize medical therapy. The goals of this study were to examine the risk of developing advanced HF in patients with newly diagnosed HF, identify risk factors for developing advanced HF, and evaluate the impact of advanced HF on outcomes. Methods: This was a population-based, retrospective cohort study of Olmsted County, Minnesota, residents with a new clinical diagnosis of HF between 2007 and 2017. Risk factors for the development of advanced HF (2018 European Society of Cardiology criteria) were examined using cause-specific Cox proportional hazard regression models. The associations of development of advanced HF with risks of hospitalization and mortality were examined using the Andersen-Gill and Cox models, respectively. Results: There were 4597 residents with incident HF from 2007 to 2017. The cumulative incidence of advanced HF was 11.5% (95% CI, 10.5%–12.5%) at 6 years after incident HF diagnosis overall and was 14.4% (95% CI, 12.3%–16.9%), 11.4% (95% CI, 8.9%–14.6%), and 11.7% (95% CI, 10.3%–13.2%) in patients with incident HF with reduced, mildly reduced, and preserved ejection fraction, respectively. Key demographics, comorbidities, and echocardiographic characteristics were independently associated with the development of advanced HF. Development of advanced HF was associated with increased risks of all-cause hospitalization (adjusted hazard ratio, 3.0 [95% CI, 2.7–3.4]; P <0.001), HF hospitalization (hazard ratio, 10.2 [95% CI, 8.7–12.1]), all-cause mortality (hazard ratio, 5.0 [95% CI, 4.5–5.6]; P <0.001), and cardiovascular mortality (hazard ratio, 7.8 [95% CI, 6.7–9.1]). Conclusions: In this population-based study, development of advanced HF was common and was associated with markedly increased morbidity and mortality. [ABSTRACT FROM AUTHOR]