Dataset Information

Home-Time After Discharge Among Patients Hospitalized With Heart Failure.

ABSTRACT:

Background

Surveys of patients with cardiovascular disease have suggested that "home-time"-being alive and out of any health care institution-is a prioritized outcome. This novel measure has not been studied among patients with heart failure (HF).

Objectives

This study sought to characterize home-time following hospitalization for HF and assess its relationship with patient characteristics and traditionally reported clinical outcomes.

Methods

Using GWTG-HF (Get With The Guidelines-Heart Failure) registry data, patients discharged alive from an HF hospitalization between 2011 and 2014 and ≥65 years of age were identified. Using Medicare claims, post-discharge home-time over 30-day and 1-year follow-up was calculated for each patient as the number of days alive and spent outside of a hospital, skilled nursing facility (SNF), or rehabilitation facility.

Results

Among 59,736 patients, 57,992 (97.1%) and 42,153 (70.6%) had complete follow-up for home-time calculation through 30 days and 1 year, respectively. The mean home-time was 21.6 ± 11.7 days at 30 days and 243.9 ± 137.6 days at 1 year. Contributions to reduced home-time varied by follow-up period, with days spent in SNF being the largest contributor though 30 days and death being the largest contributor through 1 year. Over 1 year, 2,044 (4.8%) patients had no home-time following index hospitalization discharge, whereas 8,194 (19.4%) had 365 days of home-time. In regression models, several conditions were associated with substantially reduced home-time, including chronic obstructive pulmonary disease, renal insufficiency, and dementia. Through 1 year, home-time was highly correlated with time-to-event endpoints of death (tau = 0.72) and the composite of death or HF readmission (tau = 0.59).

Conclusions

Home-time, which can be readily calculated from administrative claims data, is substantially reduced for many patients following hospitalization for HF and is highly correlated with traditional time-to-event mortality and hospitalization outcomes. Home-time represents a novel, easily measured, patient-centered endpoint that may reflect effectiveness of interventions in future HF studies.

SUBMITTER: Greene SJ

PROVIDER: S-EPMC6742493 | biostudies-literature | 2018 Jun

REPOSITORIES: biostudies-literature

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Publications

Home-Time After Discharge Among Patients Hospitalized With Heart Failure.

Greene Stephen J SJ O'Brien Emily C EC Mentz Robert J RJ Luo Nancy N Hardy N Chantelle NC Laskey Warren K WK Heidenreich Paul A PA Chang Chun-Lan CL Turner Stuart J SJ Yancy Clyde W CW Hernandez Adrian F AF Curtis Lesley H LH Peterson Pamela N PN Fonarow Gregg C GC Hammill Bradley G BG

Journal of the American College of Cardiology 20180601 23

<h4>Background</h4>Surveys of patients with cardiovascular disease have suggested that "home-time"-being alive and out of any health care institution-is a prioritized outcome. This novel measure has not been studied among patients with heart failure (HF).<h4>Objectives</h4>This study sought to characterize home-time following hospitalization for HF and assess its relationship with patient characteristics and traditionally reported clinical outcomes.<h4>Methods</h4>Using GWTG-HF (Get With The Gui ...[more]

PMID: 29880124

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Project description:BackgroundDepression is a prevalent comorbidity in patients with heart failure (HF). However, data regarding the prognostic significance of depression during the early post-discharge period in patients hospitalized with acute HF, regardless of left ventricular ejection fraction (LVEF), were scarce.Methods and resultsThe Heart Failure Registry of Patient Outcomes (HERO) study is a prospective, multicenter study of patients hospitalized with acute HF in China. At the first follow-up after discharge (median 4.0, interquartile range [IQR]: 2.4-6.1 weeks), depressive symptoms over the past 2 weeks were assessed using the Patient Health Questionnaire-9 (PHQ-9). Of 3,889 patients, 480 (12.3%) patients had depression (PHQ-9 score ≥ 10). A total of 3,456 patients (11.4% with depression) were included in the prospective analysis. After a median follow-up of 47.1 weeks (IQR: 43.9, 49.3) from the first follow-up, 508 (14.7%) patients died, and 1,479 (42.8%) patients experienced a composite event (death or HF rehospitalization). Cox proportional hazards models were used to assess the association of post-discharge depression with adverse events. After adjustment, post-discharge depression was associated with an increased risk of all-cause mortality (hazard ratio [HR] 2.38 [95% confidence interval (CI): 1.93-2.94]; p < 0.001) and the composite event (HR 1.78 [95% CI: 1.55-2.05]; p < 0.001). A per scale point increase in PHQ-9 score (ranging from 0 to 27 points) was associated with a 7.6% increase in all-cause mortality (HR 1.08 [95% CI: 1.06-1.09]; p < 0.001). In the subgroup analysis, the association between depression and the composite event was significantly stronger in relatively younger patients (< 75 vs. ≥ 75 years; p for interaction = 0.011), and the association between depression and all-cause mortality was significantly stronger in patients with preserved ejection fraction than in those with reduced ejection fraction (p for interaction = 0.036).ConclusionPost-discharge depression in patients recently hospitalized with acute HF is associated with an increased risk of adverse events, regardless of LVEF. Screening for depressive symptoms during the early post-discharge period may help to better identify high-risk patients and tailor patient management. Further studies are needed to determine how regular depression screening can help improve patient management and clinical outcomes.

Project description:ImportanceIt remains unclear whether telemonitoring approaches provide benefits for patients with heart failure (HF) after hospitalization.ObjectiveTo evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF.Design, setting, and participantsWe randomized 1437 patients hospitalized for HF between October 12, 2011, and September 30, 2013, to the intervention arm (715 patients) or to the usual care arm (722 patients) of the Better Effectiveness After Transition-Heart Failure (BEAT-HF) study and observed them for 180 days. The dates of our study analysis were March 30, 2014, to October 1, 2015. The setting was 6 academic medical centers in California. Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF.InterventionsThe intervention combined health coaching telephone calls and telemonitoring. Telemonitoring used electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight. Centralized registered nurses conducted telemonitoring reviews, protocolized actions, and telephone calls.Main outcomes and measuresThe primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, all-cause mortality at 30 and 180 days, and quality of life at 30 and 180 days.ResultsAmong 1437 participants, the median age was 73 years. Overall, 46.2% (664 of 1437) were female, and 22.0% (316 of 1437) were African American. The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of patients, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P = .74). In secondary analyses, there were no significant differences in 30-day readmission or 180-day mortality, but there was a significant difference in 180-day quality of life between the intervention and usual care groups. No adverse events were reported.Conclusions and relevanceAmong patients hospitalized for HF, combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions.Trial registrationclinicaltrials.gov Identifier: NCT01360203.

Project description:AimsTroponin levels are commonly elevated among patients hospitalized for heart failure (HF), but the prevalence and prognostic significance of early post-discharge troponin elevation are unclear. This study sought to describe the frequency and prognostic value of pre-discharge and post-discharge troponin elevation, including persistent troponin elevation from the inpatient to outpatient settings.Methods and resultsThe ASTRONAUT trial (NCT00894387; http://www.clinicaltrials.gov) enrolled hospitalized HF patients with ejection fraction ≤40% and measured troponin I prior to discharge (i.e. study baseline) and at 1-month follow-up in a core laboratory (elevation defined as >0.04 ng/mL). This analysis included 1469 (91.0%) patients with pre-discharge troponin data. Overall, 41.5% and 29.9% of patients had elevated pre-discharge [median: 0.09 ng/mL; interquartile range (IQR): 0.06-0.19 ng/mL] and 1-month (median: 0.09 ng/mL; IQR: 0.06-0.15 ng/mL) troponin levels, respectively. Among patients with pre-discharge troponin elevation, 60.4% had persistent elevation at 1 month. After adjustment, pre-discharge troponin elevation was not associated with 12-month clinical outcomes. In contrast, 1-month troponin elevation was independently predictive of increased all-cause mortality [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.18-2.13] and cardiovascular mortality or HF hospitalization (HR 1.28, 95% CI 1.03-1.58) at 12 months. Associations between 1-month troponin elevation and outcomes were similar among patients with newly elevated (i.e. normal pre-discharge) and persistently elevated levels (interaction P ≥ 0.16). The prognostic value of 1-month troponin elevation for 12-month mortality was driven by a pronounced association among patients with coronary artery disease (interaction P = 0.009).ConclusionsIn this hospitalized HF population, troponin I elevation was common during index hospitalization and at 1-month follow-up. Elevated troponin I level at 1 month, but not pre-discharge, was independently predictive of increased clinical events at 12 months. Early post-discharge troponin I measurement may offer a practical means of risk stratification and should be investigated as a therapeutic target.

Project description:AimsCongestive status, serum potassium, and renal function are major determinants of outcomes as well as critical elements for adjusting drug therapy in heart failure (HF) patients. This study aimed at describing the daily variations in estimated plasma volume (ePV, a surrogate of congestion computed from haemoglobin and haematocrit), blood potassium, and estimated glomerular filtration rate during 2 months post-hospitalization for decompensated HF with reduced ejection fraction.Methods and resultsThe study was conducted in a single tertiary referral centre. Capillary blood samples were drawn by study nurses at home (7-12 am), and haematocrit, blood haemoglobin, creatinine, and potassium were measured using an approved home-based device (ABOTT i-STAT) (ClinicalTrials.gov: NCT01655134). Among the 15 home-monitored patients, two patients died (one suddenly), and one was readmitted for ischaemic acute pulmonary oedema, with a subsequent acute coronary syndrome, and did not have a complete 2-month follow-up. The 5-day-a-week biological home monitoring revealed an ePV >5.5 mL/g Hb, suggestive of undiagnosed residual congestion at discharge in 3 out the 15 patients. It was possible to document a number of episodes of hyperkalaemia (>5: mean ± standard deviation: 2.2 ± 2.2 or 5.5: 1.7 ± 1.6 mmol/L), hypokalaemia (<4: 1.9 ± 2.4 or 3.5: 0.5 ± 1.2 mmol/L), worsening renal function (drop in estimated glomerular filtration rate > 20%: 1.3 ± 1.8 or 30%: 0.7 ± 1.2) and recongestion (ePV rise above 10%: 1.4 ± 1.5, 15%: 2.3 ± 2.4, 5.5 mL/g Hb: 1.8 ± 2.6) episodes indicative of clinically relevant and potentially actionable cardiorenal and electrolytic patterns.ConclusionsOur findings demonstrate that a 5-day-a-week home monitoring combining haemoglobin/haematocrit, potassium, and creatinine measurements was able to capture a substantial number of clinically relevant cardiorenal and electrolyte events which are frequently overlooked and potentially actionable. Whether acting on these events may help optimizing renin angiotensin aldosterone system inhibitors and diuretic therapy warrants further dedicated testing. The ongoing HERMES HF study (NCT04050904) is assessing the short-term feasibility and safety of such a monitoring strategy, complemented by a decision support system, and generating recommendations based on ESC clinical guidelines in patients discharged after an episode of worsening heart failure with reduced ejection fraction.

Project description:BackgroundHospitalization for heart failure (HF) is associated with increased risk of death among patients with chronic HF. The degree to which hospitalization for HF is a distinct biologic entity with independent prognostic value versus a marker of higher risk chronic HF patients is unclear.MethodsAfter excluding patients with new-onset HF, the ASCEND-HF trial (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) included 4205 patients hospitalized for worsening chronic HF with reduced or preserved ejection fraction. The present analysis compared patients by presence or absence of prior HF hospitalization within 12 months and by timing of prior HF hospitalization relative to index hospitalization. Associations with 180-day all-cause mortality were assessed, including adjustment for 27 prespecified clinical factors.ResultsOverall, 2241 (53.3%) patients had a HF hospitalization within the prior 12 months and 1964 (46.7%) did not. Mortality rates at 180 days were 15.5% and 11.9%, respectively. In unadjusted analyses, prior HF hospitalization was associated with increased risk of 180-day mortality (HR, 1.35 [95% CI, 1.14-1.59]; P<0.01). After adjustment, the point estimate was attenuated and the association not statistically significant (HR, 1.18 [95% CI, 0.99-1.40]; P=0.064). Similarly, after adjustment, compared with patients without prior hospitalization, prior HF hospitalization was not associated with mortality, irrespective of timing (0-4 months: HR, 1.10 [95% CI, 0.87-1.39], P=0.41; 4-8 months: HR, 0.95 [95% CI, 0.70-1.27]; P=0.72; 8-12 months: HR, 1.06 [95% CI, 0.74-1.51], P=0.77; >12 months: HR, 0.81 [95% CI, 0.63-1.06], P=0.12).ConclusionsIn this cohort of patients hospitalized for worsening HF, prior HF hospitalization was not associated with 180-day mortality after comprehensively accounting for patient characteristics measured during the index patient visit. Clinical confounders measured at the point-of-care may explain previously observed associations between prior HF hospitalization and mortality, and these clinical factors may be a more direct means of predicting patient survival. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00475852.

Dataset Information

Home-Time After Discharge Among Patients Hospitalized With Heart Failure.

Background

Objectives

Methods

Results

Conclusions

Publications

Home-Time After Discharge Among Patients Hospitalized With Heart Failure.

Similar Datasets

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