Validity of claims-based definitions of left ventricular systolic dysfunction in Medicare patients

Accuracy of heart failure ascertainment using routinely collected healthcare data: a systematic review and meta-analysis

BACKGROUND

Ascertainment of heart failure (HF) hospitalizations in cardiovascular trials is costly and complex, involving processes that could be streamlined by using routinely collected healthcare data (RCD). The utility of coded RCD for HF outcome ascertainment in randomized trials requires assessment. We systematically reviewed studies assessing RCD-based HF outcome ascertainment against "gold standard" (GS) methods to study the feasibility of using such methods in clinical trials.

METHODS

Studies assessing International Classification of Disease (ICD) coded RCD-based HF outcome ascertainment against GS methods and reporting at least one agreement statistic were identified by searching MEDLINE and Embase from inception to May 2021. Data on study characteristics, details of RCD and GS data sources and definitions, and test statistics were reviewed. Summary sensitivities and specificities for studies ascertaining acute and prevalent HF were estimated using a bivariate random effects meta-analysis. Heterogeneity was evaluated using I2 statistics and hierarchical summary receiver operating characteristic (HSROC) curves.

RESULTS

A total of 58 studies of 48,643 GS-adjudicated HF events were included in this review. Strategies used to improve case identification included the use of broader coding definitions, combining multiple data sources, and using machine learning algorithms to search free text data, but these methods were not always successful and at times reduced specificity in individual studies. Meta-analysis of 17 acute HF studies showed that RCD algorithms have high specificity (96.2%, 95% confidence interval [CI] 91.5-98.3), but lacked sensitivity (63.5%, 95% CI 51.3-74.1) with similar results for 21 prevalent HF studies. There was considerable heterogeneity between studies.

CONCLUSIONS

RCD can correctly identify HF outcomes but may miss approximately one-third of events. Methods used to improve case identification should also focus on minimizing false positives.

Differences in chronic obstructive pulmonary disease among US nursing home residents with heart failure according to sex and type of heart failure

BACKGROUND

Heart failure and chronic obstructive pulmonary disease (COPD) are leading cause of death throughout the world. Few recent studies have, however, examined possible sex and type of heart failure (HFpEF, HFrEF, and unspecified/other heart failure) differences in the prevalence of these chronic conditions among nursing home residents.

OBJECTIVES

The aim of this study is to examine the magnitude of concomitant COPD and differences according to sex and heart failure type, in terms of the prevalence of COPD among nursing home residents with heart failure.

METHODS

The principal study outcomes were examined in a cross-sectional study of 97 495 US nursing home residents with heart failure using the 2018 Minimum Data Set. The diagnoses of heart failure and COPD were operationalized through a review of nursing home admission, progress notes, and physical examination findings.

RESULTS

The average age of this study population was 81.3 ± 11.0 years, 67.3% were women, and 53.8% had COPD. A slightly higher prevalence of COPD was found among men than women. A higher proportion of unspecified heart failure type was found in both men and women, than reduced and preserved ejection fractions, respectively. In both men and women, there was a higher prevalence of COPD among those with various chronic conditions and current tobacco users.

CONCLUSIONS

COPD is highly prevalent among medically complex middle-aged and older nursing home residents with heart failure. Future research should focus on increasing our understanding of factors that influence the risk and optimal management of COPD and heart failure to improve the quality of life for nursing home residents.

Real-world safety of neurohormonal antagonist initiation among older adults following a heart failure hospitalization

AIMS

To optimize guideline-directed medical therapy for heart failure, patients may require the initiation of multiple neurohormonal antagonists (NHAs) during and following hospitalization. The safety of this approach for older adults is not well established.

METHODS AND RESULTS

We conducted an observational cohort study of 207 223 Medicare beneficiaries discharged home following a hospitalization for heart failure with reduced ejection fraction (HFrEF) (2008-2015). We performed Cox proportional hazards regression to examine the association between the count of NHAs initiated within 90 days of hospital discharge (as a time-varying exposure) and all-cause mortality, all-cause rehospitalization, and fall-related adverse events over the 90 day period following hospitalization. We calculated inverse probability-weighted hazard ratios (IPW-HRs) with 95% confidence intervals (CIs) comparing initiation of 1, 2, or 3 NHAs vs. 0. The IPW-HRs for mortality were 0.80 [95% CI (0.78-0.83)] for 1 NHA, 0.70 [95% CI (0.66-0.75)] for 2, and 0.94 [95% CI (0.83-1.06)] for 3. The IPW-HRs for readmission were 0.95 [95% CI (0.93-0.96)] for 1 NHA, 0.89 [95% CI (0.86-0.91)] for 2, and 0.96 [95% CI (0.90-1.02)] for 3. The IPW-HRs for fall-related adverse events were 1.13 [95% CI (1.10-1.15)] for 1 NHA, 1.25 [95% CI (1.21-1.30)] for 2, and 1.64 [95% CI (1.54-1.76)] for 3.

CONCLUSIONS

Initiating 1-2 NHAs among older adults within 90 days of HFrEF hospitalization was associated with lower mortality and lower readmission. However, initiating 3 NHAs was not associated with reduced mortality or readmission and was associated with a significant risk for fall-related adverse events.

Descriptive Epidemiology of Chronic Obstructive Pulmonary Disease in US Nursing Home Residents With Heart Failure

Chronic obstructive pulmonary disease (COPD) is highly prevalent in older adults with heart failure and heart failure is highly prevalent in older adults with COPD. Information is presently lacking about the extent to which COPD and heart failure co-occur among nursing home residents. The objective of this study was to describe the epidemiology of, and factors associated with, COPD among nursing home residents with heart failure. This cross-sectional study included 97,495 long-term stay nursing home residents with heart failure in 2018. The Minimum Data Set 3.0 (MDS) provided information on sociodemographic characteristics, comorbid conditions, and activities of daily living. Heart failure and COPD were defined based on notes at admission, hospitalizations, progress notes, and through physical examination findings. The majority of the study population were ≥75 years old (74.1%), women (67.3%), and Non-Hispanic Whites (77.4%). Nearly 1 in 5 residents had reduced ejection fraction findings, 23.1% had a preserved ejection fraction, and 53.8% of nursing home residents with heart failure had COPD. This pulmonary condition was less frequently noted in women, residents of advanced age, and racial/ethnic minorities and more frequently diagnosed in residents with comorbid conditions such as pneumonia, anxiety, obesity, diabetes mellitus, and coronary artery disease. We found a high prevalence of COPD, and identified several factors associated with COPD, in nursing home residents with heart failure. Our findings highlight challenges in the clinical management of COPD in nursing home residents with heart failure and how best to meet the care needs of this understudied population.

The association between beta-blockers and outcomes in patients with heart failure and concurrent Alzheimer's disease and related dementias

BACKGROUND

Contemporary patients with heart failure with reduced ejection fraction (HFrEF) are older and have a higher prevalence of cognitive impairment than those studied in trials. The risk/benefit trade-off of routine beta-blocker (BB) use in patients with HFrEF and Alzheimer's disease and related dementias (ADRD) has not been explored. This study aimed to determine the association between BB use and outcomes among patients with HFrEF and ADRD.

METHODS

Using a random 40% sample of Medicare Parts A, B, and D data we identified patients with ≥1 hospitalization for HFrEF between 2008 and 2018. Each patient was classified based on BB use prior to admission and after discharge. Outcomes include 90-day and 1-year mortality and readmission.

RESULTS

Between 2008 and 2018, we identified 357,030 patients hospitalized with HFrEF; 12.7% had ADRD. Patients with HFrEF and ADRD had higher 90-day and 1-year mortality compared to patients with HFrEF-only. Among patients admitted on a BB, 60.5% of patients with HFrEF-only were continued on therapy after discharge, compared to 56.8% of patients with HFrEF and ADRD. Discontinuing BB was associated with a 2.2-fold higher risk of 90-day mortality (p < 0.001) among patients with HF-only and a 2.- fold higher risk of 90-day mortality (p < 0.001) among patients with HFrEF + ADRD. Not starting a BB was associated with a 1.8-fold higher risk of 90-day mortality (p < 0.001) among patients with HFrEF-only and a 1.7-fold higher risk of 90-day mortality (p < 0.001) among patients with HFrEF + ADRD. Similar risks were seen at 1 year.

CONCLUSIONS

BB therapy is associated with significantly lower short and long-term mortality rates among all patients with HFrEF; the magnitude of these associated benefits appear at least as large in patients with HFrEF and ADRD compared to patients with HFrEF-only.

How many and who are patients with heart failure eligible to SGLT2 inhibitors? Responses from the combination of administrative healthcare and primary care databases

BACKGROUND

Recent successful findings (i.e. DAPA-HF trial) in patients with heart failure (HF) with/without diabetes treated with sodium-glucose co-transporter inhibitors (SGLT2-I) have fostered real-world data analyses. Fondazione Ricerca e Salute's (ReSD) administrative and Health Search's (HSD) primary healthcare databases were combined in the ReS-HS DB Consortium, to identify and characterize HF-patients eligible to SGLT2-I, and assess their costs charged to the Italian National Health Service (INHS).

METHODS AND RESULTS

Eligibility to SGLT2-I was HF diagnosis, age ≥ 18 years, reduced (≤40%) ejection fraction (HFrEF) and glomerular filtration rate (GFR) ≥30 ml/min. The HSD, including 13,313 HF-patients (1.5% of the total HSD population) was used to develop and test the algorithms for imputing HFrEF and GFR ≥ 30 ml/min, based on a set of covariates, to the ReSD, including 67,369 (1.5% of the total ReSD population). Subjects eligible to SGLT2-I were 2187 in HSD (61.1% of HFrEF); after the imputation, 15,145 in ReSD (58.8% of HFrEF). Prevalence of eligibility to SGLT2-I was higher in males then in females and increased with age; diabetic patients were 44.3% and 33.4% of HSD and ReSD populations eligible to SGLT2-I, respectively. Estimated from ReSD, the mean annual cost charged to the INHS per patient with HF eligible to SGLT2-I was €7122 (68% due to hospitalizations).

CONCLUSIONS

Approximately 20% of patients with HF was eligible to SGLT2-I. Real-world data can identify, quantify and characterize patients eligible to SGLT2-Is and assess related costs for the health care system, thus providing useful information to Regulatory Decision makers.

Relation of Household Income to Access and Adherence to Combination Sacubitril/Valsartan in Heart Failure: A Retrospective Analysis of Commercially Insured Patients

Background: Outcomes in heart failure with reduced ejection fraction (HFrEF), are influenced by access and adherence to guideline-directed medical therapy. Our objective was to study the association between annual household income and: (1) the odds of having a claim for sacubitril/valsartan among insured patients with HFrEF and (2) medication adherence (measured as the proportion of days covered [PDC]). We hypothesized that lower annual household income is associated with decreased odds of having a claim for and adhering to sacubitril/valsartan. Methods: Using the Optum de-identified Clinformatics® Data Mart, patients with HFrEF and ≥6 months of enrollment for follow up (2016-2020) were included. Covariates included age, sex, race, ethnicity, educational attainment, US region, number of prescribed medications, and Elixhauser Comorbidity Index. Prescription for sacubitril/valsartan was defined by the presence of a claim within 6 months of HFrEF diagnosis. Adherence was defined as PDC≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. Results: Among 322,007 individuals with incident HFrEF, 135,282 had complete data for analysis. Of the patients eligible for sacubitril/valsartan, 4.7% (6,372) had a claim within 6 months of HFrEF diagnosis. Following multivariable adjustment, individuals in the lowest annual income category (<$40,000) were significantly less likely (OR=0.83, 95% CI [0.76, 0.90]) to have a sacubitril/valsartan claim within 6 months of HFrEF diagnosis than those in the highest annual income category (≥$100,000). Annual income <$40,000 was associated with lower odds of PDC≥80% compared with income ≥$100,000 (OR=0.70, 95% CI [0.59, 0.83]). Conclusions: Lower household income is associated with decreased likelihood of a sacubitril/valsartan claim and medication adherence within 6 months of HFrEF diagnosis, even after adjusting for sociodemographic and clinical factors. Future analyses are needed to identify additional social factors associated with delays in sacubitril/valsartan initiation and long-term adherence.

Differences in Outcomes between Heart Failure Phenotypes in Patients with Coexistent COPD: A Cohort Study

RATIONALE

Differences in clinical presentation and outcomes between HF phenotypes in patients with COPD have not been assessed.

OBJECTIVES

The aim of this study was to compare clinical outcomes and healthcare resource use (HRU) between patients with COPD and HF with preserved (HFpEF), mildly-reduced (HFmrEF), and reduced ejection fraction (HFrEF).

METHODS

Patients with COPD and HF were identified in the United States (US) administrative claims database OptumLabs® DataWarehouse between 2008-2018. All-cause and cause-specific (HF) hospitalization, acute exacerbation of COPD (AECOPD, severe and moderate combined), mortality and HRU were compared between HF phenotypes.

RESULTS

From 5,419 patients with COPD, 70% had HFpEF, 20% had HFrEF and 10% had HFmrEF. All-cause hospitalization did not differ across groups, however patients with COPD and HFrEF had a greater risk of HF-specific hospitalization (HR 1.54, 95%CI 1.29-1.84) and mortality (HR: 1.17, 95%CI 1.03-1.33) compared to patients with COPD and HFpEF. Conversely, patients with COPD and HFrEF had a lower risk of AECOPD compared with those with COPD and HFpEF (HR 0.75, 95%CI 0.66-0.87). Rates of long-term stays (in skilled-nursing facilities) and emergency room visits were lower for those with COPD and HFrEF than for those with COPD and HFpEF.

CONCLUSION

Outcomes in patients with comorbid COPD and HFpEF are largely driven by COPD. Given the paucity in treatments for HFpEF, better differentiation between cardiac and respiratory symptoms may provide an opportunity to reduce the risk of AECOPD. Risk of death and HF hospitalization were highest among patients with COPD and HFrEF, emphasizing the importance of optimizing guideline-recommended HFrEF therapies in this group.

Patterns of Use and Clinical Outcomes with Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Acute Heart Failure and Changes in Kidney Function: An Analysis of the Veterans' Health Administrative Database

OBJECTIVE

The aim of the study was to determine patterns and predictors of utilization of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) in patients with acute heart failure (AHF) and changes in kidney function at admission, hospitalization, and discharge in relation to clinical outcomes.

METHODS

This retrospective analysis of the Veterans' Health Administration data (2016) included patients with heart failure (HF) with reduced ejection fraction who were hospitalized. Patients with an estimated glomerular filtration <15 cm3/min/1.73 m2 and those on dialysis were excluded. Patients were categorized based on the use of ACEI/ARB as continued, initiated, discontinued, or no therapy. Multivariable logistic regression evaluated predictors of being discharged home on an ACEI/ARB. Cox regression analysis evaluated outcomes (30 and 180-day mortality/HF readmissions).

RESULTS

3,652 patients were included, of which 37% of patients hospitalized for AHF had ACEI/ARB discontinued on admission, or not initiated. After adjusting for age, blood pressure, and serum potassium, a per-unit increase in admission serum creatinine (SCr) was independently associated with lower rates of continuation or initiation of ACEI/ARB odds ratio 0.51 95% confidence interval (CI) (0.46-0.57). Discharge on ACEI/ARB was independently associated with lower odds of 30- and 180-day mortality hazard ratio (HR) 0.36 95% CI (0.25-0.52), and HR 0.23 95% CI (0.19-0.27), respectively.

CONCLUSION

Higher SCr at admission is an important determinant of ACEI/ARB being discontinued or withheld in patients admitted with AHF. ACEI/ARB at discharge was associated with lower mortality in patients with AHF.

Association Between Beta-Blockers and Mortality and Readmission in Older Patients with Heart Failure: an Instrumental Variable Analysis

BACKGROUND

The demographics of heart failure are changing. The rate of growth of the "older" heart failure population, specifically those ≥ 75, has outpaced that of any other age group. These older patients were underrepresented in the early beta-blocker trials. There are several reasons, including a decreased potential for mortality benefit and increased risk of side effects, why the risk/benefit tradeoff may be different in this population.

OBJECTIVE

We aimed to determine the association between receipt of a beta-blocker after heart failure discharge and early mortality and readmission rates among patients with heart failure and reduced ejection fraction (HFrEF), specifically patients aged 75+.

DESIGN AND PARTICIPANTS

We used 100% Medicare Parts A and B and a random 40% sample of Part D to create a cohort of beneficiaries with ≥ 1 hospitalization for HFrEF between 2008 and 2016 to run an instrumental variable analysis.

MAIN MEASURE

The primary measure was 90-day, all-cause mortality; the secondary measure was 90-day, all-cause readmission.

KEY RESULTS

Using the two-stage least squared methodology, among all HFrEF patients, receipt of a beta-blocker within 30-day of discharge was associated with a - 4.35% (95% CI - 6.27 to - 2.42%, p < 0.001) decrease in 90-day mortality and a - 4.66% (95% CI - 7.40 to - 1.91%, p = 0.001) decrease in 90-day readmission rates. Even among patients ≥ 75 years old, receipt of a beta-blocker at discharge was also associated with a significant decrease in 90-day mortality, - 4.78% (95% CI - 7.19 to - 2.40%, p < 0.001) and 90-day readmissions, - 4.67% (95% CI - 7.89 to - 1.45%, p < 0.001).

CONCLUSION

Patients aged ≥ 75 years who receive a beta-blocker after HFrEF hospitalization have significantly lower 90-day mortality and readmission rates. The magnitude of benefit does not appear to wane with age. Absent a strong contraindication, all patients with HFrEF should attempt beta-blocker therapy at/after hospital discharge, regardless of age.

Effectiveness of sacubitril/valsartan versus aldosterone antagonists in heart failure with reduced ejection fraction: A retrospective cohort study

STUDY OBJECTIVE

To assess the effectiveness of sacubitril/valsartan versus angiotensin receptor antagonist therapy for prevention of heart failure (HF)-related hospitalization and all-cause hospitalization in a large cohort of patients with heart failure with reduced ejection fraction (HFrEF).

DESIGN

Retrospective cohort study.

DATA SOURCE

IBM^® MarketScan^® research databases (2014-2018).

PATIENTS

Patients aged 18 years or older with their first HFrEF hospitalization on or after January 1, 2015, who initiated sacubitril/valsartan or angiotensin receptor antagonist after hospital discharge.

INTERVENTION

Sacubitril/Valsartan versus Angiotensin receptor antagonist.

MEASUREMENTS AND MAIN RESULTS

The index date was the first sacubitril/valsartan or angiotensin receptor antagonist fill date. After 1 up to 3 propensity score matching, Cox proportional hazards regression was used with robust variance estimators to compare HF-related and all-cause hospitalizations between treatments. Subgroup and sensitivity analyses were conducted to assess the robustness of the main analysis. After propensity score matching, 1,088 sacubitril/valsartan and 2,839 angiotensin receptor antagonist new users were included. The crude incidence of HF-related hospitalization was 13 per 100 person-years for sacubitril/valsartan users and 18 per 100 person-years for angiotensin receptor antagonist users. Compared with angiotensin receptor antagonist use, sacubitril/valsartan use was associated with 27% lower risk of HF-related hospitalization (adjusted hazard ratio, 0.73; 95% confidence interval, 0.58-0.91; p = 0.006) and 31% lower risk of all-cause hospitalization (adjusted hazard ratio, 0.69; 95% confidence interval, 0.61-0.79; p < 0.001). Subgroup analyses revealed no significant heterogeneity, including subpopulations with chronic kidney disease or coronary artery disease.

CONCLUSIONS

Compared with angiotensin receptor antagonists, sacubitril/valsartan was associated with lower risk of HF-related and all-cause hospitalizations. Our data suggest that, when added sequentially, sacubitril/valsartan should be the preferred initial agent over angiotensin receptor antagonists.

The association between neurohormonal therapy and mortality in older adults with heart failure with reduced ejection fraction

BACKGROUND/OBJECTIVES

Neurohormonal therapy, which includes beta-blockers and angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACEi/ARBs), is the cornerstone of heart failure with reduced ejection fraction (HFrEF) treatment. While neurohormonal therapies have demonstrated efficacy in randomized clinical trials, older patients, which now comprise the majority of HFrEF patients, were underrepresented in those original trials. This study aimed to determine the association between short- (30 day) and long-term (1 year) mortality and the use of neurohormonal therapy in HFrEF patients, across the age spectrum.

DESIGN/SETTING/PARTICIPANTS

This is a population-based, retrospective, cohort study between January 2008 and December 2015. We used 100% Medicare Parts A and B and a random 40% sample of Part D to create a cohort of 295,494 fee-for-service beneficiaries with at least one hospitalization for HFrEF between 2008 and 2015. All analyses were performed between May 2019 and July 2020.

EXPOSURE

We used Part D data to determine exposure to beta-blocker and ACEi and ARB therapy.

RESULTS

We found that in 295,494 patients admitted for HFrEF between 2008 and 2015, the average age was 80 years, 54% were female and 17% were non-white. The baseline mortality rate was higher among those aged ≥85, but the mortality benefits of neurohormonal therapy were preserved across the age spectrum. Among those ≥85 years old, the hazard ratio for death within 30 days was 0.59 (95% confidence interval [CI] 0.56-0.62; p < 0.001) for beta-blockers and 0.47 (95% CI 0.44-0.49; p < 0.001) for ACEi/ARBs. The hazard ratio for death within 1 year was 0.37-0.56 (95% CI 0.35-0.58; p < 0.001) for beta-blockers and 0.38-0.53 (95% CI 0.37-0.55; p < 0.001) for ACEi/ARB.

CONCLUSION

At a population level, neurohormonal therapy was associated with lower short- and long-term mortality across the age spectrum.

Heart Failure, Atrioventricular Block, and Ventricular Tachycardia in Sarcoidosis

Background Sarcoidosis is a granulomatous disease usually affecting the lungs, although cardiac morbidity may be common. The risk of these outcomes and the characteristics that predict them remain largely unknown. This study investigates the epidemiology of heart failure, atrioventricular block, and ventricular tachycardia among patients with and without sarcoidosis. Methods and Results We identified California residents aged ≥21 years using the Office of Statewide Health Planning and Development ambulatory surgery, emergency, or inpatient databases from 2005 to 2015. The risk of sarcoidosis on incident heart failure, atrioventricular block, and ventricular tachycardia were each determined. Linkage to the Social Security Death Index was used to ascertain overall mortality. Among 22 527 964 California residents, 19 762 patients with sarcoidosis (0.09%) were identified. Sarcoidosis was the strongest predictor of heart failure (hazard ratio [HR], 11.2; 95% CI, 10.7-11.7), atrioventricular block (HR, 117.7; 95% CI, 103.3-134.0), and ventricular tachycardia (HR, 26.1; 95% CI, 24.2-28.1) identified among all risk factors. The presence of any cardiac involvement best predicted each outcome. Approximately 22% (95% CI, 18%-26%) of the relationship between sarcoidosis and increased mortality was explained by the presence of at least 1 of these cardiovascular outcomes. Conclusions The magnitude of risk associated with sarcoidosis as a predictor of heart failure, atrioventricular block, and ventricular tachycardia, exceeds all established risk factors. Surveillance for and anticipation of these outcomes among patients with sarcoidosis is indicated, and consideration of a sarcoidosis diagnosis may be prudent among patients with heart failure, atrioventricular block, or ventricular tachycardia.

Model-based comorbidity clusters in patients with heart failure: association with clinical outcomes and healthcare utilization

BACKGROUND

Comorbidities affect outcomes in heart failure (HF), but are not reflected in current HF classification. The aim of this study is to characterize HF groups that account for higher-order interactions between comorbidities and to investigate the association between comorbidity groups and outcomes.

METHODS

Latent class analysis (LCA) was performed on 12 comorbidities from patients with HF identified from administrative claims data in the USA (OptumLabs Data Warehouse®) between 2008 and 2018. Associations with admission to hospital and mortality were assessed with Cox regression. Negative binomial regression was used to examine rates of healthcare use.

RESULTS

In a population of 318,384 individuals, we identified five comorbidity clusters, named according to their dominant features: low-burden, metabolic-vascular, anemic, ischemic, and metabolic. Compared to the low-burden group (minimal comorbidities), patients in the metabolic-vascular group (exhibiting a pattern of diabetes, obesity, and vascular disease) had the worst prognosis for admission (HR 2.21, 95% CI 2.17-2.25) and death (HR 1.87, 95% CI 1.74-2.01), followed by the ischemic, anemic, and metabolic groups. The anemic group experienced an intermediate risk of admission (HR 1.49, 95% CI 1.44-1.54) and death (HR 1.46, 95% CI 1.30-1.64). Healthcare use also varied: the anemic group had the highest rate of outpatient visits, compared to the low-burden group (IRR 2.11, 95% CI 2.06-2.16); the metabolic-vascular and ischemic groups had the highest rate of admissions (IRR 2.11, 95% CI 2.08-2.15, and 2.11, 95% CI 2.07-2.15) and healthcare costs.

CONCLUSIONS

These data demonstrate the feasibility of using LCA to classify HF based on comorbidities alone and should encourage investigation of multidimensional approaches in comorbidity management to reduce admission and mortality risk among patients with HF.

Identification of Patients with Heart Failure in Large Datasets

Large registries, administrative data, and the electronic health record (EHR) offer opportunities to identify patients with heart failure, which can be used for research purposes, process improvement, and optimal care delivery. Identification of cases is challenging because of the heterogeneous nature of the disease, which encompasses various phenotypes that may respond differently to treatment. The increasing availability of both structured and unstructured data in the EHR has expanded opportunities for cohort construction. This article reviews the current literature on approaches to identification of heart failure, and looks toward the future of machine learning, big data, and phenomapping.

Real-World Analysis of Guideline-Based Therapy After Hospitalization for Heart Failure

Background Patients hospitalized with heart failure (HF) with reduced ejection fraction have high risk of rehospitalization or death. Despite guideline recommendations based on high-quality evidence, a substantial proportion of patients with HF with reduced ejection fraction receive suboptimal care and/or do not comply with optimal care following hospitalization. Methods and Results This retrospective observational study identified 17 106 patients with HF with reduced ejection fraction with an incident HF-related hospitalization using the Humana Medicare Advantage database (2008-2016). HF medication classes (beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, or mineralocorticoid receptor antagonists) received in the year after hospitalization were recorded, and categorized by treatment intensity (ie, number of concomitant medication classes received: none [23% of patients; n=3987], monotherapy [22%; n=3777], dual therapy [41%; n=7056], or triple therapy [13%; n=2286]). Compared with no medication, risk of primary outcome (composite of death or rehospitalization) was significantly reduced (hazard ratio [95% CI]) with monotherapy (0.68 [0.64-0.71]), dual therapy (0.56 [0.53-0.59]), and triple therapy (0.45 [0.41-0.50]). Nearly half (46%) of patients who received post-discharge medication had no dose escalation. Overall, 59% of patients had follow-up with a primary care physician within 14 days of discharge, and 23% had follow-up with a cardiologist. Conclusions In real-world clinical practice, increasing treatment intensity reduced risk of death and rehospitalization among patients hospitalized for HF, though the use of guideline-recommended dual and triple HF therapy remained low. There are opportunities to improve post-discharge medical management for patients with HF with reduced ejection fraction such as optimizing dose titration and improving post-discharge follow-up with providers.

Evidence-based beta blocker use associated with lower heart failure readmission and mortality, but not all-cause readmission, among Medicare beneficiaries hospitalized for heart failure with reduced ejection fraction

The beta blockers carvedilol, bisoprolol, and sustained-release metoprolol succinate reduce readmissions and mortality among patients with heart failure with reduced ejection fraction (HFrEF), based upon clinical trial and registry studies. Results from these studies may not generalize to the typical patient with HFrEF. We conducted a retrospective cohort study of beneficiaries in the Medicare 5% sample hospitalized for HFrEF between 2007 and 2013 and were discharged alive. We compared the 30-day and 365-day heart failure (HF) readmission, all-cause readmission, and mortality rates between beneficiaries who filled a prescription for an evidence-based beta blocker and those who did not after being hospitalized for HFrEF. Out of 12,127 beneficiaries hospitalized for HFrEF, 20% were readmitted for HF, 62% were readmitted for any cause, and 27% died within 365 days. In competing risk models adjusted for demographics, healthcare utilization, and comorbidities, beta blocker use was associated with a lower risk of HF readmission between 8-365 days post discharge (hazard ratio 0.79 [95% confidence interval 0.76, 0.82]), but was not significantly associated with all-cause readmission (1.02 [0.97-1.07]). In Cox models adjusted for the same covariates, beta blocker use was associated with lower mortality 8-365 days post discharge (0.65 [0.60-0.71]). Results were similar when follow up was truncated at 30 days post discharge. Increasing the use of beta blockers following HFrEF hospitalization may not decrease all-cause readmissions among Medicare beneficiaries, but may reduce HF-specific readmissions and mortality.

Comparison of Perioperative Outcomes in Heart Failure Patients With Reduced Versus Preserved Ejection Fraction After Noncardiac Surgery

OBJECTIVE

To compare outcome after noncardiac surgery between HF patients with reduced versus preserved ejection fraction.

SUMMARY OF BACKGROUND DATA

HF patients who undergo major noncardiac surgery have higher risks of morbidity and mortality compared to the general population. However, it is unclear whether HF subtypes confer different risk.

METHODS

This retrospective study included HF patients, 45 years or older, who underwent noncardiac surgery from January 1, 2010 to September 30, 2015 in the Nationwide Readmissions Database. Multivariable logistic regression models were used to provide adjusted rates of postoperative outcomes. Hospital-level clustering and Nationwide Readmissions Database sampling weights were applied to all models.

RESULTS

Of the weighted 296,057 HF patients [HF with reduced ejection fraction (HFrEF) 48.1%; HF with preserved ejection fraction (HFpEF) 51.9%] who underwent noncardiac surgery, 41.1% had cardiopulmonary complications, 55.7% had noncardiopulmonary complications and 5.4% died during hospitalization. Thirty-day readmission rates for the weighted 232,852 HF patients was 21.5%. The adjusted odds ratios of cardiopulmonary and noncardiopulmonary complications, in-hospital mortality and 30-day readmission for HFrEF compared to HFpEF patients were 1.01 [95% confidence interval (CI), 0.99-1.04], 1.05 (95% CI, 1.02-1.07), 1.27 (95% CI, 1.21-1.34), and 1.08 (95% CI, 1.05-1.12), respectively.

CONCLUSIONS

HFrEF patients have increased risks of noncardiopulmonary complications, mortality, and readmission after noncardiac surgery. These findings suggest that targeted perioperative care for HF subtypes may be crucial for the growing population of HF patients undergoing noncardiac surgery. Despite cardiopulmonary complications not being statistically different between HF subtypes, given the high occurrence rate, any intervention to decrease the rate would be clinically meaningful.

Potentially harmful drug prescription in elderly patients with heart failure with reduced ejection fraction

Aims

This study aimed to evaluate the prescription frequency of potentially harmful prescription drugs as defined in current heart failure guidelines among elderly patients with a diagnosis of heart failure with reduced ejection fraction and their association with clinical outcomes.

Methods and results

We used the Centers for Medicare & Medicaid Services data from a nationally representative 5% sample for the years 2014–2016 to identify patients admitted to acute care hospitals with a primary diagnosis of heart failure with reduced ejection fraction. The primary exposure was filling a prescription for a potentially harmful drug. Potentially harmful drug fills were treated as a time‐dependent covariate to examine their association on readmission and mortality. A total of 8993 patients met study criteria. Potentially harmful drugs were prescribed in 1077 (11.9%) patients within 90 days of discharge from the heart failure hospitalization. Non‐steroidal anti‐inflammatory agents were the most frequently prescribed potentially harmful drug (6.7%) followed by calcium channel blockers (4.7%), thiazolidinedione (0.59%), and select antiarrhythmic (0.33%). Factors independently associated with potentially harmful drug prescription were female gender, Hispanic ethnicity, severe obesity, among others. In the multivariable Cox model, the prescription of a potentially harmful drug was associated with an increased risk of readmission (hazard ratio 1.14; 95% confidence interval 1.05–1.23, P < 0.001). Among drug subgroups, only calcium channel blockers were associated with an increased risk of readmission (hazard ratio 1.225; 95% confidence interval 1.085–1.382, P = 0.0011).

Conclusions

In elderly patients discharged with a primary diagnosis of heart failure with reduced ejection fraction on guideline‐directed medical therapy, prescription of a potentially harmful drug was frequent. Calcium channel blockers were associated with an increased risk of readmission.

Relation of a Simple Cardiac Co-Morbidity Count and Cardiovascular Readmission After a Heart Failure Hospitalization

Although several risk calculators are available to determine risk for readmission following a heart failure (HF) hospitalization, none provide information on cause-specific readmission. Understanding risk for cause-specific readmission could aid in developing a targeted approach to reducing readmissions. We sought to determine if a simple cardiac co-morbidity count could identify individuals at high risk for a cardiovascular (CV) readmission following a HF hospitalization. Using the Nationwide Readmissions Database, we examined nonfatal hospital discharges with a principal diagnosis of HF. We calculated a 0 to 3 cardiac co-morbidity count based on the presence of coronary artery disease, atrial arrhythmia, and/or ventricular arrhythmia. We used a multinomial logistic regression to determine if the cardiac co-morbidity count was independently associated with CV readmission or non-CV readmission, adjusting for patient- and hospital-level confounders. In 380,075 discharges, 28% had a co-morbidity count of 0, 47% had a count of 1, 23% had a count of 2, and 2% had a count of 3. In a fully adjusted model, cardiac co-morbidity count was independently associated with CV readmission: compared with individuals with a count of 0, the relative risk for those with a count of 1 was 1.27 (95% confidence interval [CI]: 1.23 to 1.31); for those with a count of 2 was 1.40 (95% CI: 1.35 to 1.46); and for those with a count of 3 was 1.36 (95% CI: 1.23 to 1.51). Cardiac co-morbidity count was not independently associated with non-CV readmission. In conclusion, we found that a simple cardiac co-morbidity count was independently associated with increased risk of CV but not non-CV readmission.

Opportunities and Challenges of Claims-Based Quality Assessment: The Case of Postdischarge β-Blocker Treatment in Patients With Heart Failure With Reduced Ejection Fraction

BACKGROUND

To combat the high cost and increasing burden of quality reporting, the Medicare Payment Advisory (MedPAC) has recommended using claims data wherever possible to measure clinical quality. In this article, we use a cohort of Medicare beneficiaries with heart failure with reduced ejection fraction and existing quality metrics to explore the impact of changes in quality metric methodology on measured quality performance, the association with patient outcomes, and hospital rankings.

METHODS AND RESULTS

We used 100% Medicare Parts A and B and a random 40% sample of Part D from 2008 to 2015 to create (1) a cohort of 295 494 fee-for-service beneficiaries with ≥1 hospitalization for heart failure with reduced ejection fraction and (2) a cohort of 1079 hospitals with ≥11 heart failure with reduced ejection fraction admissions in 2014 and 2015. We used Part D data to calculate β-blocker use after discharge and β-blocker use over time. We then varied the quality metric methodologies to explore the impact on measured performance. We then used multivariable time-to-event analyses to explore the impact of metric methodology on the association between quality performance and patient outcomes and Kendall's Tau to describe impact of quality metric methodology on hospital rankings. We found that quality metric methodology had a significant impact on measured quality performance. The association between quality performance and readmissions was sensitive to changes in methodology but the association with 1-year mortality was not. Changes in quality metric methodology also had a substantial impact on hospital quality rankings.

CONCLUSIONS

This article highlights how small changes in quality metric methodology can have a significant impact on measured quality performance, the association between quality performance and utilization-based outcomes, and hospital rankings. These findings highlight the need for standardized quality metric methodologies, better case-mix adjustment and cast further doubt on the use of utilization-based outcomes as quality metrics in chronic diseases.

Comparative Effectiveness of Sacubitril-Valsartan Versus ACE/ARB Therapy in Heart Failure With Reduced Ejection Fraction

OBJECTIVES

This paper aims to compare the effectiveness of sacubitril-valsartan and angiotensin-converting enzyme inhibitor (ACE)/angiotensin receptor blocker (ARB) in systolic heart failure (HF).

BACKGROUND

Sacubitril-valsartan reduced risks of death and hospitalization for HF versus enalapril in ambulatory patients with HF and reduced ejection fraction in the PARADIGM-HF (Prospective Comparison of Angiotensin II Receptor Blocker Neprilysin Inhibitor with Angiotensin Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in HF) trial. However, the comparative effectiveness of sacubitril-valsartan and ACE/ARB in patients treated in routine clinical practice is unclear.

METHODS

We identified patients with systolic HF in a U.S. administrative claims database treated with sacubitril-valsartan or ACE/ARB from July 1, 2015, to February 2, 2018. One-to-one propensity score matching was used to balance patients on 29 clinical variables. Cox models were used to compare outcomes between treatment groups.

RESULTS

A total of 7,893 matched pairs were included; mean (SD) follow-up was 6.3 (5.4) months. Sacubitril-valsartan was associated with lower risks of all-cause mortality or all-cause hospitalization (hazard ratio [HR]: 0.86, 95% confidence interval (CI): 0.81 to 0.91; p < 0.001), all-cause mortality (HR: 0.80, 95% CI: 0.66 to 0.97; p = 0.027), and all-cause hospitalization (HR: 0.86, 95% CI: 0.80 to 0.91; p < 0.001), but not HF hospitalization (HR: 1.07, 95% CI: 0.96 to 1.19; p = 0.26). A lower risk of the primary outcome with sacubitril-valsartan was observed in white patients (HR: 0.83, 95% CI: 0.76 to 0.90) but not black patients (21% of population, HR: 1.00, 95% CI: 0.88 to 1.15; interaction p = 0.032). No statistically significant differences in treatment response by sex or age were observed.

CONCLUSIONS

Sacubitril-valsartan was associated with lower risks of death and hospitalization compared with ACE/ARB in a heterogeneous cohort of patients with systolic HF. However, our finding that outcomes with sacubitril-valsartan and ACE/ARBs were similar in black patients warrants further evaluation.

Antidiabetic medication use in patients with type 2 diabetes and chronic kidney disease

AIMS

To quantify patterns of conventional and newer antidiabetic medication use in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD).

METHODS

We used data from a large claims and integrated dataset that includes employed and commercially insured patients in the US to select patients who had T2DM and CKD with information on laboratory values and prescriptions for antidiabetic medications from January 1, 2014 to January 1, 2015. We stratified the analyses by sociodemographic variables.

RESULTS

In a cohort of 38,577 patients with T2DM and CKD, we found wide variation in the treatment of T2DM by CKD stage as well as by several sociodemographic factors. Although metformin was the most commonly prescribed medication, only about half of patients in the cohort and fewer than two-thirds of patients with early stage CKD were prescribed metformin. Approximately 10.6% of patients with CKD stage 4 and 2.1% of the patients with CKD stage 5 were prescribed metformin. Sulfonylureas with active metabolites that accumulate with impaired kidney function were prescribed in more than one-third of patients with CKD stages 3b, 4, and 5. Only 3.4% and 12.3% of patients were prescribed GLP-1 and DPP-4 respectively.

CONCLUSIONS

Prescriptions for metformin were lower than expected among patients with mild to moderate CKD. Prescriptions for newer antidiabetic medications with known safety and efficacy across the spectrum of CKD remained low. Prescriptions for agents contraindicated in advanced CKD continued to be written in a sizeable fraction of patients.

Serious Illness and End-of-Life Treatments for Nurses Compared with the General Population

OBJECTIVES

As key team members caring for people with advanced illness, nurses teach patients and families about managing their illnesses and help them to understand their options. Our objective was to determine if nurses' personal healthcare experience with serious illness and end-of-life (EOL) care differs from the general population as was shown for physicians.

DESIGN

Observational propensity-matched cohort study.

SETTING

Fee-for-service Medicare.

PARTICIPANTS

Nurses' Health Study (NHS) and a random 20% national sample of Medicare beneficiaries aged 66 years or older with Alzheimer's disease and related dementias (ADRD) or congestive heart failure (CHF) diagnosed in the hospital.

MEASUREMENTS

Characteristics of care during the first year after diagnosis and the last 6 months of life (EOL).

RESULTS

Among 57 660 NHS participants, 7380 had ADRD and 5375 had CHF; 3227 ADRD patients and 2899 CHF patients subsequently died. Care patterns in the first year were similar for NHS participants and the matched national sample: hospitalization rates, emergency visits, and preventable hospitalizations were no different in either disease. Ambulatory visits were slightly higher for NHS participants than the national sample with ADRD (13.1 vs 12.5 visits; P < .01) and with CHF (13.7 vs 12.5; P < .001). Decedents in the NHS and national sample had similar acute care use (hospitalization and emergency visits) in both diseases, but those with ADRD were less likely to use life-prolonging treatments such as mechanical ventilation (10.9% vs 13.5%; P = .001), less likely to die in a hospital with a stay in the intensive care unit (10.4% vs 12.1%; P = .03), and more likely to use hospice (58.9% vs 54.8%; P < .001). CHF at the EOL results were similar.

CONCLUSIONS

Nurses with newly identified serious illness experience similar care as the general Medicare population. However, at EOL, nurses are more likely to choose less aggressive treatments than the patients for whom they care. J Am Geriatr Soc 67:1582-1589, 2019.

Adoption of Sacubitril/Valsartan for the Management of Patients With Heart Failure

BACKGROUND

The US Food and Drug Administration approved the use of sacubitril/valsartan in patients with heart failure with reduced ejection fraction in July 2015. We aimed to assess the adoption and prescription drug costs of sacubitril/valsartan in its first 18 months after Food and Drug Administration approval.

METHODS AND RESULTS

Using a large US insurance database, we identified privately insured and Medicare Advantage beneficiaries who filled a first prescription for sacubitril/valsartan between July 1, 2015, and December 31, 2016. We compared them to patients treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Outcomes included adoption, prescription drug costs, and 180-day adherence, defined as a proportion of days covered ≥80%. A total of 2244 patients initiated sacubitril/valsartan. Although the number of users increased over time, the proportion of heart failure with reduced ejection fraction patients taking sacubitril/valsartan remained low (<3%). Patients prescribed sacubitril/valsartan were younger, more often male, with less comorbidity than those taking an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Although a majority of prescription costs were covered by the health plan (mean, $328.37; median, $362.44 per 30-day prescription), out-of-pocket costs were still high (mean, $71.16; median, $40.27). By comparison, median out-of-pocket costs were $2 to $3 for lisinopril, losartan, carvedilol, and spironolactone. Overall, 59.1% of patients were adherent to sacubitril/valsartan. Refill patterns suggested that nearly half of nonadherent patients discontinued sacubitril/valsartan within 180 days of starting.

CONCLUSIONS

Adoption of sacubitril/valsartan after Food and Drug Administration approval has been slow and may be associated with the high cost.

Identifying heart failure using EMR-based algorithms

BACKGROUND

Heart failure (HF) is a major clinical and public health problem, the management of which will benefit from large-scale pragmatic research that leverages electronic medical records (EMR). Requisite to using EMRs for HF research is the development of reliable algorithms to identify HF patients. We aimed to develop and validate computable phenotype algorithms to identify patients with HF using standardized data elements defined by the Patient Centered Outcomes Research Network (PCORnet) Common Data Model (CDM).

METHODS

We built HF computable phenotypes utilizing the data domains of HF diagnosis codes, prescribed HF-related medications and N-terminal B-type natriuretic peptide (NT-proBNP). Algorithms were validated in a cohort (n = 76,254) drawn from Olmsted County, MN between 2010-2012 a sample of whose records were manually reviewed to confirm HF according to Framingham criteria.

RESULTS

The different algorithms we tested provided different tradeoffs between sensitivity and positive predictive value (PPV). The highest sensitivity (78.7%) algorithm utilized one HF diagnosis code and had the lowest PPV (68.5%). The addition of more algorithm components, such as additional HF diagnosis codes, HF medications or elevated NT-proBNP, improved the PPV while reducing sensitivity. When added to a diagnostic code, the addition of NT-proBNP (>450 pg/mL) had a similar impact compared to additional HF medication criteria, increasing PPV by ∼3-4% and decreasing sensitivity by ∼7-10%.

CONCLUSIONS

Algorithms derived from PCORnet CDM elements can be used to identify patients with HF without manual adjudication with reasonable sensitivity and PPV. Algorithm choice should be driven by the goal of the research.

Low Utilization of Beta-Blockers Among Medicare Beneficiaries Hospitalized for Heart Failure With Reduced Ejection Fraction

BACKGROUND

The evidence-based beta-blockers carvedilol, bisoprolol, and metoprolol succinate reduce mortality and hospitalizations among patients with heart failure with reduced ejection fraction (HFrEF). Use of these medications is not well described in the general population of patients with HFrEF, especially among patients with potential contraindications.

OBJECTIVES

Our goal was to describe the patterns of prescription fills for carvedilol, bisoprolol, and metoprolol succinate among Medicare beneficiaries hospitalized for HFrEF, as well as to estimate the associations between specific contraindications for beta-blocker therapy and those patterns.

METHODS AND RESULTS

With the use of the cohort of 15,205 Medicare beneficiaries hospitalized for HFrEF from 2007 to 2013 in the 5% Medicare random sample, we described prescription fills (30 days after discharge) and dosage patterns (1 year after discharge) for beta-blockers. By means of of Fine and Gray competing risk models, we estimated the associations between potential contraindications (hypotension, chronic obstructive pulmonary disease [COPD], asthma, and syncope) and prescription fill and dosing patterns while adjusting for demographics, comorbidities, and health care utilization. For beneficiaries who did not die or readmitted to the hospital, 38% of hospitalizations were followed by a prescription fill for an evidence-based beta-blocker within 30 days, 12% were followed by prescription fills for at least 50% of the recommended dose of an evidence-based beta-blocker within 1 year, and 9% were followed by a prescription fill for an up-titrated dose of an evidence-based beta-blocker within 1 year. The prevalence of the contraindications were 21% for hypotension, 48% for COPD, 15% for asthma, and 12% for syncope. Among beneficiaries who did not fill a prescription for an evidence-based beta-blocker within 30 days, 67% had at least 1 of these contraindications. Hypotension, COPD, and syncope were each associated with a ∼10% lower risk of filling a prescription for an evidence-based beta-blocker.

CONCLUSIONS

Prescription fill and up-titration rates for evidence-based beta-blockers are low among Medicare beneficiaries with HFrEF, but contraindications explain only a minor part of these low rates.

Causes and Temporal Patterns of 30-Day Readmission Among Older Adults Hospitalized With Heart Failure With Preserved or Reduced Ejection Fraction

Background

It is unknown whether causes and temporal patterns of 30‐day readmission vary between heart failure (HF) with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF). We sought to address this question by examining a 5% national sample of Medicare beneficiaries.

Methods and Results

We included individuals who experienced a hospitalization for HFpEF or HFrEF between 2007 and 2013. We identified causes of 30‐day readmission based on primary discharge diagnosis and further classified causes of readmission as HF‐related, non–HF cardiovascular‐related, and non–cardiovascular‐related. We calculated the cumulative incidence of these classifications for HFpEF and HFrEF in a competing risks model and calculated subdistribution hazard ratios of these classifications by comparing those with HFpEF and those with HFrEF. Among 60 640 Medicare beneficiaries, we identified 13 785 unique older adults hospitalized with HFpEF and 15 205 who were hospitalized with HFrEF. Noncardiovascular diagnoses represented the most common causes of 30‐day readmission (HFpEF: 59%; HFrEF: 47%), a pattern that was observed for each week of the 30‐day study period for both HFpEF and HFrEF participants. In comparing readmission diagnoses in an adjusted model, non–cardiovascular‐related diagnoses were more common and HF‐related diagnoses were less common in HFpEF participants.

Conclusions

Non–cardiovascular‐related diagnoses represented the most common causes of 30‐day readmission following HF hospitalization for each week of the 30‐day postdischarge period. HF diagnoses were less common among those with HFpEF compared with HFrEF. Future interventions aimed at reducing 30‐day readmissions following an HF hospitalization would benefit from an increased focus on noncardiovascular comorbidity and interventions that target HFpEF and HFrEF separately.

Wilson's Disease and Cardiac Myopathy

Wilson's disease is a well-characterized disorder known to cause liver and brain disease due to abnormal copper deposition. Data regarding copper infiltration of the heart is conflicting, and the risk of heart disease has not been well described. We aimed to determine whether Wilson's disease is associated with cardiac myopathy, clinically evident in the atria as atrial fibrillation (AF) and in the ventricles as heart failure (HF). We longitudinally assessed 14.3 million patients in the California Healthcare Cost and Utilization Project database from 2005 through 2009 for diagnoses of Wilson's disease, AF, HF, and covariates using International Classification of Diseases-9th Edition codes. Cirrhosis and appendicitis diagnoses were assessed for positive and negative validation, respectively. We identified 463 patients with Wilson's disease. As expected in validation analyses, patients with Wilson's disease had a threefold greater risk of cirrhosis (hazard ratio [HR] 2.85, 95% confidence interval [CI] 2.81 to 2.90, p <0.0001) and no increased risk of appendicitis (HR 0.24, 95% CI 0.04 to 1.71, p = 0.16). Patients with Wilson's disease exhibited a 29% higher risk of AF after adjusting for age, gender, race, income, hypertension, diabetes, renal disease, hyperlipidemia, obesity, coronary disease, and obstructive sleep apnea (HR 1.29, 95% CI 1.15 to 1.45, p <0.0001). After adjusting for the same covariates, patients with Wilson's disease had a 55% higher risk of incident HF (HR 1.55, 95% CI 1.41 to 1.71, p <0.0001). Patients with Wilson's disease have an increased risk of AF and HF, supporting the need for careful surveillance for heart disease. These findings also suggest that the role of copper metabolism in heart disease should be more broadly investigated.

Who are they? Patients with heart failure in American skilled nursing facilities

BACKGROUND

Heart failure (HF) is common among skilled nursing facility (SNF) residents, yet patients with HF in the SNF setting have not been well described.

METHODS

Using Minimum Data Set 3.0 cross-linked to Medicare data (2011-2012), we studied 150,959 HF patients admitted to 13,858 SNFs throughout the USA. ICD-9 codes were used to differentiate patients with HF with preserved ejection fraction (HFpEF), reduced ejection fraction (HFrEF), or unspecified HF.

RESULTS

The median age of the study population was 82 years, 68% were women, 34% had HFpEF, and 27% had HFrEF. HFpEF patients were older than those with HFrEF. Moderate/severe physical limitations (82%) and cognitive impairment (37%) were common, regardless of HF type. The burden and pattern of common comorbidities, with the exception of coronary heart disease, were similar among all groups, with a median of five comorbidities. One half of patients with HF had been prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 39% evidence-based β-blockers.

CONCLUSIONS

SNF residents with HF are old and suffer from significant physical limitations and cognitive impairment and a high degree of comorbidity. These patients differ substantially from HF patients enrolled in randomized clinical trials and that might explain divergence from treatment guidelines.

Alcohol Abuse and Cardiac Disease

BACKGROUND

Understanding the relationship between alcohol abuse, a common and theoretically modifiable condition, and the most common cause of death in the world, cardiovascular disease, may inform potential prevention strategies.

OBJECTIVES

The study sought to investigate the associations among alcohol abuse and atrial fibrillation (AF), myocardial infarction (MI), and congestive heart failure (CHF).

METHODS

Using the Healthcare Cost and Utilization Project database, we performed a longitudinal analysis of California residents ≥21 years of age who received ambulatory surgery, emergency, or inpatient medical care in California between 2005 and 2009. We determined the risk of an alcohol abuse diagnosis on incident AF, MI, and CHF. Patient characteristics modifying the associations and population-attributable risks were determined.

RESULTS

Among 14,727,591 patients, 268,084 (1.8%) had alcohol abuse. After multivariable adjustment, alcohol abuse was associated with an increased risk of incident AF (hazard ratio [HR]: 2.14; 95% confidence interval [CI]: 2.08 to 2.19; p < 0.0001), MI (HR: 1.45; 95% CI: 1.40 to 1.51; p < 0.0001), and CHF (HR: 2.34; 95% CI: 2.29 to 2.39; p < 0.0001). In interaction analyses, individuals without conventional risk factors for cardiovascular disease exhibited a disproportionately enhanced risk of each outcome. The population-attributable risk of alcohol abuse on each outcome was of similar magnitude to other well-recognized modifiable risk factors.

CONCLUSIONS

Alcohol abuse increased the risk of AF, MI, and CHF to a similar degree as other well-established risk factors. Those without traditional cardiovascular risk factors are disproportionately prone to these cardiac diseases in the setting of alcohol abuse. Thus, efforts to mitigate alcohol abuse might result in meaningful reductions of cardiovascular disease.

Heart Failure and Mortality of Adult Survivors from Acute Myocarditis Requiring Intensive Care Treatment - A Nationwide Cohort Study

Background The correlation between severity and long-term outcomes of pediatric myocarditis have been reported, however this correlation in adults has rarely been studied. Materials and Methods This nationwide population-based cohort study used data from the National Health Insurance Research Database in Taiwan. Patients aged < 75 and > 18 years admitted to an intensive care unit due to acute myocarditis were enrolled and divided into three groups according to mechanical circulatory support (MCS) after excluding major comorbidities. All-cause mortality, cardiovascular death, and heart failure hospitalization were evaluated from January 1, 2001 to December 31, 2011. Results There were 1145 patients with acute myocarditis (mean age 40.2 years, SD: 14.8 years), of which 851 did not require MCS, 99 underwent intra-aortic balloon pump (IABP) support, and 195 extracorporeal membrane oxygenation (ECMO) support. There was no significant difference in heart failure hospitalization between the three groups after index admission. The incidence of cardiovascular death after discharge ranged from 10 % to 22%, which was highest in the ECMO group, and was also significantly different between the three groups within 3 months (p<0.001) but it disappeared after 3 months (p=0.458). The trend was also noted in incidence of all-cause mortality. Conclusions The severity of acute myocarditis did not affect long-term outcomes, however, it was associated with cardiovascular/all-cause death within 3 months after discharge.

Antihypertensive Medication Use in Older Patients Transitioning from Chronic Kidney Disease to End-Stage Renal Disease on Dialysis

BACKGROUND AND OBJECTIVES

The transition from CKD to ESRD can be particularly unstable, with high rates of death and hospitalizations. Few studies have examined medication use during this critical period. We examined patterns of antihypertensive medication use from the four quarters before and eight quarters after incident ESRD treated with maintenance dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used the US Renal Data System to identify patients aged ≥67 years initiating dialysis for ESRD between January 2008 and December 2010 with Medicare Part D and a low-income subsidy. We ascertained the incidence of AKI and hyperkalemia during each quarter on the basis of having at least 1 payment claim for the condition. We used Poisson regression with robust SEMs to formally test for changes in the trend and level of antihypertensive medication use in a series of intervention analyses.

RESULTS

The number of antihypertensive drugs used increased as patients neared ESRD, peaking at an average of 3.4 in the quarter immediately preceding dialysis initiation, then declining to 2.2 medications by 2 years later. Angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use was stable at approximately 40%, even among patients with coronary disease and systolic heart failure, and did not correlate with AKI or hyperkalemia. Dialysis initiation was associated with a 40% (95% confidence interval, 38% to 43%) lower adjusted level of diuretic use, which continued to decline after ESRD. Three- and four-drug combinations that included a diuretic were most common before ESRD, whereas after ESRD, one- and two-drug β-blocker or calcium-channel blocker-based combinations were most common.

CONCLUSIONS

The use of antihypertensive medications, particularly angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers and diuretics, may be suboptimal during the transition from CKD to ESRD, especially in patients with coronary disease or systolic heart failure. Future studies are needed to identify strategies to increase the appropriate use of antihypertensive medications during this critical transition period.

Comparison of Length of Stay, 30-Day Mortality, and 30-Day Readmission Rates in Medicare Patients With Heart Failure and With Reduced Versus Preserved Ejection Fraction

Length of stay (LOS), 30-day mortality, and 30-day readmission rates have not been compared between Medicare beneficiaries with heart failure (HF) with reduced ejection fraction (HFrEF) and beneficiaries with heart failure with preserved ejection fraction (HFpEF), although HFpEF is common in patients with HF. To determine whether type of HF (HFrEF or HFpEF) was associated with LOS, 30-day mortality, and 30-day readmission, we used a cohort of 19,477 Medicare beneficiaries admitted to the hospital and discharged alive with a primary discharge diagnosis of HF between 2007 and 2011. Gamma regression, Poisson regression, and Cox proportional hazards with a competing risk for death were used to model LOS, 30-day mortality, and 30-day readmission rate, respectively. All models were adjusted for HF severity, co-morbidities, demographics, nursing home residence, and calendar year of admission. Beneficiaries with HFpEF had an LOS 0.02 days shorter than beneficiaries with HFrEF and a nearly identical 30-day readmission rate. Thirty-day mortality was 10% lower in beneficiaries with HFpEF versus HFrEF. In conclusion, readmission rates were as high in those with HFpEF as they are in those with HFrEF, with comparable LOS in the hospital.

Using linked electronic data to validate algorithms for health outcomes in administrative databases

The validity of algorithms used to identify health outcomes in claims-based and administrative data is critical to the reliability of findings from observational studies. The traditional approach to algorithm validation, using medical charts, is expensive and time-consuming. An alternative method is to link the claims data to an external, electronic data source that contains information allowing confirmation of the event of interest. In this paper, we describe this external linkage validation method and delineate important considerations to assess the feasibility and appropriateness of validating health outcomes using this approach. This framework can help investigators decide whether to pursue an external linkage validation method for identifying health outcomes in administrative/claims data.

Poor record linkage sensitivity biased outcomes in a linked cohort analysis

OBJECTIVES

To examine the validity of deterministic compared to probabilistic record linkage in the ascertainment of hospitalizations in two linked cohorts.

STUDY DESIGN AND SETTING

HIV-negative (HIV-ve) (n = 1,325) and HIV-positive (HIV+ve) gay and bisexual men (n = 557) recruited in Sydney, Australia, were probabilistically and deterministically linked to a statewide hospital registry (July 2000-June 2012).

RESULTS

Using probabilistic linkage as the reference standard, deterministic linkage had higher specificity but much lower sensitivity [34.67% (95% confidence interval: 33.44, 35.92)]. A disproportionate number of links missed were individuals with poorer socioeconomic and health indicators, including HIV status. Risk of hospitalization compared to the general male population [HIV+ve standardized incidence ratio (SIR) = 1.45 (1.33-1.59); HIV-ve SIR = 0.72 (0.67-0.78)] was significantly underestimated when deterministic linkage was used [HIV+ve SIR = 0.46 (0.37-0.58); HIV-ve SIR = 0.29 (0.24-0.35)]. The impact of linkage strategy on the calculation of incidence rate ratios (IRRs) was less, but a greater discrepancy in IRRs was seen for diagnostic categories where event rates were low or where the sensitivity of the deterministic linkage was differential between the two cohorts.

CONCLUSION

Linkage without proven high sensitivity and specificity should be carefully considered. In circumstances of undetermined sensitivity, SIRs should not be calculated as the extent of underestimation is unknown. The comparison of linked events within or between cohorts is more robust to linkage misclassification; however, selection bias does affect estimates and should be considered before linkage.

Linkage of a de-identified United States rheumatoid arthritis registry with administrative data to facilitate comparative effectiveness research

OBJECTIVE

Linkages between registries and administrative data may provide a valuable resource for comparative effectiveness research. However, personal identifiers that uniquely identify individuals are not always available. Here we describe methods to link a de-identified arthritis registry and US Medicare data. The linked data set was also used to evaluate the generalizability of the registry to the US Medicare population.

METHODS

Rheumatoid arthritis (RA) patients participating in the Consortium of Rheumatology Researchers of North America (CORRONA) registry were linked to Medicare data restricted to rheumatology claims or claims for RA. Deterministic linkage was performed using age, sex, provider identification number, and geographic location of the CORRONA site. We then searched for visit dates in Medicare matching visit dates in CORRONA, requiring ≥1 exact matching date. Linkage accuracy was quantified as a positive predictive value in a subcohort (n = 1,581) with more precise identifiers.

RESULTS

CORRONA participants with self-reported Medicare (n = 11,001) were initially matched to 30,943 Medicare beneficiaries treated by CORRONA physicians. A total of 8,431 CORRONA participants matched on ≥1 visit; 5,317 matched uniquely on all visits. The number of patients who linked and linkage accuracy (from the subcohort) were high for patients with >2 visits (n = 3,458, 98% accuracy), exactly 2 visits (n = 822, 96% accuracy), and 1 visit (n = 1,037, 79% accuracy) that matched exactly on calendar date. Demographics and comorbidity profiles of registry participants were similar to nonparticipants, except participants were more likely to take disease-modifying antirheumatic drugs and biologic agents.

CONCLUSION

Linkage between a national, de-identified outpatient arthritis registry and Medicare data on multiple nonunique identifiers appears feasible and valid.

β-Blocker dialyzability and mortality in older patients receiving hemodialysis

Some β-blockers are efficiently removed from the circulation by hemodialysis ("high dialyzability") whereas others are not ("low dialyzability"). This characteristic may influence the effectiveness of the β-blockers among patients receiving long-term hemodialysis. To determine whether new use of a high-dialyzability β-blocker compared with a low-dialyzability β-blocker associates with a higher rate of mortality in patients older than age 66 years receiving long-term hemodialysis, we conducted a propensity-matched population-based retrospective cohort study using the linked healthcare databases of Ontario, Canada. The high-dialyzability group (n=3294) included patients initiating atenolol, acebutolol, or metoprolol. The low-dialyzability group (n=3294) included patients initiating bisoprolol or propranolol. Initiation of a high- versus low-dialyzability β-blocker was associated with a higher risk of death in the following 180 days (relative risk, 1.4; 95% confidence interval, 1.1 to 1.8; P<0.01). Supporting this finding, we repeated the primary analysis in a cohort of patients not receiving hemodialysis and found no significant association between dialyzability and the risk of death (relative risk, 1.0; 95% confidence interval, 0.9 to 1.3; P=0.71). β-Blocker exposure was not randomly allocated in this study, so a causal relationship between dialyzability and mortality cannot be determined. However, our findings should raise awareness of this potentially important drug characteristic and prompt further study.

Validity of deterministic record linkage using multiple indirect personal identifiers: linking a large registry to claims data

BACKGROUND

Linking patient registries with administrative databases can enhance the utility of the databases for epidemiological and comparative effectiveness research. However, registries often lack direct personal identifiers, and the validity of record linkage using multiple indirect personal identifiers is not well understood.

METHODS AND RESULTS

Using a large contemporary national cardiovascular device registry and 100% Medicare inpatient data, we linked hospitalization-level records. The main outcomes were the validity measures of several deterministic linkage rules using multiple indirect personal identifiers compared with rules using both direct and indirect personal identifiers. Linkage rules using 2 or 3 indirect, patient-level identifiers (ie, date of birth, sex, admission date) and hospital ID produced linkages with sensitivity of 95% and specificity of 98% compared with a gold standard linkage rule using a combination of both direct and indirect identifiers.

CONCLUSIONS

Ours is the first large-scale study to validate the performance of deterministic linkage rules without direct personal identifiers. When linking hospitalization-level records in the absence of direct personal identifiers, provider information is necessary for successful linkage.

Risk of Cardiovascular Events, Stroke, Congestive Heart Failure, Interstitial Lung Disease, and Acute Liver Injury: Dronedarone versus Amiodarone and Other Antiarrhythmics

No published studies have evaluated the risks of cardiovascular (CV) events, stroke, congestive heart failure (CHF), interstitial lung disease (ILD), and severe acute liver injury (ALI) related to antiarrhythmics treatment in real-world clinical practice setting. We examined the relationship between the above events and the selected antiarrhythmics in the real-world setting in the US. Using a retrospective cohort design, the hazard ratios of the outcome events were analyzed from 10,455 adult patients with a diagnosis of atrial fibrillation/atrial flutter and a new treatment with dronedarone (comparison drug), amiodarone, sotalol, flecainide, or propafenone between 07/20/2009 and 12/31/2010 from the Clinformatics Data MartTM database. The patients were followed until: 1) switch to another antiarrhythmic drug, 2) occurrence of the outcome event, 3) end of enrollment, or 4) end of the study period, whichever occurred first. No significant differences were observed in the hazard ratios of the outcome events between dronedarone, amiodarone, and the other antiarrhythmics, except that amiodarone was associated with a higher risk of CV events (adjusted HR = 1.7, 95%CI: 1.1-2.4) and stroke (adjusted HR = 2.0, 95%CI: 1.33.2), compared to dronedarone, especially amongst patients without a CHF history (adjusted HR = 2.4, 95%CI: 1.4-3.8 and 2.2, 95%CI: 1.23.9). A higher risk of CHF was also associated with amiodarone in patients without history of CHF at baseline (adjusted HR = 2.7, 95%CI: 2.03.6). In this real-world investigation, no difference in risk was observed between dronedarone, sotalol, and propafenone initiators for CV events, stroke, CHF, ILD, and ALI. Amiodarone was associated with higher risks of CV events, stroke, and CHF than dronedarone in patients without a CHF history, indicating dronedarone could be an alternative therapy option with lower risk of CV events than amiodarone for the above patients.

Database queries for hospitalizations for acute congestive heart failure: flexible methods and validation based on set theory

BACKGROUND AND OBJECTIVE

Electronic health records databases are increasingly used for identifying cohort populations, covariates, or outcomes, but discerning such clinical 'phenotypes' accurately is an ongoing challenge. We developed a flexible method using overlapping (Venn diagram) queries. Here we describe this approach to find patients hospitalized with acute congestive heart failure (CHF), a sampling strategy for one-by-one 'gold standard' chart review, and calculation of positive predictive value (PPV) and sensitivities, with SEs, across different definitions.

MATERIALS AND METHODS

We used retrospective queries of hospitalizations (2002-2011) in the Indiana Network for Patient Care with any CHF ICD-9 diagnoses, a primary diagnosis, an echocardiogram performed, a B-natriuretic peptide (BNP) drawn, or BNP >500 pg/mL. We used a hybrid between proportional sampling by Venn zone and over-sampling non-overlapping zones. The acute CHF (presence/absence) outcome was based on expert chart review using a priori criteria.

RESULTS

Among 79,091 hospitalizations, we reviewed 908. A query for any ICD-9 code for CHF had PPV 42.8% (SE 1.5%) for acute CHF and sensitivity 94.3% (1.3%). Primary diagnosis of 428 and BNP >500 pg/mL had PPV 90.4% (SE 2.4%) and sensitivity 28.8% (1.1%). PPV was <10% when there was no echocardiogram, no BNP, and no primary diagnosis. 'False positive' hospitalizations were for other heart disease, lung disease, or other reasons.

CONCLUSIONS

This novel method successfully allowed flexible application and validation of queries for patients hospitalized with acute CHF.

Impact of baseline heart failure burden on post-implantable cardioverter-defibrillator mortality among medicare beneficiaries

OBJECTIVES

This study sought to assess the impact of baseline heart failure (HF) burden on survival with primary implantable cardioverter-defibrillator (ICD) among Medicare recipients.

BACKGROUND

Survival after primary ICD implantation may differ between trial and Medicare populations.

METHODS

Linking data from the CMS (Centers for Medicare and Medicaid Services) ICD registry and the Medicare files (2005 to 2009), we identified primary ICD recipients age ≥66 years with ejection fraction ≤35%. Number of previous HF hospitalizations (prev-HF-hosp) and length of hospitalization prior to implantation were used to define HF burden. Crude all-cause mortality was estimated. Adjusted hazard ratios (HR) were derived from Cox models.

RESULTS

Of 66,974 ICD recipients (73% men, 88% white, mean age 75 years), 11,876 died (average follow-up = 1.4 years), with 3-year mortality of 31%. Among patients with no prev-HF-hosp, 3-year mortality was 27% compared with 63% in those with ≥3 prev-HF-hosp (adjusted HR: 1.8). Among patients with same-day implantation, 3-year mortality was 25% compared with 53% in those with >1-week hospitalization days prior to implantation (adjusted HR: 1.9). Mortality at 3-year follow-up among the 31,685 ICD recipients with no prev-HF-hosp and same-day implantation (low HF burden) was similar to that in trials (22%).

CONCLUSIONS

Nearly one-third of Medicare ICD recipients died within 3 years, reflecting a population with more advanced age and disease than seen in trial populations for primary prevention ICD. Nearly one-half of Medicare recipients had a low HF burden and had a survival similar to trial ICD recipients. Future research is warranted to understand the effectiveness of primary ICD implantation among Medicare beneficiaries with heavy HF burdens.

Validation of a proxy for estrogen receptor status in breast cancer patients using dispensing data

AIM

To assess the performance of a proxy for estrogen receptor (ER) status in breast cancer patients using dispensing data.

METHODS

We derived our proxy using 167 patients. ER+ patients had evidence of at least one dispensing record for hormone therapy during the lookback period, irrespective of diagnosis date and ER- had no dispensing records for hormone therapy during the period. We validated the proxy against our gold standard, ER status from pathology reports or medical records. We assessed the proxy's performance using three lookback periods: 4.5 years, 2 years, 1 year.

RESULTS

More than half of our cohort (62%) were >50 years, 54% had stage III/IV breast cancer at recruitment, (46%) were diagnosed with breast cancer in 2009 and 23% were diagnosed before 2006. Sensitivity and specificity were high for the 4.5 year lookback period (93%, 95% CI: 86-96%; and 95%: 83-99%), respectively) and remained high for the 2-year lookback period (91%: 84-95%; and 95%: 83-99%). Sensitivity decreased (83%: 75.2-89%) but specificity remained high (95%: 83-99%) using the 1-year lookback period and the period is long enough to allow sufficient time for hormone therapy to be dispensed.

CONCLUSION

Our proxy accurately infers ER status in studies of breast cancer treatment based on secondary health data. The proxy is most robust with a minimum lookback period of 2 years.

Data sources for heart failure comparative effectiveness research

Existing data sources for heart failure research offer advantages and disadvantages for CER. Clinical registries collect detailed information about disease presentation, treatment, and outcomes on a large number of patients and provide the "real-world" population that is the hallmark of CER. Data are not collected longitudinally, however, and follow-up is often limited. Large administrative datasets provide the broadest population coverage with longitudinal outcomes follow-up but lack clinical detail. Linking clinical registries with other databases to assess longitudinal outcomes holds great promise. The Federal Coordinating Council for Comparative Effectiveness Research recommends further efforts on longitudinal linking of administrative or EHR-based databases, patient registries, private sector databases (particularly those with commercially insured populations that are not covered under federal and state databases), and other relevant data sources containing pharmacy, laboratory, adverse events, and mortality information. Advancing the infrastructure to provide robust, scientific data resources for patient-centered CER must remain a priority.

Rates and predictors of 30-day readmission among commercially insured and Medicaid-enrolled patients hospitalized with systolic heart failure

BACKGROUND

Heart failure (HF) readmission rates are primarily derived from Medicare enrollees. Given increasing public scrutiny of HF readmissions, understanding the rate and predictors in populations covered by other payers is also important, particularly among patients with systolic dysfunction, for whom most HF-specific therapies are targeted.

METHODS AND RESULTS

MarketScan Commercial and Medicaid Administrative Claims Databases were used to identify all first hospitalizations with an International Classification of Diseases-9 discharge diagnosis code for HF (primary position) and systolic HF (any position) between January 1, 2005, and June 30, 2008. Among 4584 unique systolic HF index admissions (mean age 55 years), 30-day crude readmission rates were higher for Medicaid than commercially insured patients: all-cause 17.4% versus 11.8%; HF-related 6.7% versus 4.0%, respectively. In unadjusted analysis, higher comorbidity and prior healthcare utilization predicted readmission; age, sex, and plan type did not. After adjustment for case mix, the odds of all-cause and HF-related readmission were 32% and 68% higher, respectively, among Medicaid than commercially insured patients (P<0.02 for both). No significant differences in readmission rates were seen for managed care versus fee-for-service or capitated versus noncapitated plan types.

CONCLUSIONS

Compared with commonly cited Medicare HF readmission rates of 20% to 25%, Medicaid patients with systolic HF had lower 30-day readmission rates, and commercially insured patients had even lower rates. Even after adjustment for case mix, Medicaid patients were more likely to be readmitted than commercially insured patients, suggesting that more attention should be focused on readmissions among socioeconomically disadvantaged populations.

The inpatient experience and predictors of length of stay for patients hospitalized with systolic heart failure: comparison by commercial, Medicaid, and Medicare payer type

OBJECTIVE

Descriptions of the inpatient experience for patients hospitalized with systolic heart failure (HF) are limited and lack a cross-sectional representation of the US population. While length of stay (LOS) is a primary determinant of resource use and post-discharge events, few models exist for estimating LOS.

RESEARCH DESIGN AND METHODS

MarketScan(®) administrative claims data from 1/1/2005-6/30/2008 were used to select hospitalized patients aged ≥18 years with discharge diagnoses for both HF (primary diagnosis) and systolic HF (any diagnostic position) without prior HF hospitalization or undergoing transplantation.

RESULTS

Among 17,597 patients with systolic HF; 4109 had commercial; 2118 had Medicaid; and 11,370 had Medicare payer type. Medicaid patients had longer mean LOS (7.1 days) than commercial (6.3 days) or Medicare (6.7 days). In-hospital mortality was highest for patients with Medicaid (2.4%), followed by Medicare (1.3%) and commercial (0.6%). Commercial patients were more likely to receive inpatient procedures. Renal failure, pressure ulcer, malnutrition, a non-circulatory index admission DRG, receipt of a coronary artery bypass procedure or cardiac catheterization, or need for mechanical ventilation during the index admission were associated with increased LOS; receipt of a pacemaker device at index was associated with shorter LOS.

LIMITATIONS

Selection of patients with systolic HF is limited by completeness and accuracy of medical coding, and results may not be generalizable to patients with diastolic HF or to international populations.

CONCLUSION

Inpatient care, LOS, and in-hospital survival differ by payer among patients hospitalized with systolic HF, although co-morbidity and inpatient procedures consistently influence LOS across payer types. These findings may refine risk stratification, allowing for targeted intensive inpatient management and/or aggressive transitional care to improve outcomes and increase the efficiency of care.