Assessing the impact of heart failure specialist services on patient populations

Delayed Improvement of Left Ventricular Function in Newly Diagnosed Heart Failure Depends on Etiology-A PROLONG-II Substudy

In patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF), three months of optimal therapy are recommended before considering a primary preventive implantable cardioverter-defibrillator (ICD). It is unclear which patients benefit from a prolonged waiting period under protection of the wearable cardioverter-defibrillator (WCD) to avoid unnecessary ICD implantations. This study included all patients receiving a WCD for newly diagnosed HFrEF (n = 353) at our center between 2012 and 2017. Median follow-up was 2.7 years. From baseline until three months, LVEF improved in patients with all peripartum cardiomyopathy (PPCM), myocarditis, dilated cardiomyopathy (DCM), or ischemic cardiomyopathy (ICM). Beyond this time, LVEF improved in PPCM and DCM only (10 ± 8% and 10 ± 12%, respectively), whereas patients with ICM showed no further improvement. The patients with newly diagnosed HFrEF were compared to 29 patients with a distinct WCD indication, which is an explantation of an infected ICD. This latter group had a higher incidence of WCD shocks and poorer overall survival. All-cause mortality should be considered when deciding on WCD prescription. In patients with newly diagnosed HFrEF, the potential for delayed LVEF recovery should be considered when timing ICD implantation, especially in patients with PPCM and DCM.

Population impact of stricter adherence to recommendations for pharmacological and lifestyle interventions over one year in patients with coronary heart disease

STUDY OBJECTIVE

To assess the potential number of lives saved associated with the full implementation of aspects of the National Service Framework (NSF) for coronary heart disease (CHD) in England using recently developed population impact measures.

DESIGN

Modelling study.

SETTING

Primary care.

DATA SOURCES

Published data on prevalence of acute myocardial infarction and heart failure, baseline risk of mortality, the relative risk reduction associated with different interventions and the proportion treated, eligible for treatment and adhering to each intervention.

MAIN RESULTS

Adopting the NSF recommendations for pharmacological interventions would prevent an extra 1027 (95% CI 418 to 1994) deaths in post-acute myocardial infarction (AMI) patients and an extra 37 899 (95% CI 25 690 to 52 503) deaths in heart failure patients in the first year after diagnosis. Lifestyle based interventions would prevent an extra 848 (95% CI 71 to 1 614) deaths in post-AMI patients and an extra 7249 (95% CI 995 to 16 696) deaths in heart failure patients.

CONCLUSIONS

Moving from current to "best" practice as recommended in the NSF will have a much greater impact on one year mortality rates among heart failure patients compared with post-AMI patients. Meeting pharmacological based recommendations for heart failure patients will prevent more deaths than meeting lifestyle based recommendations. Population impact numbers can help communicate the impact on a population of the implementation of guidelines and, when created using local data, could help policy makers assess the local impact of implementing a range of health care targets.

Factors influencing emergency medical readmission risk in a UK district general hospital: A prospective study

Background

Over recent years increased emphasis has been given to performance monitoring of NHS hospitals, including overall number of hospital readmissions, which however are often sub-optimally adjusted for case-mix. We therefore conducted a study to examine the effect of various patient and disease factors on the risk of emergency medical readmission.

Methods

The study setting was a District General Hospital in Greater Manchester and the study period was 4.5-years. All index emergency medical admission during the study period leading to a live discharge were included in the study (n = 20,209). A multivariable proportional hazards modelling was used, based on Hospital Episodes Statistics data, to examine the influence of various baseline factors on readmission risk. Deprivation status was measured with the Townsend deprivation index score. Hazard ratios (HR) and associated 95% confidence intervals (CI) of unplanned emergency medical admission by sex, age group, admission method, diagnostic group, number of coded co-morbidities, length of stay and patient's deprivation status quartile, were calculated.

Results

Significant independent predictors of readmission risk at 12 months were male sex (HR 1.13, CI: 1.07–1.2), age (age >75 (HR 1.57, CI 1.45–1.7), number of coded co-morbidities (HR for >4 coded co-morbidities: 1.49 CI: 1.26–1.76), admission via GP referral (HR 0.93, CI 0.88–0.99) and primary diagnosis of heart failure (HR 1.33, CI: 1.16–1.53) and chronic obstructive pulmonary disease/asthma (HR 1.34, CI: 1.21–1.48). Higher level of deprivation was also significantly and independently associated and with increased emergency medical readmission risk at three (HR for the most deprived quartile 1.21, CI: 1.08–1.35), six (HR 1.21, CI: 1.1–1.33) and twelve months (HR 1.25, CI: 1.16–1.36).

Conclusions

There is a potential for improving health and reducing demand for emergency medical admissions with more effective management of patients with heart failure and chronic obstructive airways disease/asthma. There is also a potential for improving health and reducing demand if reasons for increased readmission risk in more deprived patients are understood. The potential influence of deprivation status on readmission risk should be acknowledged, and NHS performance indicators adjustment for deprivation case-mix would be prudent.