Preventability of readmissions for patients with heart failure - A scoping review

BACKGROUND

Heart failure (HF) remains a significant global health issue and poses challenges to patient families and healthcare systems through index hospitalizations and subsequent readmissions. The readmission rate has been utilized as a quality indicator, and a proportion of readmissions are perceived preventable. However, the definitions and measures of preventability remain unclear and inconsistent, lacking an explicit integration, analysis, and critique of current evidence.

OBJECTIVES

This scoping review aims to improve the understanding of the definitions and measures of preventable readmissions for patients with HF, by identifying the judgements in published literature and examining the reasonings behind them.

METHODS

Systematic literature searches with a search strategy combining three compartments describing preventability, readmission, and HF were conducted. The inclusion and exclusion were performed against prespecified eligibility criteria.

RESULTS

A total of 15 papers were identified. Substantial heterogeneity was observed in study characteristics and judgement of preventability. The proportion of readmissions deemed preventable ranged vastly from 6.66 % to 86 % and required careful interpretation due to inconsistency of denominators. The reasonings behind preventability can be categorized into four groups based on nature, focus, and purpose.

CONCLUSIONS

There is currently no consensus on definitions and measures of preventable readmissions for patients with HF. Scattered research efforts were observed with inconsistent and unstandardized methods, criteria, and data used for judgement of preventability. Adopting an identical readmission calculation framework is critical for fair comparison. The timeframe of readmission is worth further reconsideration and investigation. Comprehensive, explicit, and disease-specific judgement criteria for preventable readmissions are urgently needed.

Usability of a digital health platform to support home hospitalization in heart failure patients: a multicentre feasibility study among healthcare professionals

AIMS

Heart failure (HF) is a common cause of mortality and (re)hospitalizations. The NWE-Chance project explored the feasibility of providing hospitalizations at home (HH) supported by a newly developed digital health platform. The aim of this study was to explore the perceived usability by healthcare professionals (HCPs) of a digital platform in addition to HH for HF patients.

METHODS AND RESULTS

A prospective, international, multicentre, single-arm interventional study was conducted. Sixty-three patients and 22 HCPs participated. The HH consisted of daily home visits by the nurse and use of the platform, consisting of a portable blood pressure device, weight scale, pulse oximeter, a wearable chest patch to measure vital signs (heart rate, respiratory rate, activity level, and posture), and an eCoach for the patient. Primary outcome was usability of the platform measured by the System Usability Scale halfway and at the end of the study. Overall usability was rated as sufficient (mean score 72.1 ± 8.9) and did not differ between the measurements moments (P = 0.690). The HCPs reported positive experiences (n = 7), negative experiences (n = 13), and recommendations (n = 6) for the future. Actual use of the platform was 79% of the HH days.

CONCLUSION

A digital health platform to support HH was considered usable by HCPs, although actual use of the platform was limited. Therefore, several improvements in the integration of the digital platform into clinical workflows and in defining the precise role of the digital platform and its use are needed to add value before full implementation.

REGISTRATION

clinicaltrials.gov NCT04084964.

Characteristics of symptoms and symptom change across different heart failure subtypes: a sex-stratified analysis

AIMS

To examine sex-stratified differences in the association of left ventricular ejection fraction-based heart failure (HF) subtypes and the characteristics and correlates of self-reported changes in HF symptoms.

METHODS AND RESULTS

We report a secondary data analysis from 528 hospitalized individuals diagnosed with HF characterised by a reduced, mildly reduced, or preserved ejection fraction [HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF), or HF with preserved ejection fraction (HFpEF)] who completed 12-month follow-up within a multicentre disease management trial. There were 302 men (71.1 ± 11.9 years, 58% with HFrEF) and 226 women (77.1 ± 10.6 years, 49% with HFpEF). The characteristics of self-reported symptoms measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and 12-month were analysed. At baseline, shortness of breath and fatigue predominated; with key differences according to HF subtypes in bilateral ankle oedema (both sexes), walking problems (women) and depressive symptoms (men). At 12-month follow-up, most KCCQ scores had not significantly changed. However, 25% of individuals reported worse symptom. In women, those with HFpEF had worse symptoms than those with HFmrEF/HFrEF (P = 0.025). On an adjusted basis, women [odds ratios (OR): 1.78, 95% confidence interval (CI): 1.00-3.16 vs. men], those with coronary artery disease (OR: 2.01, 95% CI: 1.21-3.31) and baseline acute pulmonary oedema (OR: 1.67, 95% CI: 1.02-2.75) were most likely to report worsening symptoms. Among men, worsening symptoms correlated with a history of hypertension (OR: 2.16, 95% CI: 1.07-4.35) and a non-English-speaking background (OR: 2.30, 95% CI: 1.02-5.20).

CONCLUSION

We found significant heterogeneity (with potential clinical implications) in the symptomatic characteristics and subsequent symptom trajectory according to the sex and HF subtype of those hospitalized with the syndrome.

TRIAL REGISTRATION

ANZCTR12613000921785.

Healthcare resource use of patients with transthyretin amyloid cardiomyopathy

Aims

Transthyretin amyloid cardiomyopathy (ATTR‐CM) is the cardiac manifestation of transthyretin amyloidosis (ATTR). The aim of this study was to estimate healthcare resource use for ATTR‐CM patients compared with heart failure (HF) patients, in Denmark, Finland, Norway, and Sweden.

Methods and results

Data from nationwide healthcare registers in the four countries were used. ATTR‐CM patients were defined as individuals diagnosed with amyloidosis and cardiomyopathy or HF between 2008 and 2018. Patients in the ATTR‐CM cohort were matched to patients with HF but without ATTR‐CM diagnosis. Resource use included number of visits to specialty outpatient and inpatient hospital care. A total of 1831 ATTR‐CM and 1831 HF patients were included in the analysis. The mean number of hospital‐based healthcare contacts increased in both the ATTR‐CM and HF cohort during 3 years pre‐diagnosis and was consistently higher for the ATTR‐CM cohort compared with the HF cohort, with 6.1 [CI: 5.9–6.3] vs. 3.2 [CI: 3.1–3.3] outpatient visits and 1.03 [CI: 0.96–1.1] vs. 0.7 [CI: 0.7–0.8] hospitalizations. In the first year following diagnosis, patients with ATTR‐CM continued to visit outpatient care (10.2 [CI: 10.1, 10.4] vs. 5.7 [CI: 5.6, 5.9]) and were admitted to hospital more frequently (3.3 [CI: 3.2, 3.4] vs. 2.5 [CI: 2.5, 2.6]) than HF patients.

Conclusions

Transthyretin amyloid cardiomyopathy imposes a high burden on healthcare systems with twice as many outpatient specialist visits and 50% more hospitalizations in the year after diagnosis compared with HF patients without ATTR‐CM. Studies to investigate if earlier diagnosis and treatment of ATTR‐CM may lower resource use are warranted.

Burden of hospitalization for heart failure in the United States: a systematic literature review

BACKGROUND: Heart failure (HF) affects approximately 6 million Americans, with prevalence projected to increase by 46% and direct medical costs to reach $53 billion by 2030. Hospitalizations are the largest component of direct costs for HF; however, recent syntheses of the economic and clinical burden of hospitalization for heart failure (HHF) are lacking. OBJECTIVE: To synthesize contemporary estimates of cost and clinical outcomes of HHF in the United States. METHODS: A systematic literature review was conducted using MEDLINE and Embase to identify articles reporting cost or charge per HHF in the United States published between January 2014 and May 2019. Subgroups of interest were those with both HF and renal disease or diabetes, as well as HF with reduced or preserved ejection fraction (HFrEF or HFpEF). RESULTS: 23 studies reporting cost and/or charge per HHF were included. Sample sizes ranged from 989 to approximately 11 million (weighted), mean age from 65 to 83 years, and 39% to 74% were male. Cost per HHF ranged from $7,094 to $9,769 (median) and $10,737 to $17,830 (mean). Charge per HHF ranged from $22,162 to $40,121 (median), and $50,569 to $50,952 (mean). Among patients with renal disease, HHF mean cost ranged from $9,922 to $41,538. For those with HFrEF or HFpEF, mean cost ranged from $11,600 to $17,779 and $7,860 to $10,551, respectively. No eligible studies were identified that reported HHF costs or charges among patients with HF and diabetes. Cost and charge per HHF increased with length of stay, which ranged from 3 to 5 days (median) and 4 to 7 days (mean). CONCLUSIONS: This synthesis demonstrates the substantial economic burden of HHF and the variability in estimates of this burden. Factors contributing to variability in estimates include length of stay, age and sex of the sample, HF severity, and frequencies of comorbidities. Further research into cost drivers of HHF is warranted to understand potential mechanisms to reduce associated costs. DISCLOSURES: This study was funded by Boehringer Ingelheim Pharmaceuticals. Osenenko, Deighton, and Szabo are employees of Broadstreet HEOR, which received funds from Boehringer Ingelheim Pharmaceuticals for this work. Kuti and Pimple are employees of Boehringer Ingelheim Pharmaceuticals. This study was presented in abstract form at the 2020 American Heart Association (AHA) Quality of Care and Outcomes Research (QCOR) 2020 Scientific Sessions (May 15-16, Virtual Meeting).