Emergency department returns and early follow-up visits after heart failure hospitalization: Cohort study examining the role of race

Post-Acute Transition to Home With Supportive Care (PATHS): A Novel Nurse Practitioner-Led Telehealth Intervention to Improve End-of-Life Oncology Care

CONTEXT

Patients with advanced cancer discharged from the hospital with no plan for further disease-directed treatment (on 'best supportive care'; BSC) and without specialized palliative care at home are extremely vulnerable to end-of-life suffering and hospital readmission.

OBJECTIVES

To assess preliminary outcomes of PATHS (Post-Acute Transition to Home with Supportive Care), a nurse practitioner-led telehealth intervention delivering proactive, intensive, specialized palliative care in the immediate two-week post-discharge period.

METHODS

We conducted a single-arm prospective quality improvement evaluation of PATHS with patients ≥21 years with advanced solid tumor malignancies discharged from the hospital on BSC having initially declined hospice. Sociodemographic and illness characteristics, index hospital admission (IHA) and discharge data, and PATHS outcomes were descriptively analyzed. Competing-risks analysis provided cumulative incidence of hospital readmission following IHA discharge (primary outcome).

RESULTS

Patients (n = 30) had a median age of 67 years and were predominantly female (53%) and white (63%). Colorectal cancer was the most common diagnosis (30%) and pain the most common IHA reason (33%). The 30-day cumulative incidence of hospital readmission was 33% (95% CI: 16, 51) compared to a historical control rate of 43% (95% CI: 26, 59). No patient receiving timely hospice care at home was readmitted to the hospital. At PATHS completion, 11 patients (36%) had transitioned to hospice, nine of whom accepted a hospice referral during their first PATHS visit.

CONCLUSION

PATHS fills a substantive practice gap, potentially reducing end-of-life hospital readmissions while increasing home-based, specialized palliative care access for BSC patients with cancer approaching death after hospitalization.

Equal Treatment, Unequal Outcomes? Debunking the Racial Disparity in Renin Angiotensin Aldosterone System Inhibitor-Associated Reduction in Heart Failure Hospitalizations

BACKGROUND

Renin angiotensin aldosterone system inhibitors (RAASi) are a mainstay treatment in patients with heart failure with reduced ejection fraction (HFrEF) in part to prevent hospitalizations. However, whether RAASi reduce the risk of hospitalization in Black patients is not entirely clear because enrollment of Black patients in previous clinical trials was low and a previous meta-analysis showed a significant racial disparity: reduction in hospitalizations with an RAASi in White patients but not Black patients. Previous studies relied on the use of self-identified race instead of genomic ancestry. Therefore, this study aimed to investigate the role of self-identified race and genomic ancestry in the racial disparity in RAASi-associated reductions in HFrEF hospitalizations.

METHODS

The primary outcome was time to first heart failure hospitalization. Data from the Henry Ford Heart Failure Pharmacogenomic Registry (HFPGR) and the GUIDE-IT multi-center randomized control trial were analyzed with Cox proportional hazards models un/adjusted for clinical risk factors, death as a competing risk, and time-varying RAASi exposure. The proportion of Yoruba African ancestry was quantified. Analyses of self-identified race were performed in both the HFPGR and GUIDE-IT. Analysis of genomic ancestry was only performed in the HFPGR since this information was not available in GUIDE-IT. A fixed effect meta-analysis combined results of both the HFPGR and GUIDE-IT for race.

RESULTS

The HFPGR had 1010 total HFrEF patients (Black = 509 and White = 501) with 852 having ancestry quantification (>80% Yoruba African Ancestry = 381 and <5% Yoruba African Ancestry = 471). GUIDE-IT had 810 HFrEF patients (Black = 322 and White = 488). There was no significant difference in the association of RAASi exposure with heart failure hospitalization by race (meta-analysis P value for race*RAASi exposure interaction = .49; Black patients hazard ratio [HR, 95% confidence interval] for RAASi exposure = 0.89 [0.64-1.23)], P = .47; White patients = 1.20 [0.83-1.75], P = .34). Results were similar when analyzed by ancestry (P value for ancestry*RAASi exposure interaction = 0.57; >80% Yoruba African Ancestry = 0.93 [0.51-1.69], P = .80; <5% Yoruba African Ancestry = 1.29 [0.57-2.92], P = .54).

CONCLUSIONS

In contrast to a previous meta-analysis, this more contemporary analysis of 2 HFrEF patient datasets demonstrates the absence of a racial disparity in RAASi-associated reductions in heart failure hospitalizations. The difference in this racial disparity over time may be due to improvements in background heart failure therapies, racial differences in health care usage, and the use of more advanced statistical approaches.

Prognostic Impact of Hospital Discharge After Heart Failure Admission Without Structured Heart Failure Follow-Up

(1) Objective. The aim was to evaluate the risk of new exacerbations of heart failure (HF) in patients discharged from hospital emergency departments (EDs) without a structured HF follow-up. (2) Methods. This prospective, single-center cohort study included patients discharged from the ED following hospital admission for acute HF. The study analyzed the profile of patients seen in the ED and assessed their risk of new ED visits or HF-related hospitalizations within 12 months of discharge. (3) Results. A total of 779 patients were included, with a mean age of 82 ± 8 years; 471 were women (60.4%), and 674 (86.7%) had a history of prior HF episodes. Of these, 591 patients (76.1%) were referred to an unstructured HF follow-up in primary care (PC). Patients who experienced HF exacerbations within 12 months of ED discharge had a higher incidence of chronic kidney disease, elevated natriuretic peptide levels, and a higher number of prior HF exacerbations and were more likely to receive unstructured HF follow-up in PC. The presence of the last two factors was associated with the highest risk of HF exacerbation within 12 months of discharge (HR: 2.83; 95% CI: 1.60-5.03; p < 0.001). (4) Conclusions. Patients discharged from the ED after an HF episode and referred to PC without a structured HF follow-up have a high risk of ED revisits or rehospitalization for HF.