Cherinne Arundel

Systolic Blood Pressure and Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

Importance Lower systolic blood pressure (SBP) levels are associated with poor outcomes in patients with heart failure. Less is known about this association in heart failure with preserved ejection fraction (HFpEF). Objective To determine the associations of SBP levels with mortality and other outcomes in HFpEF. Design, Setting, and Participants A propensity score–matched observational study of the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry included 25 354 patients who were discharged alive; 8873 (35.0%) had an ejection fraction of at least 50%, and of these, 3915 (44.1%) had stable SBP levels (⩽20 mm Hg admission to discharge variation). Data were collected from 259 hospitals in 48 states between March 1, 2003, and December 31, 2004. Data were analyzed from March 1, 2003, to December 31, 2008. Exposure Discharge SBP levels less than 120 mm Hg. A total of 1076 of 3915 (27.5%) had SBP levels less than 120 mm Hg, of whom 901 (83.7%) were matched by propensity scores with 901 patients with SBP levels of 120 mm Hg or greater who were balanced on 58 baseline characteristics. Main Outcomes and Measures Thirty-day, 1-year, and overall all-cause mortality and heart failure readmission through December 31, 2008. Results The 1802 matched patients had a mean (SD) age of 79 (10) years; 1147 (63.7%) were women, and 134 (7.4%) were African American. Thirty-day all-cause mortality occurred in 91 (10%) and 45 (5%) of matched patients with discharge SBP of less than 120 mm Hg vs 120 mm Hg or greater, respectively (hazard ratio [HR], 2.07; 95% CI, 1.45-2.95; P < .001). Systolic blood pressure level less than 120 mm Hg was also associated with a higher risk of mortality at 1 year (39% vs 31%; HR, 1.36; 95% CI, 1.16-1.59; P < .001) and during a median follow-up of 2.1 (overall 6) years (HR, 1.17; 95% CI, 1.05-1.30; P = .005). Systolic blood pressure level less than 120 mm Hg was associated with a higher risk of heart failure readmission at 30 days (HR, 1.47; 95% CI, 1.08-2.01; P = .02) but not at 1 or 6 years. Hazard ratios for the combined end point of heart failure readmission or all-cause mortality associated with SBP level less than 120 mm at 30 days, 1 year, and overall were 1.71 (95% CI, 1.34-2.18; P < .001), 1.21 (95% CI, 1.07-1.38; P = .004), and 1.12 (95% CI, 1.01-1.24; P = .03), respectively. Conclusions and Relevance Among hospitalized patients with HFpEF, an SBP level less than 120 mm Hg is significantly associated with poor outcomes. Future studies need to prospectively evaluate optimal SBP treatment goals in patients with HFpEF.

Medication Errors Despite Using Electronic Health Records: The Value of a Clinical Pharmacist Service in Reducing Discharge-Related Medication Errors.

Background: Medication errors continue to exist despite the use of electronic health records and electronic prescribing; patient-centered medication reconciliation is important to decrease errors. Objective: To identify whether a team-based approach with a pharmacist performing medication management and discharge medication reconciliation will reduce discharge-related medication errors in an academic tertiary care hospital already using an electronic health record and computerized physician order entry. Design: Prospective nonrandomized controlled trial. Patients: All patients were admitted to 2 of the 6 medicine teams from August 1, 2012, through October 31, 2012. Intervention: On the intervention team, a pharmacist assisted with medication management, medication reconciliation, and medication education upon discharge. Although the physicians on the control team had access to a pharmacist, they rarely collaborated with the pharmacist. The numbers of discharge-related medication discrepancies on the intervention and control teams were compared. Results: Collaboration with a pharmacist reduced discharge-related medication errors. The percentage of patients without medication errors within 72 hours of discharge was 93.8% on the intervention team compared with 40.2% on the control team (P < .0001). Conclusion: Pharmacists involvement in the patient care team improved patient safety by decreasing discharge medication errors caused by using electronic health records and computerized physician order entry.

Safe Medication Reconciliation: An Intervention to Improve Residents' Medication Reconciliation Skills

BACKGROUND Medication errors during hospitalization are a major patient safety concern. Medication reconciliation is an effective tool to reduce medication errors, yet internal medicine residents rarely receive formal education on the process. OBJECTIVE We assessed if an educational intervention on quality improvement principles and effective medication reconciliation for internal medicine residents will lead to fewer medication discrepancies and more accurate discharge medication lists. METHODS From July 2012 to May 2013, internal medicine residents from 3 academic institutions who were rotating at the Washington DC VA Medical Center received twice-monthly interactive educational sessions on medication reconciliation, using both institutional summary metrics and data from their own discharges. Sessions were led by a faculty member or chief resident. Accuracy of discharge instructions for residents in the intervention group was compared to the accuracy of discharge data from June 2012 for a group of residents who did not receive the intervention. We used χ(2) analysis to assess for differences. RESULTS The number of duplicate medications (23% versus 12%, P = .01); extraneous medications (14% versus 6%, P = .014); medications sorted by disease or indication (25% versus 77%, P < .001); and the number of discrepancies in discharge summaries (34% versus 11%, P < .001) statistically improved. No difference in the number of omissions was found between the 2 groups (17% versus 15%, P = .62). CONCLUSIONS An educational intervention targeting internal medicine residents can be implemented with reasonable staff and time costs, and is effective in reducing the number of medication discrepancies at discharge.

INITIATION OF LOOP DIURETIC THERAPY IS ASSOCIATED WITH A LOWER RISK OF 30-DAY ALL-CAUSE READMISSION IN PATIENTS WITH HEART FAILURE NOT RECEIVING DIURETICS PRIOR TO HOSPITALIZATION

Heart failure (HF) is the leading cause of 30-day all-cause readmission. Diuretics are often used to achieve and maintain euvolemia. However, they may cause neurohormonal activation and electrolyte imbalance and their use may increase the risk of long-term poor outcomes. We examined the association

PREDICTORS OF 6-MONTH HEART FAILURE READMISSION AND DEATH IN OLDER PATIENTS WITH HEART FAILURE WITH PRESERVED VERSUS REDUCED EJECTION FRACTION

Determining a 6mo life expectancy for hospice referral may be challenging in heart failure (HF) patients, especially in HFpEF. We conducted 2 case-control studies to identify admission clinical features associated with 6-month poor outcomes in HFpEF and HFrEF. In Medicare-linked OPTIMIZE-HF, 8873

Discharge home health services referral and 30-day all-cause readmission in older adults with heart failure

Introduction Heart failure (HF) is the leading cause of hospital readmission. Medicare home health services provide intermittent skilled nursing care to homebound Medicare beneficiaries. We examined whether discharge home health referral is associated with a lower risk of 30-day all-cause readmission in HF. Material and methods Of the 8049 Medicare beneficiaries hospitalized for acute HF and discharged alive from 106 Alabama hospitals, 6406 (76%) patients were not admitted from nursing homes and were discharged home without discharge hospice referrals. Of these, 1369 (21%) received a discharge home health referral. Using propensity scores for home health referral, we assembled a matched cohort of 1253 pairs of patients receiving and not receiving home health referrals, balanced on 33 baseline characteristics. Results The 2506 matched patients had a mean age of 78 years, 61% were women, and 27% were African American. Thirty-day all-cause readmission occurred in 28% and 19% of matched patients receiving and not receiving home health referrals, respectively (hazard ratio (HR) = 1.52; 95% confidence interval (CI): 1.29–1.80; p < 0.001). Home health referral was also associated with a higher risk of 30-day all-cause mortality (HR = 2.32; 95% CI: 1.58–3.41; p < 0.001) but not with 30-day HF readmission (HR = 1.28; 95% CI: 0.99–1.64; p = 0.056). HRs (95% CIs) for 1-year all-cause readmission, all-cause mortality, and HF readmission are 1.24 (1.13–1.36; p < 0.001), 1.37 (1.20–1.57; p < 0.001) and 1.09 (0.95–1.24; p = 0.216), respectively. Conclusions Hospitalized HF patients who received discharge home health services referral had a higher risk of 30-day and 1-year all-cause readmission and all-cause mortality, but not of HF readmission.

CLINICAL EFFECTIVENESS OF SPIRONOLACTONE IN HOSPITALIZED OLDER ELIGIBLE (EF LESS THAN OR EQUAL TO 35% AND EGFR GREATER THAN OR EQUAL TO 30 ML/MIN/1.73 M2) PATIENTS WITH HEART FAILURE

Background: Randomized controlled trials have established the efficacy of aldosterone antagonists in patients with heart failure and reduced ejection fraction (HFrEF). However, there is limited evidence of their clinical effectiveness in real-world eligible patients with HFrEF (PMID: 23188026). We

CHRONIC ALPHA BLOCKER USE AND OUTCOMES IN OLDER MALE MEDICARE BENEFICIARIES HOSPITALIZED FOR HEART FAILURE

Background: Alpha-blockers have been shown to be associated with higher risk of heart failure (HF) among those with hypertension. However, prior studies of alpha-blockers in patients with HF have produced mixed findings. Methods: Of the 8049 Medicare beneficiaries hospitalized for decompensated HF

EARLY (1-10 DAYS) READMISSION IS ASSOCIATED WITH A SIGNIFICANTLY LOWER 2-12 MONTHS POST-DISCHARGE ALL-CAUSE MORTALITY AMONG OLDER MEDICARE BENEFICIARIES HOSPITALIZED FOR HEART FAILURE WITH 30-DAY ALL-CAUSE READMISSIONS

Heart failure (HF) is the leading cause of 30-day all-cause readmission. It has been suggested that early 30-day readmissions may reflect suboptimal care during index hospitalization and may provide opportunities to improve outcomes. We examined the association of early (vs. late) 30-day all-cause