Gregg Fonarow

Incremental Value of Clinical Data Beyond Claims Data in Predicting 30-Day Outcomes After Heart Failure Hospitalization

Background— Administrative claims data are used routinely for risk adjustment and hospital profiling for heart failure outcomes. As clinical data become more readily available, the incremental value of adding clinical data to claims-based models of mortality and readmission is unclear. Methods and Results— We linked heart failure hospitalizations from the Get With The Guidelines–Heart Failure registry with Medicare claims data for patients discharged between January 1, 2004, and December 31, 2006. We evaluated the performance of claims-only and claims-clinical regression models for 30-day mortality and readmission, and compared hospital rankings from both models. There were 25 766 patients from 308 hospitals in the mortality analysis, and 24 163 patients from 307 hospitals in the readmission analysis. The claims-clinical mortality model (area under the curve [AUC], 0.761; generalized R 2=0.172) had better fit than the claims-only mortality model (AUC, 0.718; R 2=0.113). The claims-only readmission model (AUC, 0.587; R 2=0.025) and the claims-clinical readmission model (AUC, 0.599; R 2=0.031) had similar performance. Among hospitals ranked as top or bottom performers by the claims-only mortality model, 12% were not ranked similarly by the claims-clinical model. For the claims-only readmission model, 3% of top or bottom performers were not ranked similarly by the claims-clinical model. Conclusions— Adding clinical data to claims data for heart failure hospitalizations significantly improved prediction of mortality, and shifted mortality performance rankings for a substantial proportion of hospitals. Clinical data did not meaningfully improve the discrimination of the readmission model, and had little effect on performance rankings.

Primary Prevention Implantable Cardioverter-Defibrillators in Older Racial and Ethnic Minority Patients

Background—Racial and ethnic minorities are under-represented in clinical trials of primary prevention implantable cardioverter-defibrillators (ICDs). This analysis investigates the association between primary prevention ICDs and mortality among Medicare, racial/ethnic minority patients. Methods and Results—Data from Get With The Guidelines-Heart Failure Registry and National Cardiovascular Data Registry’s ICD Registry were used to perform an adjusted comparative effectiveness analysis of primary prevention ICDs in Medicare, racial/ethnic minority patients (nonwhite race or Hispanic ethnicity). Mortality data were obtained from the Medicare denominator file. The relationship of ICD with survival was compared between minority and white non-Hispanic patients. Our analysis included 852 minority patients, 426 ICD and 426 matched non-ICD patients, and 2070 white non-Hispanic patients (1035 ICD and 1035 matched non-ICD patients). Median follow-up was 3.1 years. Median age was 73 years, and median ejection fraction was 23%. Adjusted 3-year mortality rates for minority ICD and non-ICD patients were 44.9% (95% confidence interval [CI], 44.2%–45.7%) and 54.3% (95% CI, 53.4%–55.1%), respectively (adjusted hazard ratio, 0.79; 95% CI, 0.63–0.98; P=0.034). White non-Hispanic patients receiving an ICD had lower adjusted 3-year mortality rates of 47.8% (95% CI, 47.3%–48.3%) compared with 57.3% (95% CI, 56.8%–57.9%) for those with no ICD (adjusted hazard ratio, 0.75; 95% CI, 0.67%–0.83%; P<0.0001). There was no significant interaction between race/ethnicity and lower mortality risk with ICD (P=0.70). Conclusions—Primary prevention ICDs are associated with lower mortality in nonwhite and Hispanic patients, similar to that seen in white, non-Hispanic patients. These data support a similar approach to ICD patient selection, regardless of race or ethnicity.

MANAGEMENT AND OUTCOMES OF PATIENTS WITH ATRIAL FIBRILLATION AND CANCER: THE ORBIT-AF REGISTRY

Cancer is a prothrombotic state and may further increase the risk of thrombotic events in pts with atrial fibrillation (AF). Due to the need to balance thrombotic and bleeding risks in this population and lack of evidence-based guidance, management of pts with AF and cancer is challenging.nnWithin

Reassessment of Cardiac Function and Implantable Cardioverter-Defibrillator Use Among Medicare Patients With Low Ejection Fraction After Myocardial Infarction.

Background: Guidelines recommend that patients with low ejection fraction (EF) after myocardial infarction (MI) have their EF reassessed 40 days after MI for implantable cardioverter-defibrillator (ICD) candidacy. This study examines rates of EF reassessment and their association with 1-year ICD implantation in post-MI patients with low EF. Methods: We examined rates of postdischarge EF reassessment and ICD implantation among 10u2009289 Medicare-insured patients ≥65 years of age with an EF⩽35% during the index MI admission from January 2007 through September 2010 in ACTION Registry–GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines). Multivariable Cox models tested the association between time-dependent EF reassessment and 1-year ICD implantation, stratified by revascularization status during the index MI admission. Results: Among patients with EF ⩽35% during the index MI admission, 66.8% (95% confidence interval [CI], 65.9–67.8) had EF reassessment within the next year. Revascularized patients were more likely to have EF reassessment (76.9% [95% CI, 75.8–78.0)] versus 53.7% [95% CI, 52.2–55.2]; P<0.001) and had shorter times to EF reassessment (median, 67 versus 84 days; P<0.001) than nonrevascularized patients. Among patients with EF reassessment, only 11% received an ICD within 1 year. Reassessment of EF was associated with a higher likelihood of ICD implantation for both revascularized (unadjusted, 12.1% versus 2.4%, P<0.001; adjusted hazard ratio, 10.6, 95% CI, 7.7–14.8) and nonrevascularized (unadjusted, 10.0% versus 1.7%, P<0.001; adjusted hazard ratio, 6.1, 95% CI, 4.1–9.2) patients. Conclusions: In US practice, EF reassessments are commonly performed among patients with MI with an initially reduced EF. Although 1-year EF reassessment is associated with increased likelihood of ICD implantation, 1-year ICD implantation rates remain very low even among patients with EF reassessment, regardless of revascularization status.

TIME TO INTRAVENOUS THERAPY AND CLINICAL OUTCOMES IN OLDER PATIENTS PRESENTING WITH ACUTE DECOMPENSATED HEART FAILURE: AN ANALYSIS OF THE ADHERE REGISTRY EMERGENCY MODULE

Most patients hospitalized with acute decompensated heart failure (ADHF) present through the emergency department (ED). Prior studies suggest that ED treatment delay may be associated with an increased risk of in-hospital mortality; however, the association with 30-day mortality and re-admission

Health Status Variation Across Practices in Outpatients With Heart Failure: Insights From the CHAMP-HF (Change the Management of Patients With Heart Failure) Registry

Background: Although a key treatment goal for patients with heart failure with reduced ejection fraction is to optimize their health status (their symptoms, function, and quality of life), the variability across outpatient practices in achieving this goal is unknown. Methods and Results: In the CHAMP-HF (Change the Management of Patients With Heart Failure) registry, associations between baseline practice characteristics and Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary (OS) and Symptom Frequency (SF) scores were assessed in 3494 patients across 140 US practices using hierarchical regression after accounting for 23 patient and 11 treatment characteristics. We then calculated an adjusted median odds ratio to quantify the average difference in likelihood that a patient would have excellent (KCCQ-OS, ≥75) health status or minimal (monthly or fewer) symptoms (KCCQ-SF, ≥75) when treated at one practice versus another, at random. The mean (±SD) KCCQ-OS and KCCQ-SF were 64.2±24 and 68.9±25.6, with 40% (n=1380) and 50% (n=1760) having KCCQ scores ≥75, respectively. The adjusted median odds ratio across practices, for KCCQ-OS ≥75, was 1.70 (95% confidence interval, 1.54–1.99; P<0.001) indicating a median 70% higher odds of a patient having good-to-excellent health status when treated at one random practice versus another. In regard to KCCQ-SF, the adjusted median odds ratio for KCCQ-SF ≥75 was 1.54 (95% confidence interval, 1.41–1.76; P=0.001). Conclusions: In a large, contemporary registry of outpatients with chronic heart failure with reduced ejection fraction, we observed significant practice-level variability in patients’ health status. Quantifying patients’ health status as a measure of quality should be explored as a foundation for improving care. Clinical Trial Registration: URL: https://www.centerwatch.com. Unique identifier: TX144901.Background nWhile a key treatment goal for patients with heart failure and reduced ejection fraction (HFrEF) is to optimize their health status (their symptoms, function, and quality of life), the variability across outpatient practices in achieving this goal is unknown.

OBSTRUCTIVE SLEEP APNEA AND ATRIAL FIBRILLATION: FINDINGS FROM ORBIT-AF

Obstructive sleep apnea (OSA) has been shown to be associated with risk of developing atrial fibrillation (AF), however, impact of OSA on outcomes in patients with AF in clinical practice is not well described.nnThe Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) is

COMPARISON OF SYMPTOMS AND QUALITY OF LIFE IN ATRIAL FIBRILLATION: RESULTS FROM THE ORBIT-AF REGISTRY

Abstract Category: 16. Arrhythmias: AF/SVTPresentation Number: 1239-271Authors: Jonathan P. Piccini, Dajuanicia Holmes, Laine Thomas, Gregg C. Fonarow, Bernard J. Gersh, Peter R. Kowey, Paul Chang, Paul S. Chan, John A. Spertus, Eric D. Peterson, Duke Clinical Research Institute, Durham, NC, USA Background: In addition to stroke prevention, improvement of symptoms and quality of life (QoL) is a primary goal in the treatment of atrial fibrillation (AF).Methods: The Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) is a recently developed disease-specific QOL tool for AF. AFEQT scores were compared across European Heart Rhythm Association (EHRA) symptom levels within a large, community-based AF-registry (ORBIT-AF). We also evaluated patient factors associated with AFEQT scores.Results: Baseline health status was assessed in 1,975 AF patients from 99 US sites participating in the ORBIT registry. The mean population age was 74 ± 11; 43% were female and 48% , 16% and 2% had mild, severe, or debilitating AF symptoms respectivley. EHRA symptom status correlated with lower (worse) AFEQT scores (Figure, p<.0001). Additionally, those with new onset AF had lower AFEQT scores than those with persistent or permanent AF (70±24 vs 76±21 vs 79±18, respectively) . Younger patients also had lower AFEQT scores: <65 yrs (74±22), vs 65-79 yrs (77±19), and ≥80 yrs (80±19)]. Female sex, COPD, obstructive sleep apnea, and heart failure were all associated with significantly decreased AFEQT scores (p<.0001 for all).Conclusions: These data represent the largest experience to date assessing quality of life in AF patients. Symptom severity, new onset AF younger patients and certain comorbid illnesses had worse QoL with AF.

Relationship between hospital 30-day mortality rates for heart failure and patterns of early inpatient comfort care

BACKGROUND The Centers for Medicare & Medicaid Services rewards hospitals that have low 30-day risk-standardized mortality rates (RSMR) for heart failure (HF). OBJECTIVE To describe the use of early comfort care for patients with HF, and whether hospitals that more commonly initiate comfort care have higher 30-day mortality rates. DESIGN A retrospective, observational study. SETTING Acute care hospitals in the United States. PATIENTS A total of 93,920 fee-for-service Medicare beneficiaries admitted with HF from January 2008 to December 2014 to 272 hospitals participating in the Get With The Guidelines-Heart Failure registry. EXPOSURE Early comfort care (defined as comfort care within 48 hours of hospitalization) rate. MEASUREMENTS A 30-day RSMR. RESULTS Hospitals’ early comfort care rates were low for patients admitted for HF, with no change over time (2.5% to 2.6%, from 2008 to 2014, P = .56). Rates varied widely (0% to 40%), with 14.3% of hospitals not initiating comfort care for any patients during the first 2 days of hospitalization. Risk-standardized early comfort care rates were not correlated with RSMR (median RSMR = 10.9%, 25th to 75th percentile = 10.1% to 12.0%; Spearman’s rank correlation = 0.13; P = .66). CONCLUSIONS Hospital use of early comfort care for HF varies, has not increased over time, and on average, is not correlated with 30-day RSMR. This suggests that current efforts to lower mortality rates have not had unintended consequences for hospitals that institute early comfort care more commonly than their peers.

Early Ambulation Among Hospitalized Heart Failure Patients Is Associated With Reduced Length of Stay and 30-Day Readmissions

Background: Early ambulation (EA) is associated with improved outcomes for mechanically ventilated and stroke patients. Whether the same association exists for patients hospitalized with acute heart failure is unknown. We sought to determine whether EA among patients hospitalized with heart failure is associated with length of stay, discharge disposition, 30-day post discharge readmissions, and mortality. Methods and Results: The study population included 369 hospitals and 285u2009653 patients with heart failure enrolled in the Get With The Guidelines-Heart Failure registry. We used multivariate logistic regression with generalized estimating equations at the hospital level to identify predictors of EA and determine the association between EA and outcomes. Sixty-five percent of patients ambulated by day 2 of the hospital admission. Patient-level predictors of EA included younger age, male sex, and hospitalization outside of the Northeast (P<0.01 for all). Hospital size and academic status were not predictive. Hospital-level analysis revealed that those hospitals with EA rates in the top 25% were less likely to have a long length of stay (defined as >4 days) compared with those in the bottom 25% (odds ratio, 0.83; confidence interval, 0.73–0.94; P=0.004). Among a subgroup of fee-for-service Medicare beneficiaries, we found that hospitals in the highest quartile of rates of EA demonstrated a statistically significant 24% lower 30-day readmission rates (P<0.0001). Both end points demonstrated a dose–response association and statistically significant P for trend test. Conclusions: Multivariable-adjusted hospital-level analysis suggests an association between EA and both shorter length of stay and lower 30-day readmissions. Further prospective studies are needed to validate these findings.