- Email: [email protected]
Home INR Monitoring Versus Lab Monitoring in Patients With Left Ventricular Assist Device
S80 Journal of Cardiac Failure Vol. 22 No. 8S August 2016 225 Effects of Respiratory Variation on CardioMEMSTM HF Measured Pressure Values: Comparison of Device-Calculated and Visually Inspected Pressure Waveforms Aaron M. Wolfson1, Omid Yousefian1, Lindsay Short1, Guy Talmor2, Jessica Y. Qiu3, Michael W. Fong1, Rahul N. Doshi1, Luanda Grazette1, Leslie A. Saxon1, David M. Shavelle1; 1University of Southern California, Los Angeles, CA; 2Keck University School of Medicine, Los Angeles, CA; 3University of Washington, Seattle, WA Introduction: Heart failure (HF) management guided by remote hemodynamic monitoring using an implantable pulmonary artery pressure (PAP) sensor reduces future hospitalization for HF compared to standard of care. Transmitted data from the CardioMEMSTM HF system includes an 18-second PAP waveform which allows a devicecalculated pulmonary artery systolic pressure (PASP), pulmonary artery diastolic pressure (PADP), and mean PAP. The agreement of these device-calculated values with visual estimation of PAP at end-expiration are unknown. The aim of this analysis was to evaluate the agreement between device-calculated PAP and visually estimated endexpiratory PAP. Methods: From a cohort of 46 patients implanted with the CardioMEMSTM HF system with at least 3 months of follow-up, daily pressure waveforms were evaluated from the St Jude Medical Merlin remote monitoring system. Patients with medication changes and/or hospitalization within 2 weeks were excluded to identify stable hemodynamic time periods. Two-hundred and eight daily PAP waveforms were visually inspected with measurement of PASP, PADP and mean PAP taken at endexpiration. Each waveform was evaluated for the presence of respiratory variation (RV), defined as an absolute difference between highest and lowest PASP measurement of >20 mm Hg. Bland-Altman analysis was applied to compare visually estimated versus device-calculated pressures. Results: All patients had NYHA class III symptoms, mean age 80 ± 10 years and 20% with preserved EF. Bland-Altman analysis of all 208 recordings revealed a mean PAP and PADP that fell 1.56 mmHg above and 0.84 mmHg below the zero line, respectively; a negative bias indicating device-calculated measurements underestimated visually determined end-expiratory PAP. Among the recordings with RV (52, 25%), the mean difference in Bland-Altman plot comparing the two measurement techniques for mean PAP and PADP was 0.75 mmHg above and 2.27 mmHg below the zero line, respectively. For recordings without RV (156, 75%), BlandAltman analysis found a mean difference for mean PAP and PADP of 1.83 mmHg above and 0.36 mmHg below the zero line, respectively. Conclusions: In the absence of RV both measurement methods of PADP have excellent agreement. Additional study is required to evaluate the effect of RV on patients being managed with the CardioMEMSTM HF system.
HF UBCL met weekly to review every 30 day HF readmission and every 7 day all cause readmission. We categorized every readmission into one of the following categories: progression of disease, systems issue and poor social partnering. Social work was deployed for the poor social partners, progression of disease cases were reviewed for opportunity for therapeutic intervention and the systems issue cohort were used to alter practices in the institution to allow improved transitions. Multidisciplinary rounds, discharge time out with the bedside nurse and team pharmacist, improved communication with providers, development of a nurse practitioner run advanced heart failure clinic and a 48 hour post discharge phone call were implemented as a result of case review. With these interventions, despite a sick population of patients, our 30 day HF readmission rate has been consistently below the nationally reported rate.
227 Home INR Monitoring Versus Lab Monitoring in Patients With Left Ventricular Assist Device Samreena Saleem, Santosh G. Menon, Gregory F. Egnaczyk, Thomas M. O’Brien, Valerie Gadomski, Cathy Stugmeyer, Eugene S. Chung; The Christ Hospital, Cincinnati, OH Introduction: Heart failure patients implanted with an axial or centrifugal left ventricular assist device (LVAD) are treated with warfarin to prevent pump thrombosis. Given the propensity for gastrointestinal bleeding with these patients, careful management of anticoagulation is an essential part of post-operative care. Given the intense involvement of these patients and care-givers, we hypothesized that home monitoring of international normalized ratio (INR) may be more effective than traditional laboratory testing. Methods: We performed a retrospective study of 42 LVAD patients for a six-month period at The Christ Hospital in Cincinnati, OH. INR targets were patientspecific based on clinical history. Twenty-six patients used home testing (HOME: Roche, Alere) with guidance from the LVAD team while 16 patients were monitored using laboratory INR testing (LAB). Monitoring choice was based on patient/physician preference and insurance coverage. Results: Home monitored patients were tested fewer times over the 6 month period than the laboratory group (27 versus 37). In the HOME group, 52% of the INR’s were within target range and 48% were outside (26% above and 22% below target). In the LAB group, 36% of INR’s were within range and 64% were outside (27% above and 37% below target). Accordingly, percentage of patients experiencing either a bleeding or thrombotic complication was less common in the HOME group compared to LAB (15% versus 25%). Number of thrombotic complications was similar between the two groups, but bleeding complications were less frequent in the HOME group (3 in 26 patients) vs. LAB (7 in 16 patients). Conclusions: LVAD Patients monitored for INR at home required fewer tests, were more likely to be in therapeutic range, and suffered fewer bleeding complications. Relatively low rate of in-target INR’s are likely related to narrow ranges and multiple patient factors.
228 Symptom Perception, Evaluation, and Response and Care-Seeking Delay Among Patients With Heart Failure Akiko Okada 1 , Yoshiyuki Aoki 2 , Mariko Fukawa 3 , Shiho Matsuoka 4 , Miyuki Tsuchihashi-Makaya5; 1Saitama Medical University International Medical Center, Saitama, Japan; 2Saku Central Hospital Advanced Care Center, Nagano, Japan; 3Odawara Cardiovascular Hospital, Kanagawa, Japan; 4Graduate School of Medicine & Dental Sciences, Tokyo Medical & Dental University, Tokyo, Japan; 5School of Nursing, Kitasato University, Kanagawa, Japan
226 Successful Decrease in 30-Day Heart Failure Readmission Rate in a Quaternary Care Academic Hospital Joyce W. Wald, Daniel Kolansky, Leah Moran, Stephanie Ottemiller, Linda Hoke; University of Pennsylvania, Philadelphia, PA Background: Changes in healthcare delivery has impacted readmission rates: Centers for Medicare and Medicaid Services (CMS) has focused on decreasing length of stay for any given diagnosis and various economic factors have forced changes in the work force. Increased work load on bedside nurses so less time is spent teaching patients. (1) The 30 day heart failure (HF) readmission rate has been reported to be as high as 24.6%. (2)The HF Unit Based Clinical Leadership Team (UBCL) sought to better understand the current environment at the University of Pennsylvania Heart Failure Unit, understand the reasons for readmission to our institution while using a common language to describe these patients and then to more efficiently deploy resources tailored to the individual needs of each hospitalized patient in order to decrease risk of readmission. Methods: The Admit-Discharge-Transfer System (ADT) was utilized to capture readmissions. That data is then sent through Siemens Medical Systems (SMS) and Health Data Management (HDM) to our Penn Data Store and uploaded to the Quality Data Mart (QDM), which displays the information to the user. CMS definition of 30 day HF readmission was utilized. Results: From fiscal year 2007 through 2015 and 2016 (year to date), our 30 day HF readmission rates were as follows: 25.42%, 22.89%, 24.08%, 19,53%, 17.08%, 16.54%, 15.23%, 18.34%, 16.25% and 17.98%. Conclusions: The
Introduction: A delay in seeking care for symptoms is associated with longer hospital stays and higher mortality in heart failure (HF) patients. Care-seeking behavior consists of the perception and evaluation of and response to symptoms. However, the relationship between care-seeking delay and symptom perception, evaluation, and response, as well as potentially relevant factors, has not been fully evaluated. Objectives: Aims of this study were to 1) assess the perception and evaluation of and the response to symptoms, and 2) examine the determinants of care-seeking delay among patients with HF. Methods: Patients hospitalized due to HF were enrolled in this study. Structured interviews, self-administered questionnaires, and medical record reviews were conducted 3–7 days after admission to explore the recognized symptoms, patient evaluation of the symptom cause, and self-help and care-seeking behaviors in the prehospital phase. We also obtained data of sociodemographic and clinical factors. Participants were divided into long-delay and short-delay groups by median time from symptom recognition to hospital admission. Multivariate logistic regression analysis was conducted to estimate determinants of care-seeking delay. Results: A total 109 patients with HF were assessed (mean age 74.9 years; 64.2% male). Recognized symptoms were dyspnea (55.0%), edema (38.5%), and fatigue (26.6%). Only 37.6% of participants believed their symptoms were associated with heart problems, 19.3% had no idea what was causing their symptoms, 13.8% believed they had lung problems, and 11.9% linked their symptoms to advanced age. Responses to worsening symptoms included trying to relax (37.6%), informing family (33.0%), and seeking non-cardiac care (20.2%). Median time from perception of worsening symptoms to hospital admission was 5.2 days. Factors associated with time delays were fatigue (OR 3.87, 95% CI: 1.16–12.9, P = 0.028), seeking non-cardiac care (OR 4.67, 95% CI: 1.14–19.2, P = 0.033), evaluating symptom cause as aging (OR 0.10, 95% CI: 0.02–0.57, P = 0.009), failure to recognize a cause of worsening symptoms (OR 0.22, 95% CI: 0.06–0.89, P = 0.033), failure to inform family about worsening symptoms (OR 0.26, 95% CI: 0.08–0.79, P = 0.018), and valvular heart disease as the etiology of HF (OR 0.29, 95% CI: 0.10–0.84, P = 0.022).
HF UBCL met weekly to review every 30 day HF readmission and every 7 day all cause readmission. We categorized every readmission into one of the following categories: progression of disease, systems issue and poor social partnering. Social work was deployed for the poor social partners, progression of disease cases were reviewed for opportunity for therapeutic intervention and the systems issue cohort were used to alter practices in the institution to allow improved transitions. Multidisciplinary rounds, discharge time out with the bedside nurse and team pharmacist, improved communication with providers, development of a nurse practitioner run advanced heart failure clinic and a 48 hour post discharge phone call were implemented as a result of case review. With these interventions, despite a sick population of patients, our 30 day HF readmission rate has been consistently below the nationally reported rate.
227 Home INR Monitoring Versus Lab Monitoring in Patients With Left Ventricular Assist Device Samreena Saleem, Santosh G. Menon, Gregory F. Egnaczyk, Thomas M. O’Brien, Valerie Gadomski, Cathy Stugmeyer, Eugene S. Chung; The Christ Hospital, Cincinnati, OH Introduction: Heart failure patients implanted with an axial or centrifugal left ventricular assist device (LVAD) are treated with warfarin to prevent pump thrombosis. Given the propensity for gastrointestinal bleeding with these patients, careful management of anticoagulation is an essential part of post-operative care. Given the intense involvement of these patients and care-givers, we hypothesized that home monitoring of international normalized ratio (INR) may be more effective than traditional laboratory testing. Methods: We performed a retrospective study of 42 LVAD patients for a six-month period at The Christ Hospital in Cincinnati, OH. INR targets were patientspecific based on clinical history. Twenty-six patients used home testing (HOME: Roche, Alere) with guidance from the LVAD team while 16 patients were monitored using laboratory INR testing (LAB). Monitoring choice was based on patient/physician preference and insurance coverage. Results: Home monitored patients were tested fewer times over the 6 month period than the laboratory group (27 versus 37). In the HOME group, 52% of the INR’s were within target range and 48% were outside (26% above and 22% below target). In the LAB group, 36% of INR’s were within range and 64% were outside (27% above and 37% below target). Accordingly, percentage of patients experiencing either a bleeding or thrombotic complication was less common in the HOME group compared to LAB (15% versus 25%). Number of thrombotic complications was similar between the two groups, but bleeding complications were less frequent in the HOME group (3 in 26 patients) vs. LAB (7 in 16 patients). Conclusions: LVAD Patients monitored for INR at home required fewer tests, were more likely to be in therapeutic range, and suffered fewer bleeding complications. Relatively low rate of in-target INR’s are likely related to narrow ranges and multiple patient factors.
228 Symptom Perception, Evaluation, and Response and Care-Seeking Delay Among Patients With Heart Failure Akiko Okada 1 , Yoshiyuki Aoki 2 , Mariko Fukawa 3 , Shiho Matsuoka 4 , Miyuki Tsuchihashi-Makaya5; 1Saitama Medical University International Medical Center, Saitama, Japan; 2Saku Central Hospital Advanced Care Center, Nagano, Japan; 3Odawara Cardiovascular Hospital, Kanagawa, Japan; 4Graduate School of Medicine & Dental Sciences, Tokyo Medical & Dental University, Tokyo, Japan; 5School of Nursing, Kitasato University, Kanagawa, Japan
226 Successful Decrease in 30-Day Heart Failure Readmission Rate in a Quaternary Care Academic Hospital Joyce W. Wald, Daniel Kolansky, Leah Moran, Stephanie Ottemiller, Linda Hoke; University of Pennsylvania, Philadelphia, PA Background: Changes in healthcare delivery has impacted readmission rates: Centers for Medicare and Medicaid Services (CMS) has focused on decreasing length of stay for any given diagnosis and various economic factors have forced changes in the work force. Increased work load on bedside nurses so less time is spent teaching patients. (1) The 30 day heart failure (HF) readmission rate has been reported to be as high as 24.6%. (2)The HF Unit Based Clinical Leadership Team (UBCL) sought to better understand the current environment at the University of Pennsylvania Heart Failure Unit, understand the reasons for readmission to our institution while using a common language to describe these patients and then to more efficiently deploy resources tailored to the individual needs of each hospitalized patient in order to decrease risk of readmission. Methods: The Admit-Discharge-Transfer System (ADT) was utilized to capture readmissions. That data is then sent through Siemens Medical Systems (SMS) and Health Data Management (HDM) to our Penn Data Store and uploaded to the Quality Data Mart (QDM), which displays the information to the user. CMS definition of 30 day HF readmission was utilized. Results: From fiscal year 2007 through 2015 and 2016 (year to date), our 30 day HF readmission rates were as follows: 25.42%, 22.89%, 24.08%, 19,53%, 17.08%, 16.54%, 15.23%, 18.34%, 16.25% and 17.98%. Conclusions: The
Introduction: A delay in seeking care for symptoms is associated with longer hospital stays and higher mortality in heart failure (HF) patients. Care-seeking behavior consists of the perception and evaluation of and response to symptoms. However, the relationship between care-seeking delay and symptom perception, evaluation, and response, as well as potentially relevant factors, has not been fully evaluated. Objectives: Aims of this study were to 1) assess the perception and evaluation of and the response to symptoms, and 2) examine the determinants of care-seeking delay among patients with HF. Methods: Patients hospitalized due to HF were enrolled in this study. Structured interviews, self-administered questionnaires, and medical record reviews were conducted 3–7 days after admission to explore the recognized symptoms, patient evaluation of the symptom cause, and self-help and care-seeking behaviors in the prehospital phase. We also obtained data of sociodemographic and clinical factors. Participants were divided into long-delay and short-delay groups by median time from symptom recognition to hospital admission. Multivariate logistic regression analysis was conducted to estimate determinants of care-seeking delay. Results: A total 109 patients with HF were assessed (mean age 74.9 years; 64.2% male). Recognized symptoms were dyspnea (55.0%), edema (38.5%), and fatigue (26.6%). Only 37.6% of participants believed their symptoms were associated with heart problems, 19.3% had no idea what was causing their symptoms, 13.8% believed they had lung problems, and 11.9% linked their symptoms to advanced age. Responses to worsening symptoms included trying to relax (37.6%), informing family (33.0%), and seeking non-cardiac care (20.2%). Median time from perception of worsening symptoms to hospital admission was 5.2 days. Factors associated with time delays were fatigue (OR 3.87, 95% CI: 1.16–12.9, P = 0.028), seeking non-cardiac care (OR 4.67, 95% CI: 1.14–19.2, P = 0.033), evaluating symptom cause as aging (OR 0.10, 95% CI: 0.02–0.57, P = 0.009), failure to recognize a cause of worsening symptoms (OR 0.22, 95% CI: 0.06–0.89, P = 0.033), failure to inform family about worsening symptoms (OR 0.26, 95% CI: 0.08–0.79, P = 0.018), and valvular heart disease as the etiology of HF (OR 0.29, 95% CI: 0.10–0.84, P = 0.022).