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TEMPORAL TRENDS IN HEART FAILURE PREVALENCE AND OUTCOMES IN BRITISH COLUMBIA
Abstracts
Canadian Cardiovascular Society (CCS) Oral IMPROVING HEART FAILURE CARE AND OUTCOMES Saturday, October 22, 2016 041 PATIENT ENGAGEMENT WITH E-COUNSELLING PROMOTES SELF-CARE IN HEART FAILURE RP Nolan, A Payne, R Tanaka, H Ross, B D’Antono, S Chan, M White, L Mielniczuk Toronto, Ontario BACKGROUND:
Sustained adherence to self-care behaviour is problematic among patients with heart failure (HF). The main objective of this study was to evaluate adherence to selfcare associated with patient engagement with our multifunctional e-counselling platform over the initial 16 weeks of a 12month e-counselling program. To that end, we initially examined the longitudinal pattern of patient engagement with the e-counseling program, which proactively contacted patients weekly. Each e-counseling session included (i) self-care information, (ii) films (self-help training, dramatic vignettes, focus group), and (iii) interactive e-tools and e-trackers. METHODS: We used a k-means partitioning algorithm to evaluate how a sample of 102 patients engaged with our multifunctional ecounseling platform on a weekly basis over 16 weeks. Clusters were defined by the cumulative proportion of e-pages accessed by patients, relative to the number of available e-pages. Betweenand within-cluster covariance was optimized using the Calinski and Harabatz criterion. Background characteristics were examined to determine whether Clusters differed at Baseline. We evaluated 16-week outcomes with Analysis of Variance for selfcare: active living (4-day step count) and diet (daily fruit and vegetable intake, Diet History Questionnaire). Bonferroni correction was used for post-hoc comparisons. Partial correlations were used to assess the association between cumulative e-pages accessed and self-care behaviour at 16 weeks. RESULTS: Four clusters of patient engagement were identified from the longitudinal data; p < 0.001. For Group 1 (Optimal Engagement), e-pages were accessed regularly each week, with adherence at 87% at week 16. In Group 2 (Sub-optimal Engagement) weekly access of e-pages was stable, with above 55% adherence at week 16. Group 3 (Habituation) showed progressive disengagement over time with only 4% adherence at week 16. Group 4 (Low Engagement) showed a consistent but low response across time with 25% adherence at week 16. At baseline, Groups did not differ by sex or age. Group 1 (Optimal engagement) significantly increased 4-day step count, p ¼ 0.006. Group differences were not observed for daily fruit and vegetable intake. Overall, patient engagement (cumulative e-pages accessed) was independently associated with increased readiness to adhere to exercise (p ¼ 0.03) and to limit use of substances (smoking and alcohol; p ¼ 0.03). CONCLUSION: Our findings contribute to a growing evidence base which indicates that patient engagement with an
S89
e-counseling program that is standardized, evidence-based, and clinically grounded can promote therapeutic change in active living and motivational readiness to adhere to self-care among patients with HF.
042 TEMPORAL TRENDS IN HEART FAILURE PREVALENCE AND OUTCOMES IN BRITISH COLUMBIA L Ding, S Harle, B Catlin, P Ramsay, S Virani Vancouver, British Columbia BACKGROUND:
Heart Failure (HF) is a growing public health concern affecting a large portion of our elderly population. The number of individuals with HF in BC is expected to rise over the next decade with an associated increase in HF related healthcare utilization. The aim of the current study is to describe temporal trends for HF in BC including disease prevalence, mortality and healthcare costs as an opportunity to gauge the impact of BC’s comprehensive HF Strategy on patient and system related outcomes. METHODS: BC Ministry of Health administrative data sources were analyzed to describe temporal trends for HF between 2001/02 and 2013/14. Indicators used for the purposes of this evaluation were all-cause mortality for the prevalent population and 30-day re-hospitalization after incident HF episode. Healthcare costs attributable to HF were calculated from hospitalization data, Medical Services Plan (MSP) billing data, and PharmaNet drug records. RESULTS: The crude incidence rate of HF in BC has increased by 21.4% over the period of 2001/02-2013/14, from 0.28% to 0.34% while the age-standardized incidence rate has remained relatively stable. However, the crude prevalence rate of HF has increased by 43.8% from 1.6% to 2.3%; with an increase in the age-standardized prevalence rate of 12.9%. Despite growing prevalence, crude all-cause mortality of HF has decreased by 19.4% from 13.4% to 10.8%, with a substantial decrease in the age-standardized mortality rate by 42.3%. During the evaluation period from 2001/02 to 2012/ 13, there was an increase in MSP billing costs by 39.2%, hospital costs by 4.3%, and a small decrease in PharmaNet costs by 0.94%. There were striking differences in hospital costs across BC’s five geographical health authorities. Despite variability across health authorities, the total-per-patient cost for HF increased by 9.8% during this time period. The unplanned hospital readmission rate within 30 days of index HF episode was available for 2008/09-2012/13 fiscal years. There was an overall increase of 4.6% in recurrent HF admission although geographic variability in these rates was also noted. CONCLUSION: As in other jurisdictions, BC has realized increased HF prevalence over the last decade. Encouragingly, despite a growing HF population, mortality has improved suggesting improved HF care processes and better application of guideline-driven therapies which are primary goals for BC’s Heart Failure Network. Despite improved patient outcomes,
S90
the cost of health care delivery for HF patients has risen, with clear differences across regions, particularly with respect to MSP billing and re-hospitalization. 043 AN EVALUATION OF THE EFFECT OF SPIRONOLACTONE ON THE RISK OF NEW-ONSET DIABETES IN A POPULATION-BASED STUDY OF PATIENTS WITH HEART FAILURE S Korol, M White, E O’Meara, JL Rouleau, B White-Guay, M Dorais, A Ahmed, S Perreault, S de Denus Montréal, Québec BACKGROUND:
The non-selective mineralocorticoid receptor antagonist spironolactone is an established treatment for heart failure (HF). However, some evidence suggests that it may have a deleterious effect on glucose homeostasis. The objective of this study was to assess whether spironolactone use is associated with a higher risk of developing diabetes in a large cohort of HF patients. METHODS: We studied a cohort of hospitalized patients, with a primary discharge diagnosis of HF, using two administrative databases: the Québec government administrative database of hospital discharges (MED-ECHO) and the Québec medical services and prescription claims database (RAMQ) from January 1995 to December 2009. Patients were categorized as new users of spironolactone and non-users. The primary outcome was defined as new-onset diabetes defined according to the ICD-9 250 or ICD-10 codes for diabetes or new treatment with antidiabetic drugs. RESULTS: The cohort consisted of 5,773 hospitalized patients with a primary discharge diagnosis of HF, free of diabetes at discharge, of which 873 were new users of spironolactone. The incidence of new-onset diabetes was greater in spironolactone users (6.3 per 100 person-years) than in nonusers (4.8 per 100 person-years). This increase was significant in both the crude, unadjusted model, with a hazard ratio (HR) of 1.31; 95% CI: 1.08-1.58; p ¼ 0.005, and in an adjusted Cox proportional hazard model (HR: 1.23; 95% CI: 1.011.50; p ¼ 0.0447). Analysis of a 1:3 propensity score-matched cohort analysis revealed consistent results (HR 1.28; 1.041.58; p-value ¼ 0.0185). CONCLUSION: Among hospitalized HF patients, a discharge prescription of spironolactone is associated with a higher risk of new-onset diabetes. The clinical impact of these findings remains to be demonstrated. 044 EFFECTS OF EMPAGLIFLOZIN ON CARDIOVASCULAR MORTALITY BY PREVALENT OR INCIDENT HEART FAILURE IN THE EMPAREG OUTCOME TRIAL D Fitchett, B Zinman, JM Lachin, M Mattheus, J George, O Johansen, SE Inzucchi Toronto, Ontario BACKGROUND:
In EMPA-REG OUTCOME, the SGLT2 inhibitor empagliflozin reduced 3-point major adverse CV
Canadian Journal of Cardiology Volume 32 2016
events (MACE) vs. placebo in T2D patients with overt CV disease (CVD), driven by a 38% reduction of CV mortality. Moreover, a 35% decrease in risk of hospitalization for heart failure (HHF) was also observed. We analyzed the interrelationship between heart failure (HF) and CV mortality by analyzing the impact of empagliflozin on CV mortality by prevalent and/or incident heart failure. METHODS: 7020 patients with T2D and CVD received empagliflozin 10 mg or 25 mg or placebo in addition to standard of care. In addition to the previously reported prespecified outcome in patients with vs. without HF at baseline (HFBL), we assessed treatment group differences in CV mortality among patients who satisfied the following criteria: 1) Experiencing at least one HHF following randomisation (adjudicated), 2) Experiencing HF identified by the investigator as an adverse event (HFAE) following randomisation (irrespective of HFBL status and not necessarily involving hospitalization), 3) Having HFBL or experiencing HHF or HFAE following randomisation. All outcomes were analysed for the pooled empagliflozin group versus placebo and followed time to first event approach. RESULTS: Consistent with the effects on CV mortality in the main study (HR 0.62 (95% CI 0.49, 0.77)), based on 172 patients in the empagliflozin group and 137 in the placebo with CV death, CV mortality was also significantly reduced amongst the 958 patients in the trial who either had HFBL or had an incident HF episode (HR 0.67 (95% CI 0.47, 0.97)) (table) and the total number of deaths in this population comprised w38% of the overall CV deaths. CV mortality following incident HF was also lower in the empagliflozin treated patients, consistent with the overall study resutls, yet the differences did not reach statistical significance (table). As indicated in the figure, the CV mortality reduction with empagliflozin in the patients with HF at baseline or incident HF was observed early. CONCLUSIONS: Approximately 38% of all 309 CV deaths in EMPA-REG OUTCOME occurred in patients who either had a history of HF at entry or developed HF following randomisation. Empagliflozin significantly reduced CV mortality in this composite high risk population. However the majority (w62%) of the CV mortality benefit from empagliflozin occurred in patients who neither had HF at baseline nor developed HF following randomisation. Consequently the reduction of mortality with empagliflozin is experienced by both patients with and without HF.
Canadian Cardiovascular Society (CCS) Oral IMPROVING HEART FAILURE CARE AND OUTCOMES Saturday, October 22, 2016 041 PATIENT ENGAGEMENT WITH E-COUNSELLING PROMOTES SELF-CARE IN HEART FAILURE RP Nolan, A Payne, R Tanaka, H Ross, B D’Antono, S Chan, M White, L Mielniczuk Toronto, Ontario BACKGROUND:
Sustained adherence to self-care behaviour is problematic among patients with heart failure (HF). The main objective of this study was to evaluate adherence to selfcare associated with patient engagement with our multifunctional e-counselling platform over the initial 16 weeks of a 12month e-counselling program. To that end, we initially examined the longitudinal pattern of patient engagement with the e-counseling program, which proactively contacted patients weekly. Each e-counseling session included (i) self-care information, (ii) films (self-help training, dramatic vignettes, focus group), and (iii) interactive e-tools and e-trackers. METHODS: We used a k-means partitioning algorithm to evaluate how a sample of 102 patients engaged with our multifunctional ecounseling platform on a weekly basis over 16 weeks. Clusters were defined by the cumulative proportion of e-pages accessed by patients, relative to the number of available e-pages. Betweenand within-cluster covariance was optimized using the Calinski and Harabatz criterion. Background characteristics were examined to determine whether Clusters differed at Baseline. We evaluated 16-week outcomes with Analysis of Variance for selfcare: active living (4-day step count) and diet (daily fruit and vegetable intake, Diet History Questionnaire). Bonferroni correction was used for post-hoc comparisons. Partial correlations were used to assess the association between cumulative e-pages accessed and self-care behaviour at 16 weeks. RESULTS: Four clusters of patient engagement were identified from the longitudinal data; p < 0.001. For Group 1 (Optimal Engagement), e-pages were accessed regularly each week, with adherence at 87% at week 16. In Group 2 (Sub-optimal Engagement) weekly access of e-pages was stable, with above 55% adherence at week 16. Group 3 (Habituation) showed progressive disengagement over time with only 4% adherence at week 16. Group 4 (Low Engagement) showed a consistent but low response across time with 25% adherence at week 16. At baseline, Groups did not differ by sex or age. Group 1 (Optimal engagement) significantly increased 4-day step count, p ¼ 0.006. Group differences were not observed for daily fruit and vegetable intake. Overall, patient engagement (cumulative e-pages accessed) was independently associated with increased readiness to adhere to exercise (p ¼ 0.03) and to limit use of substances (smoking and alcohol; p ¼ 0.03). CONCLUSION: Our findings contribute to a growing evidence base which indicates that patient engagement with an
S89
e-counseling program that is standardized, evidence-based, and clinically grounded can promote therapeutic change in active living and motivational readiness to adhere to self-care among patients with HF.
042 TEMPORAL TRENDS IN HEART FAILURE PREVALENCE AND OUTCOMES IN BRITISH COLUMBIA L Ding, S Harle, B Catlin, P Ramsay, S Virani Vancouver, British Columbia BACKGROUND:
Heart Failure (HF) is a growing public health concern affecting a large portion of our elderly population. The number of individuals with HF in BC is expected to rise over the next decade with an associated increase in HF related healthcare utilization. The aim of the current study is to describe temporal trends for HF in BC including disease prevalence, mortality and healthcare costs as an opportunity to gauge the impact of BC’s comprehensive HF Strategy on patient and system related outcomes. METHODS: BC Ministry of Health administrative data sources were analyzed to describe temporal trends for HF between 2001/02 and 2013/14. Indicators used for the purposes of this evaluation were all-cause mortality for the prevalent population and 30-day re-hospitalization after incident HF episode. Healthcare costs attributable to HF were calculated from hospitalization data, Medical Services Plan (MSP) billing data, and PharmaNet drug records. RESULTS: The crude incidence rate of HF in BC has increased by 21.4% over the period of 2001/02-2013/14, from 0.28% to 0.34% while the age-standardized incidence rate has remained relatively stable. However, the crude prevalence rate of HF has increased by 43.8% from 1.6% to 2.3%; with an increase in the age-standardized prevalence rate of 12.9%. Despite growing prevalence, crude all-cause mortality of HF has decreased by 19.4% from 13.4% to 10.8%, with a substantial decrease in the age-standardized mortality rate by 42.3%. During the evaluation period from 2001/02 to 2012/ 13, there was an increase in MSP billing costs by 39.2%, hospital costs by 4.3%, and a small decrease in PharmaNet costs by 0.94%. There were striking differences in hospital costs across BC’s five geographical health authorities. Despite variability across health authorities, the total-per-patient cost for HF increased by 9.8% during this time period. The unplanned hospital readmission rate within 30 days of index HF episode was available for 2008/09-2012/13 fiscal years. There was an overall increase of 4.6% in recurrent HF admission although geographic variability in these rates was also noted. CONCLUSION: As in other jurisdictions, BC has realized increased HF prevalence over the last decade. Encouragingly, despite a growing HF population, mortality has improved suggesting improved HF care processes and better application of guideline-driven therapies which are primary goals for BC’s Heart Failure Network. Despite improved patient outcomes,
S90
the cost of health care delivery for HF patients has risen, with clear differences across regions, particularly with respect to MSP billing and re-hospitalization. 043 AN EVALUATION OF THE EFFECT OF SPIRONOLACTONE ON THE RISK OF NEW-ONSET DIABETES IN A POPULATION-BASED STUDY OF PATIENTS WITH HEART FAILURE S Korol, M White, E O’Meara, JL Rouleau, B White-Guay, M Dorais, A Ahmed, S Perreault, S de Denus Montréal, Québec BACKGROUND:
The non-selective mineralocorticoid receptor antagonist spironolactone is an established treatment for heart failure (HF). However, some evidence suggests that it may have a deleterious effect on glucose homeostasis. The objective of this study was to assess whether spironolactone use is associated with a higher risk of developing diabetes in a large cohort of HF patients. METHODS: We studied a cohort of hospitalized patients, with a primary discharge diagnosis of HF, using two administrative databases: the Québec government administrative database of hospital discharges (MED-ECHO) and the Québec medical services and prescription claims database (RAMQ) from January 1995 to December 2009. Patients were categorized as new users of spironolactone and non-users. The primary outcome was defined as new-onset diabetes defined according to the ICD-9 250 or ICD-10 codes for diabetes or new treatment with antidiabetic drugs. RESULTS: The cohort consisted of 5,773 hospitalized patients with a primary discharge diagnosis of HF, free of diabetes at discharge, of which 873 were new users of spironolactone. The incidence of new-onset diabetes was greater in spironolactone users (6.3 per 100 person-years) than in nonusers (4.8 per 100 person-years). This increase was significant in both the crude, unadjusted model, with a hazard ratio (HR) of 1.31; 95% CI: 1.08-1.58; p ¼ 0.005, and in an adjusted Cox proportional hazard model (HR: 1.23; 95% CI: 1.011.50; p ¼ 0.0447). Analysis of a 1:3 propensity score-matched cohort analysis revealed consistent results (HR 1.28; 1.041.58; p-value ¼ 0.0185). CONCLUSION: Among hospitalized HF patients, a discharge prescription of spironolactone is associated with a higher risk of new-onset diabetes. The clinical impact of these findings remains to be demonstrated. 044 EFFECTS OF EMPAGLIFLOZIN ON CARDIOVASCULAR MORTALITY BY PREVALENT OR INCIDENT HEART FAILURE IN THE EMPAREG OUTCOME TRIAL D Fitchett, B Zinman, JM Lachin, M Mattheus, J George, O Johansen, SE Inzucchi Toronto, Ontario BACKGROUND:
In EMPA-REG OUTCOME, the SGLT2 inhibitor empagliflozin reduced 3-point major adverse CV
Canadian Journal of Cardiology Volume 32 2016
events (MACE) vs. placebo in T2D patients with overt CV disease (CVD), driven by a 38% reduction of CV mortality. Moreover, a 35% decrease in risk of hospitalization for heart failure (HHF) was also observed. We analyzed the interrelationship between heart failure (HF) and CV mortality by analyzing the impact of empagliflozin on CV mortality by prevalent and/or incident heart failure. METHODS: 7020 patients with T2D and CVD received empagliflozin 10 mg or 25 mg or placebo in addition to standard of care. In addition to the previously reported prespecified outcome in patients with vs. without HF at baseline (HFBL), we assessed treatment group differences in CV mortality among patients who satisfied the following criteria: 1) Experiencing at least one HHF following randomisation (adjudicated), 2) Experiencing HF identified by the investigator as an adverse event (HFAE) following randomisation (irrespective of HFBL status and not necessarily involving hospitalization), 3) Having HFBL or experiencing HHF or HFAE following randomisation. All outcomes were analysed for the pooled empagliflozin group versus placebo and followed time to first event approach. RESULTS: Consistent with the effects on CV mortality in the main study (HR 0.62 (95% CI 0.49, 0.77)), based on 172 patients in the empagliflozin group and 137 in the placebo with CV death, CV mortality was also significantly reduced amongst the 958 patients in the trial who either had HFBL or had an incident HF episode (HR 0.67 (95% CI 0.47, 0.97)) (table) and the total number of deaths in this population comprised w38% of the overall CV deaths. CV mortality following incident HF was also lower in the empagliflozin treated patients, consistent with the overall study resutls, yet the differences did not reach statistical significance (table). As indicated in the figure, the CV mortality reduction with empagliflozin in the patients with HF at baseline or incident HF was observed early. CONCLUSIONS: Approximately 38% of all 309 CV deaths in EMPA-REG OUTCOME occurred in patients who either had a history of HF at entry or developed HF following randomisation. Empagliflozin significantly reduced CV mortality in this composite high risk population. However the majority (w62%) of the CV mortality benefit from empagliflozin occurred in patients who neither had HF at baseline nor developed HF following randomisation. Consequently the reduction of mortality with empagliflozin is experienced by both patients with and without HF.