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A Multidisciplinary Team Approach for Heart Failure May Not Be Effective in Patients with Limited Resources
The 9th Annual Scientific Meeting
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HFSA
S165
281
283
Severe Acute Decompensated Heart Failure: Epidemiology, Therapy and Hospitalization Costs Gregory M. Giesler1, Alexander Butkevich1, Biswajit Kar3, Douglas Gregory, Marvin Konstam2, Reynolds Delgado3; 1Cardiology, U. Texas Health Sciences Center, Houston, TX; 2Cardiology, Tufts-New England Medical Center, Boston, MA; 3 Cardiology, St. Lukes Episcopal/ Texas Heart Institute, Houston, TX
Comorbid Mental Disorder among Patients Hospitalized with Heart Failure Steven L. Sayers1, Nancy Hanrahan2, Ann M. Kutney2, Sean Clark2, Brendali Reis3, Barbara Riegel2; 1Psychiatry, University of Pennsylvania and Philadelphia VA Medical Center, Philadelphia, PA; 2School of Nursing, University of Pennsylvania, Philadelphia, PA; 3Institute for Graduate Clinical Psychology, Widener University, Chester, PA
Background: Heart failure (HF) is the fourth leading cause of hospital admissions in the US today comprising 5–10% of all admissions. As well it is the leading cause of admission in patients ⬎65 y/o and the single largest expense for Medicare. With the 500 Premier Registry hospitals, representing a wide range of US facilities, we aimed to evaluate the trends in hospitalization for severe acute decompensated of heart failure. Methods: The Premier Prospective Comparative Database collected 2.5 billion daily patient service records with 5 million hospital discharges from 1999– 2003 with the primary or secondary diagnosis of heart failure. Extrapolation from Premier hospitals to full US data utilized hospital specific projection weights. For year 2003, data was divided into all admissions for acute decompensated heart failure (ADHF) and severe ADHF (SADHF) (⬎3 days of IV inotropes or vasodilator therapy). Demographics, therapy and total costs were then evaluated. Results: 4.8 million admissions had the diagnosis of HF, an increase of 4.9% from 1999. 234,478 admissions were classified as SADHF, which is a 6.9% increase from 1999. The mean age of all patients was 74 (71% ⬎65 y/o and 56% female), whereas those with SADHF were younger and more predominately male (Mean age 70 and 43% female). Coronary disease was present in 57% of SADHF patients with 15% having an acute myocardial infarction. Renal insufficiency was markedly increased in the more severe patients (35% vs. 11%). Invasive devices (pulmonary artery catheters: 9% vs. 1% and IABP: 6% vs. 1%) were more likely to be utilized in patients with SADHF. Use of diuretic therapy was also more prolonged (8 days vs. 2.5 days). Average length of stay for all HF patients was 7 days while those with severe ADHF was 16 days (5.4 days in a ICU setting). In hospital mortality for SADHF was surprisingly low (3% vs. 6%) with similar 30-day readmission rates (27% v. 28%). The cost of hospitalization for SADHF was 3.2 times the cost per case of all HF patients and comprised 19% of the total HF annual cost. Conclusion: ADHF admissions continue to rise as the treatments for coronary artery disease and HF improve and the population ages. Although in hospital mortality rates in ADHF and SADHF are similar, SADHF remains costly with frequent readmissions and prolonged hospital and ICU stay.
There is growing recognition of the high prevalence of depression and impaired cognition in persons with heart failure (HF), but little attention has been given to other comorbid mental disorders. Mental disorders may interfere with self-care in HF patients and contribute to poor outcomes. Purpose: The purpose of this study was to explore the rates of comorbid mental disorders recorded for Medicare patients hospitalized for HF. Methods: A cross-sectional secondary analysis was conducted of administrative data collected from a 5% national sample from hospital records in the 1999 Medicare MedPar file. Individuals were selected from ICD-9-CM heart disease codes 410-414, 428, and 429.2. The AHRQ Clinical Classification System (CCS) was used to group heart disease and mental disorder ICD-9-CM codes into clinically relevant categories. Results: The full 5% sample included 357,232 unique individuals, 38.75% (N ⫽ 134,441) of whom were hospitalized for some form of heart disease. This sample was predominately white (86.8%), female (59.5%), and elderly (75.8 SD 9.54 years) although 9.8% was ⬍65 years. About one-fifth (21.1%) also had Medicaid coverage. Of the patients with heart disease, 72,160 (53.67%) had HF and 32.35% (22,619) of these had a comorbid discharge diagnosis of a mental disorder. Comorbid mental disorder diagnoses were depression (9.69%; CI 9.47%– 9.91%), dementia (8.98; CI 8.77%–9.19%), substance abuse (6.82%; CI 6.63%–7.0%); and anxiety (3.69%; CI 3.56%–3.83%). Conclusion: Evidence of a mental disorder was found in almost one-third of hospitalized HF patients. The high rate of substance abuse has not been previously described and deserves further probing. Detection of anxiety, depression, and substance abuse disorders in nonpsychiatric medical settings is known to be poor so the sizeable rates of the disorders seen here suggests that actual rates may be much higher. The impact of these disorders on outcomes needs further exploration.
282 Patterns of Digoxin Use and Digoxin Toxicity in the Post-DIG Trial Era Paul J. Hauptman1, Zainal M. Hussain1; 1Medicine, Saint Louis University School of Medicine, St. Louis, MO Background: Following the publication of the results of the DIG Trial, several reports [Lindsey et al 1999; Rathore et al 2002; Lader et al 2003] have called into question the continued use of digoxin (dig) for patients with normal sinus rhythm, LV systolic dysfunction and symptomatic heart failure (HF). However, little is known about current patterns of use of the drug and its polyclonal antibody antidote for use in cases of toxicity. Methods: We obtained data on toxicity from the American Association of Poison Control Centers’ Toxic Exposure Surveillance system (www.aapcc.org; calendar years 1998–2003); use of dig antibody (digibind, digiFab) from pharmaceutical marketing data estimates (GSK Business Development, calendar years 2000– 2004); and trends in dig use among patients hospitalized for HF (ADHERE쑓 Registry, 2001–2004). Results: As shown in the Table, digoxin use at time of hospitalization for HF is decreasing (31.4% to 24.7%, p ⬍ 0.00001 for trend) while reports of dig overdose and dig antibody administration remain essentially unchanged. Conclusions: Dig use is decreasing but toxicity does not appear to be lessening in incidence to the same degree. Further studies are needed to determine if the decrease in dig use may be occurring primarily in patients with lesser severity of HF and fewer comorbidities (with associated lower toxicity risk); if the threshold for dig antibody use has changed; and the temporal relationship between these trends and the publication of key studies on dig efficacy and effectiveness. Dig and Dig Antibody Use
2004 2003 2002 2001 2000 1999 1998
Dig Use (% of HF Admissions)
Reported Dig Toxicity Cases/ Exposures
Number of Deaths due to Dig Toxicity
Cases: Dig Antibody Administered
Units Dig Antibody Sold (000s)
24.69 26.52 28.72 31.41 NA NA NA
NA 2820 2923 2977 2960 2810 2972
NA 16 13 13 11 20 23
NA 446 346 314 328 334 296
38 39 41 43 37 NA NA
sources: Dig Use-ADHERE쑓 Registry; AAPCC; other. NA ⫽ not available
284 A Multidisciplinary Team Approach for Heart Failure May Not Be Effective in Patients with Limited Resources John C. Champion1, Rajiv Gupta2, Sangeeta Shah2, Susan Bionat2, Daniel J. Lenihan1; 1Cardiology, MD Anderson Cancer Center, Houston, TX; 2Cardiology, UTMB, Galveston, TX Background: There has been an important trend toward proactive management of patients with the use of specialized HF clinics and multidisciplinary teams to optimize therapy and to improve outcomes. The beneficial effect of such an approach has been most clearly demonstrated in pre-transplant and elderly patient populations, but this data may not apply to a broader group of HF patients. We hypothesized that an unselected group of patients with either systolic or diastolic HF, especially those with limited financial resources, would benefit from a multidisciplinary team (MDT) approach to management. Method: Patients admitted to the hospital with a primary or secondary diagnosis of HF were randomized to either standard care or MDT approach. The physician-directed, multidisciplinary team made therapeutic recommendations and addressed any psychosocial, financial, educational, or medical compliance barriers to effective treatment. Both groups were followed for up to one year, and chart review was performed at the end of the study for confirmation of endpoints. Results: 187 patients were enrolled in the study. The most common contributors to the index HF admission were knowledge deficits about HF, non-optimized medical therapy, and major financial constraints (Table 1). Also, most patients were not compliant with recommendations for daily weight and sodium or fluid restriction. 50% of the patients in the standard care group had at least one HF readmission compared to 46% in the MDT group (p ⫽ 0.66). There were also no significant differences in mortality (p ⫽ 0.72) or ER visits for HF (p ⫽ 0.46). Conclusion: The MDT approach to management has a limited impact on readmission and survival in an unselected population of HF patients. These data suggest that, although education remains important, social issues such as major financial constraints and poor compliance have become even greater barriers to effective medical care. As the cost for medical therapy escalates, these socioeconomic pressures will likely amplify the burden placed on patients with limited resources. Factors Contributing to Heart Failure Admissions* (n ⫽ 187) Factor Major financial constraints Poor social support Emotional distress Knowledge deficit Medical therapy non-optimized Noncompliance with sodium restriction Noncompliance with daily weight
Study Group (%) 99 55 49 117 103 96 152
(53) (29) (26) (63) (55) (51) (81)
*Values followed by a number in parentheses are numbers of patients and percentages of the group.
•
HFSA
S165
281
283
Severe Acute Decompensated Heart Failure: Epidemiology, Therapy and Hospitalization Costs Gregory M. Giesler1, Alexander Butkevich1, Biswajit Kar3, Douglas Gregory, Marvin Konstam2, Reynolds Delgado3; 1Cardiology, U. Texas Health Sciences Center, Houston, TX; 2Cardiology, Tufts-New England Medical Center, Boston, MA; 3 Cardiology, St. Lukes Episcopal/ Texas Heart Institute, Houston, TX
Comorbid Mental Disorder among Patients Hospitalized with Heart Failure Steven L. Sayers1, Nancy Hanrahan2, Ann M. Kutney2, Sean Clark2, Brendali Reis3, Barbara Riegel2; 1Psychiatry, University of Pennsylvania and Philadelphia VA Medical Center, Philadelphia, PA; 2School of Nursing, University of Pennsylvania, Philadelphia, PA; 3Institute for Graduate Clinical Psychology, Widener University, Chester, PA
Background: Heart failure (HF) is the fourth leading cause of hospital admissions in the US today comprising 5–10% of all admissions. As well it is the leading cause of admission in patients ⬎65 y/o and the single largest expense for Medicare. With the 500 Premier Registry hospitals, representing a wide range of US facilities, we aimed to evaluate the trends in hospitalization for severe acute decompensated of heart failure. Methods: The Premier Prospective Comparative Database collected 2.5 billion daily patient service records with 5 million hospital discharges from 1999– 2003 with the primary or secondary diagnosis of heart failure. Extrapolation from Premier hospitals to full US data utilized hospital specific projection weights. For year 2003, data was divided into all admissions for acute decompensated heart failure (ADHF) and severe ADHF (SADHF) (⬎3 days of IV inotropes or vasodilator therapy). Demographics, therapy and total costs were then evaluated. Results: 4.8 million admissions had the diagnosis of HF, an increase of 4.9% from 1999. 234,478 admissions were classified as SADHF, which is a 6.9% increase from 1999. The mean age of all patients was 74 (71% ⬎65 y/o and 56% female), whereas those with SADHF were younger and more predominately male (Mean age 70 and 43% female). Coronary disease was present in 57% of SADHF patients with 15% having an acute myocardial infarction. Renal insufficiency was markedly increased in the more severe patients (35% vs. 11%). Invasive devices (pulmonary artery catheters: 9% vs. 1% and IABP: 6% vs. 1%) were more likely to be utilized in patients with SADHF. Use of diuretic therapy was also more prolonged (8 days vs. 2.5 days). Average length of stay for all HF patients was 7 days while those with severe ADHF was 16 days (5.4 days in a ICU setting). In hospital mortality for SADHF was surprisingly low (3% vs. 6%) with similar 30-day readmission rates (27% v. 28%). The cost of hospitalization for SADHF was 3.2 times the cost per case of all HF patients and comprised 19% of the total HF annual cost. Conclusion: ADHF admissions continue to rise as the treatments for coronary artery disease and HF improve and the population ages. Although in hospital mortality rates in ADHF and SADHF are similar, SADHF remains costly with frequent readmissions and prolonged hospital and ICU stay.
There is growing recognition of the high prevalence of depression and impaired cognition in persons with heart failure (HF), but little attention has been given to other comorbid mental disorders. Mental disorders may interfere with self-care in HF patients and contribute to poor outcomes. Purpose: The purpose of this study was to explore the rates of comorbid mental disorders recorded for Medicare patients hospitalized for HF. Methods: A cross-sectional secondary analysis was conducted of administrative data collected from a 5% national sample from hospital records in the 1999 Medicare MedPar file. Individuals were selected from ICD-9-CM heart disease codes 410-414, 428, and 429.2. The AHRQ Clinical Classification System (CCS) was used to group heart disease and mental disorder ICD-9-CM codes into clinically relevant categories. Results: The full 5% sample included 357,232 unique individuals, 38.75% (N ⫽ 134,441) of whom were hospitalized for some form of heart disease. This sample was predominately white (86.8%), female (59.5%), and elderly (75.8 SD 9.54 years) although 9.8% was ⬍65 years. About one-fifth (21.1%) also had Medicaid coverage. Of the patients with heart disease, 72,160 (53.67%) had HF and 32.35% (22,619) of these had a comorbid discharge diagnosis of a mental disorder. Comorbid mental disorder diagnoses were depression (9.69%; CI 9.47%– 9.91%), dementia (8.98; CI 8.77%–9.19%), substance abuse (6.82%; CI 6.63%–7.0%); and anxiety (3.69%; CI 3.56%–3.83%). Conclusion: Evidence of a mental disorder was found in almost one-third of hospitalized HF patients. The high rate of substance abuse has not been previously described and deserves further probing. Detection of anxiety, depression, and substance abuse disorders in nonpsychiatric medical settings is known to be poor so the sizeable rates of the disorders seen here suggests that actual rates may be much higher. The impact of these disorders on outcomes needs further exploration.
282 Patterns of Digoxin Use and Digoxin Toxicity in the Post-DIG Trial Era Paul J. Hauptman1, Zainal M. Hussain1; 1Medicine, Saint Louis University School of Medicine, St. Louis, MO Background: Following the publication of the results of the DIG Trial, several reports [Lindsey et al 1999; Rathore et al 2002; Lader et al 2003] have called into question the continued use of digoxin (dig) for patients with normal sinus rhythm, LV systolic dysfunction and symptomatic heart failure (HF). However, little is known about current patterns of use of the drug and its polyclonal antibody antidote for use in cases of toxicity. Methods: We obtained data on toxicity from the American Association of Poison Control Centers’ Toxic Exposure Surveillance system (www.aapcc.org; calendar years 1998–2003); use of dig antibody (digibind, digiFab) from pharmaceutical marketing data estimates (GSK Business Development, calendar years 2000– 2004); and trends in dig use among patients hospitalized for HF (ADHERE쑓 Registry, 2001–2004). Results: As shown in the Table, digoxin use at time of hospitalization for HF is decreasing (31.4% to 24.7%, p ⬍ 0.00001 for trend) while reports of dig overdose and dig antibody administration remain essentially unchanged. Conclusions: Dig use is decreasing but toxicity does not appear to be lessening in incidence to the same degree. Further studies are needed to determine if the decrease in dig use may be occurring primarily in patients with lesser severity of HF and fewer comorbidities (with associated lower toxicity risk); if the threshold for dig antibody use has changed; and the temporal relationship between these trends and the publication of key studies on dig efficacy and effectiveness. Dig and Dig Antibody Use
2004 2003 2002 2001 2000 1999 1998
Dig Use (% of HF Admissions)
Reported Dig Toxicity Cases/ Exposures
Number of Deaths due to Dig Toxicity
Cases: Dig Antibody Administered
Units Dig Antibody Sold (000s)
24.69 26.52 28.72 31.41 NA NA NA
NA 2820 2923 2977 2960 2810 2972
NA 16 13 13 11 20 23
NA 446 346 314 328 334 296
38 39 41 43 37 NA NA
sources: Dig Use-ADHERE쑓 Registry; AAPCC; other. NA ⫽ not available
284 A Multidisciplinary Team Approach for Heart Failure May Not Be Effective in Patients with Limited Resources John C. Champion1, Rajiv Gupta2, Sangeeta Shah2, Susan Bionat2, Daniel J. Lenihan1; 1Cardiology, MD Anderson Cancer Center, Houston, TX; 2Cardiology, UTMB, Galveston, TX Background: There has been an important trend toward proactive management of patients with the use of specialized HF clinics and multidisciplinary teams to optimize therapy and to improve outcomes. The beneficial effect of such an approach has been most clearly demonstrated in pre-transplant and elderly patient populations, but this data may not apply to a broader group of HF patients. We hypothesized that an unselected group of patients with either systolic or diastolic HF, especially those with limited financial resources, would benefit from a multidisciplinary team (MDT) approach to management. Method: Patients admitted to the hospital with a primary or secondary diagnosis of HF were randomized to either standard care or MDT approach. The physician-directed, multidisciplinary team made therapeutic recommendations and addressed any psychosocial, financial, educational, or medical compliance barriers to effective treatment. Both groups were followed for up to one year, and chart review was performed at the end of the study for confirmation of endpoints. Results: 187 patients were enrolled in the study. The most common contributors to the index HF admission were knowledge deficits about HF, non-optimized medical therapy, and major financial constraints (Table 1). Also, most patients were not compliant with recommendations for daily weight and sodium or fluid restriction. 50% of the patients in the standard care group had at least one HF readmission compared to 46% in the MDT group (p ⫽ 0.66). There were also no significant differences in mortality (p ⫽ 0.72) or ER visits for HF (p ⫽ 0.46). Conclusion: The MDT approach to management has a limited impact on readmission and survival in an unselected population of HF patients. These data suggest that, although education remains important, social issues such as major financial constraints and poor compliance have become even greater barriers to effective medical care. As the cost for medical therapy escalates, these socioeconomic pressures will likely amplify the burden placed on patients with limited resources. Factors Contributing to Heart Failure Admissions* (n ⫽ 187) Factor Major financial constraints Poor social support Emotional distress Knowledge deficit Medical therapy non-optimized Noncompliance with sodium restriction Noncompliance with daily weight
Study Group (%) 99 55 49 117 103 96 152
(53) (29) (26) (63) (55) (51) (81)
*Values followed by a number in parentheses are numbers of patients and percentages of the group.