- Email: [email protected]
Long Term Continuous Milrinone as Destination Therapy in Patients With Advanced Heart Failure
The 16th Annual Scientific Meeting
HFSA
S107
353 Long Term Continuous Milrinone as Destination Therapy in Patients With Advanced Heart Failure Saurabh Kapoor, Matthew Porac, Bernard Kim, Fatima Samad, Robert Berkowitz; Heart Failure and Pulmonary Hypertension Program, Heart and Vascular Hospital at Hackensack University Medical Center, Hackensack, NJ Objective: To assess the long term effect of continuous milrinone on rehospitalization and mortality in advanced heart failure patients who were not candidates for heart transplantation or left ventricular assist device (LVAD). Background: Patients with advanced heart failure who receive standard medical therapy typically exhibit a high mortality at one year. These patients are either unable to tolerate or are refractory to standard medical therapy. There is limited data about the long term effects of continuous milrinone infusion on morbidity and mortality in this patient population. Methods: This was a retrospective analysis of observational patient data from the heart failure program at Hackensack University Medical Center, New Jersey. Twenty five patients (mean age 72.8 [SD511.6]) with systolic heart failure (Left ventricular ejection fraction 2065, cardiac index 1.660.2) were treated with continuous milrinone using a portable pump at home along with standard medical therapy. Due to the ethical and practical difficulties in performing placebo-controlled trial in NYHA class 4 patients, a control group of conventional medical therapy could not be established. However, we used as a historical control, the medical therapy group from the REMATCH trial. Primary endpoint was mortality at one year. Secondary endpoints were all cause rehospitalization within 30 days and improvement in NYHA class at 1 year. Results: Twenty five patients started on milrinone were followed up for a one year period. A one year cumulative incidence of mortality estimate of 0.206 (95% CI, 0.174 to 0.239) was observed in this study. Medical therapy group from the REMATCH trial, encouraged discontinuation of inotropic therapy, showed a mortality of 75% at one year. In our study group, all cause rehospitalization within 30 days was 8%(n52) and NYHA class was 2.560.6 at one year. Conclusion: The use of continuous milrinone along with standard medical therapy resulted in a clinically meaningful survival benefit, decreased rehospitalization and improvement in NYHA class at 1 year.
Fig. 1. Readmission assesments by 3 chart reviewers.
Fig. 2. Venn diagram of preventable readmission by 3 chart reviewers.
355
354 Chart Review To Determine Which Heart Failure Readmissions are Preventable Priti Mehla, Aline Iskandar, Rebecca Andrews, Marybeth Barry, Jason Ryan; University of Connecticut Health Center, Farmington, CT Background: At the UCONN Health Center, we launched a hospital-wide program that reduced the 30-day all-cause readmission rate for our HF population by 30% suggesting nearly one third of rehospitalizations were avoidable. We reviewed the charts of readmitted patients in the year prior to our initiative to determine if we could identify which readmissions were preventable. Methods: We used the Connecticut Hospital Association’s Chimedata database to determine the 30-day all-cause readmission rate in the year before (2008) and the year after (2011) our initiative. For unplanned readmissions to our own institution in 2008, three providers (cardiologist, internist, heart failure APRN) reviewed the clinical charts from hospitalization, rehospitalization, and any outpatient visits within our own system. Each reviewer determined whether the readmission was preventable, not preventable, or indeterminate based on their experience. Results: Our 30-day all-cause readmission rate fell from 27.1% in 2008 to 19.1% in 2011 (p ! 0.01), a decrease of 30%. In 2008, 40 HF patients had an unplanned readmission to our own hospital. Of these, providers identified 20 to 30% as preventable although reviewers disagreed over which readmissions were avoidable (Figures 1 & 2). All 3 chart reviewers considered over half of readmissions not preventable. The most commonly cited intervention that could have avoided a readmission was closer monitoring in the outpatient setting. Conclusion: Retrospective chart review identified avoidable readmissions at a frequency close to the readmission reduction achieved by our HF program. This suggests subjective chart review by providers may be able to predict the success of a HF readmission reduction program.
Self-Reported Awareness of Chronic Heart Failure (CHF) in a VA Population Diagnosed With CHF: Implications for Individual Patients, Caregivers, Providers, and Organizations Nancy L. Oliva1,2, Laura Gaskin2, Anju Sahay2, Parisa Gholami2, Paul Heidenreich2,3; 1Geriatric Research, Education & Clinical Center, VA Palo Alto Health System, Palo Alto, CA; 2VA CHF-QUERI, @VA Palo Alto Health System, Palo Alto, CA; 3Medicine-Cardiovascular Medicine/Health Research & Policy, Stanford University School of Medicine, Stanford, CA The VA Quality Enhancement Research Initiative (QUERI) was implemented in 1998 as one element of a system-wide transformation to improve the quality of healthcare for Veterans. VA QUERI Centers promote evidence-based clinical practice in 10 high-risk and/or high prevalence diseases/conditions affecting Veterans, including CHF. The VA Palo Alto Health Care System (VAPAHCS) CHF QUERI program routinely surveys all Veterans diagnosed and treated for CHF there through a mailed, six-question, self-report Health Status Survey (HSS). Veterans are identified through the VA clinical information system (Computerized Patient Record System, CPRS) by primary or secondary CHF diagnoses. In calendar years 2010 and 2011, Veterans and caregivers returned 1,254 questionnaires, reflecting a 70% response rate; 3/4ths of surveys are completed by Veterans, 1/4th by caregivers. Most Veterans with CHF in the VA and our CHFQUERI HHS respondents are age 65 and over. Sixty percent (60%, n5754) of HSS respondents reported that they had been told that they (Veteran) had CHF, while 32% (n5417) reported that they had not been told they had CHF. Another 4% of respondents (n545) reported that they did not remember a CHF diagnosis. Nearly 1/3rd of respondents reported not being told of a CHF diagnosis, though clinicians had previously documented CHF in the CPRS record. Various sources of patient-clinician diagnosis disconnect are described in health services literature. They can arise from health literacy limitations, cultural beliefs and other barriers in understanding and applying health information. Provider-level actions such as overlooking limited literacy or self-care capacity can magnify communication and education disconnects.
HFSA
S107
353 Long Term Continuous Milrinone as Destination Therapy in Patients With Advanced Heart Failure Saurabh Kapoor, Matthew Porac, Bernard Kim, Fatima Samad, Robert Berkowitz; Heart Failure and Pulmonary Hypertension Program, Heart and Vascular Hospital at Hackensack University Medical Center, Hackensack, NJ Objective: To assess the long term effect of continuous milrinone on rehospitalization and mortality in advanced heart failure patients who were not candidates for heart transplantation or left ventricular assist device (LVAD). Background: Patients with advanced heart failure who receive standard medical therapy typically exhibit a high mortality at one year. These patients are either unable to tolerate or are refractory to standard medical therapy. There is limited data about the long term effects of continuous milrinone infusion on morbidity and mortality in this patient population. Methods: This was a retrospective analysis of observational patient data from the heart failure program at Hackensack University Medical Center, New Jersey. Twenty five patients (mean age 72.8 [SD511.6]) with systolic heart failure (Left ventricular ejection fraction 2065, cardiac index 1.660.2) were treated with continuous milrinone using a portable pump at home along with standard medical therapy. Due to the ethical and practical difficulties in performing placebo-controlled trial in NYHA class 4 patients, a control group of conventional medical therapy could not be established. However, we used as a historical control, the medical therapy group from the REMATCH trial. Primary endpoint was mortality at one year. Secondary endpoints were all cause rehospitalization within 30 days and improvement in NYHA class at 1 year. Results: Twenty five patients started on milrinone were followed up for a one year period. A one year cumulative incidence of mortality estimate of 0.206 (95% CI, 0.174 to 0.239) was observed in this study. Medical therapy group from the REMATCH trial, encouraged discontinuation of inotropic therapy, showed a mortality of 75% at one year. In our study group, all cause rehospitalization within 30 days was 8%(n52) and NYHA class was 2.560.6 at one year. Conclusion: The use of continuous milrinone along with standard medical therapy resulted in a clinically meaningful survival benefit, decreased rehospitalization and improvement in NYHA class at 1 year.
Fig. 1. Readmission assesments by 3 chart reviewers.
Fig. 2. Venn diagram of preventable readmission by 3 chart reviewers.
355
354 Chart Review To Determine Which Heart Failure Readmissions are Preventable Priti Mehla, Aline Iskandar, Rebecca Andrews, Marybeth Barry, Jason Ryan; University of Connecticut Health Center, Farmington, CT Background: At the UCONN Health Center, we launched a hospital-wide program that reduced the 30-day all-cause readmission rate for our HF population by 30% suggesting nearly one third of rehospitalizations were avoidable. We reviewed the charts of readmitted patients in the year prior to our initiative to determine if we could identify which readmissions were preventable. Methods: We used the Connecticut Hospital Association’s Chimedata database to determine the 30-day all-cause readmission rate in the year before (2008) and the year after (2011) our initiative. For unplanned readmissions to our own institution in 2008, three providers (cardiologist, internist, heart failure APRN) reviewed the clinical charts from hospitalization, rehospitalization, and any outpatient visits within our own system. Each reviewer determined whether the readmission was preventable, not preventable, or indeterminate based on their experience. Results: Our 30-day all-cause readmission rate fell from 27.1% in 2008 to 19.1% in 2011 (p ! 0.01), a decrease of 30%. In 2008, 40 HF patients had an unplanned readmission to our own hospital. Of these, providers identified 20 to 30% as preventable although reviewers disagreed over which readmissions were avoidable (Figures 1 & 2). All 3 chart reviewers considered over half of readmissions not preventable. The most commonly cited intervention that could have avoided a readmission was closer monitoring in the outpatient setting. Conclusion: Retrospective chart review identified avoidable readmissions at a frequency close to the readmission reduction achieved by our HF program. This suggests subjective chart review by providers may be able to predict the success of a HF readmission reduction program.
Self-Reported Awareness of Chronic Heart Failure (CHF) in a VA Population Diagnosed With CHF: Implications for Individual Patients, Caregivers, Providers, and Organizations Nancy L. Oliva1,2, Laura Gaskin2, Anju Sahay2, Parisa Gholami2, Paul Heidenreich2,3; 1Geriatric Research, Education & Clinical Center, VA Palo Alto Health System, Palo Alto, CA; 2VA CHF-QUERI, @VA Palo Alto Health System, Palo Alto, CA; 3Medicine-Cardiovascular Medicine/Health Research & Policy, Stanford University School of Medicine, Stanford, CA The VA Quality Enhancement Research Initiative (QUERI) was implemented in 1998 as one element of a system-wide transformation to improve the quality of healthcare for Veterans. VA QUERI Centers promote evidence-based clinical practice in 10 high-risk and/or high prevalence diseases/conditions affecting Veterans, including CHF. The VA Palo Alto Health Care System (VAPAHCS) CHF QUERI program routinely surveys all Veterans diagnosed and treated for CHF there through a mailed, six-question, self-report Health Status Survey (HSS). Veterans are identified through the VA clinical information system (Computerized Patient Record System, CPRS) by primary or secondary CHF diagnoses. In calendar years 2010 and 2011, Veterans and caregivers returned 1,254 questionnaires, reflecting a 70% response rate; 3/4ths of surveys are completed by Veterans, 1/4th by caregivers. Most Veterans with CHF in the VA and our CHFQUERI HHS respondents are age 65 and over. Sixty percent (60%, n5754) of HSS respondents reported that they had been told that they (Veteran) had CHF, while 32% (n5417) reported that they had not been told they had CHF. Another 4% of respondents (n545) reported that they did not remember a CHF diagnosis. Nearly 1/3rd of respondents reported not being told of a CHF diagnosis, though clinicians had previously documented CHF in the CPRS record. Various sources of patient-clinician diagnosis disconnect are described in health services literature. They can arise from health literacy limitations, cultural beliefs and other barriers in understanding and applying health information. Provider-level actions such as overlooking limited literacy or self-care capacity can magnify communication and education disconnects.