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Multifaceted Care Model for CHF Improves Health System and Patient Economic Outcome
The 23rd Annual Scientific Meeting HFSA 351 Health Related Quality of Life a Predictor of 30 Day Hospital Readmission among Heart Failure Patients Lydia H. Albuquerque; William Paterson University, Wayne, NJ Background: Heart failure (HF) is the leading cause of hospital readmission among patients, age 65 years and older with the prevalence increasing 46% from 2012 to 2030, resulting in more than 8 million Americans affected. As defined by Healthy People 2020, health related quality of life measures, the way in which HF diagnosis could affect the physical, emotional, mental and social dimensions of the patient’s life. Quality of life refers to patients subjective perceptions of the effect of HF on their activity of daily living. Overall quality of life is subjective and individualized. Research is limited regarding the prediction of 30 day hospital readmissions and the use of self-reporting tools among Heart failure (HF). It is important to understand the variables associated with healthrelated quality of life (HRQOL). Purpose: The purpose of this project was to examine the relationship between self-reported Health related quality of life (HRQOL) to 30 day hospital re-admission rates among patients with HF as measured by the Minnesota Living with heart failure questionnaire (MLHQ). The independent variables in this study is quality of life; the dependent variable is 30-day hospital readmission rate. Research Question: What is the relationship between health related quality of life to 30 day hospital readmission rates among patients with diagnosis of heart failure? Hypothesis: There will be a positive correlation between increase in health related quality of life challenges as measured by the Minnesota Living with heart failure questionnaire (MLHQ) and 30 day hospital readmissions. Methods: A quantitative, descriptive co-relational research design (n=66) was used to examine the correlation between the predictor variable, Health related quality of life, to 30-day hospital readmission rates among patients with HF. The Minnesota Living with Heart failure questionnaire (MLHFQ) was utilized as a self- reporting tool to assess quality of life scores. IRB was obtained from the institution of study, participants who volunteered to participate in the study and met the eligibility criteria were consented and requested to complete the MLHFQ as a self - reported tool. Results: A total of seventy participants were recruited to the study, of which four participants were excluded due to mortality, lack of contactable phone number or having opted for palliative care. An independent sample t-test done to test for relationship between health quality of life and readmission was significant (p <0.05). A one- way ANOVA was calculated comparing the demographic variable to 30 day readmission rates revealed a significant difference between monthly income and readmission (F=2.864, p <0.05) and the number of times patients were admitted in the hospital in the past year to readmissions (F=3.333, p <0.01). These findings support the hypothesis that Health related quality of life is a predictor of hospital readmissions. Conclusions: The results of this study provide Health care providers information about predictors of readmissions among participants diagnosed with HF.
352 Impact of Renal Dysfunction on Periprocedural Outcomes in Patients with Ischemic Cardiomyopathy Undergoing Elective Coronary Artery Bypass Graft (CABG) Aasim Afzal, Tariq Nisar, Aayla Jamil, Aaron Kluger, Joost Felius, Shelley Hall, Parag Kale; Baylor University Medical Center, Dallas, TX Background: Ischemic cardiomyopathy is associated with multiple comorbidities including diabetes, hypertension, hyperlipidemia, and kidney disease. Patients with end-stage renal disease (ESRD) and left ventricular systolic heart failure have a 2-year cumulative survival as low as 33%. Chronic kidney disease (CKD) dramatically increases the Society of Thoracic Surgeons (STS) risk score for CABG. Hypothesis: Patients with preoperative CKD undergoing elective revascularization with CABG for ischemic cardiomyopathy will have worse periprocedural outcomes. Methods: From the 2006-2014 National Inpatient Sample, we identified hospitalizations for systolic heart failure (ICD-9 codes 428.1, 428.X, 428.4X, or 428.9) undergoing CABG (ICD-9 procedure codes 36.1X). Those with acute myocardial infarction (code 410.X) were excluded. Patients were categorized into normal preoperative renal function, preoperative CKD stages 1-4 (diagnosis codes 585.1-4 or 585.9), and preoperative ESRD (diagnosis codes 585.5-6), and compared in terms of demographics, comorbidities, in-hospital mortality, length of stay (LOS), cost of care, and postoperative complications. Trends over time were assessed with the Cochran Armitage and Cuzick tests. Multivariate models were constructed with logistic and linear regression (gamma function) using NIS discharge weights and adjusted for age and comorbidities (hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking, and family history of myocardial infarction). Results: Over the study period, trends showed a decline in in-hospital mortality in normal preoperative renal function and CKD stages 1-4 (p<0.05) groups, but remained unchanged for the ESRD group (p=0.91). Patients with ESRD had greater in-hospital mortality (OR = 3.40; 95% confidence interval 3.04 3.80) than those with normal renal function. LOS remained unchanged in all groups, but patients with ESRD had an average of 7 days longer LOS (6.4 - 7.8) compared to those with normal renal function. Total charges increased over the study period, but hospitalization cost on average was $120,996 more for the ESRD group than patients with normal renal function. Patients with ESRD had increased risk of stroke (OR=2.31; 1.55-2.86), while patients with CKD stages 1-4 had increased odds of post-procedural renal failure (OR=1.84; 1.65-2.05) compared to
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the normal renal function group. Conclusions: Patient with ESRD undergoing CABG for ischemic cardiomyopathy continue to have elevated in-hospital mortality despite an overall improvement in the non ESRD cohorts.
353 Home for the Holidays Campaign to Reduce Seasonal Heart Failure Hospitalizations Tulay Aksoy, Jessica Dekhtyar, Linda Gillespie, Nadine Katz, Benjamin Koo, John Loehner, Andrea Porrovecchio, Jeffrey Weiss, Katherine E. Di Palo; Montefiore Medical Center, Bronx, NY Introduction: Heart failure (HF) is a progressive syndrome and previous studies have shown that HF patients are more likely to be hospitalized during colder winter months. These seasonal variations coincide with holidays and can cause an additional emotional burden on patients, family members, and caregivers. Historically, 1 out of 4 HF patients at our institution experienced multiple hospitalizations during this period compared to 1 out of 5 in all other months. Therefore, we created a Home for the Holidays campaign to engage interdisciplinary care teams (IDT) and patients. We hypothesized that these efforts, in conjunction with existing hospital readmission reduction program interventions, would reduce the 30-day all-cause HF readmission rate. Methods: A readmission rate goal of less than 15% was established for 23 nursing units across 3 hospital campuses within a large, urban academic health system. Units that achieved this goal received recognition and breakfast with senior executive health system leadership. A toolkit consisting of a low sodium holiday menu, education workbook and magnet advertising the post-discharge helpline were distributed in a tote bag to all patients identified with acute decompensated HF (ADHF). IDT members focused on self-care management and early symptom recognition with patients and caregivers, as well as timely follow-up appointments. Results: Between 2014 and 2017 the average 30-day all-cause HF readmission rate for the month of December was 24.3%. In December 2018, 235 patients were admitted for ADHF, 37 patients were subsequently readmitted within 30 days and the readmission rate was 15.7%. The Home for the Holidays campaign contributed to a 35.4% rate reduction (p= 0.046) and 9 units achieved the institutional goal of less than 15%. Conclusions: Implementation of the toolkit, along with enhanced counseling and post-discharge follow-up, successfully reduce HF hospital readmissions. Health systems can easily integrate a seasonal campaign to increase awareness and stimulate transitional care and educational activities to keep patients healthy and at home for the holidays.
354 Multifaceted Care Model for CHF Improves Health System and Patient Economic Outcome Azam Hadi1, Michaelle Callihan1, Samuel Neiswender2, Srinivas Murali1; 1Allegheny, Pittsburgh, PA; 2Allegheny/Highmark, Pittsburgh, PA Introduction: Inconsistent piece-meal care for a chronic multidimensional disease like CHF results in poor clinical outcomes, therefore a chronic disease Care model that provides multifaceted holistic chronic disease management in the post-acute
S130 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 setting, aligning a multidisciplinary dedicated heart care team to a narrow network of home/community service providers implementing evidence based protocols across the continuum; namely a Care pathway improves outcomes. Specifically, this pathway may include daily inpatient CHF identification and navigation as follows: Heart protocol implementation & training at exclusively partnered Skilled Nursing/LTAC/ Home Health after concerted CHF Education (at those facilities) of Nurse practitioners (32 hours) RN Aides (3 hours) and RN (6 hours) of evidence based curriculum.Participating in daily phone huddle along with daily telehealth from the partnered facilities and home health with daily reporting/monitoring of progress eg., vitals, diet, PT/OT progress, etc.Incorporating care of chronic comorbidities including Diabetes and COPD and working concomitantly with those Care pathways.Discharge planning under the supervision of central CRNP and multi-disciplinary team including physician follow-up < 7 days, medication reconciliation via Pharmacy, referral to Cardiac Rehab, etc.Intervention protocols at various touch points for high risk patients at home to prevent adverse outcomes and to abort exacerbation of disease. The above model and it’s pathways revealed improvement in clinical outcomes, particularly 30 day readmissions that were reported at the HFSA 2018 but the economic impact of such interventions are unknown. Hypothesis: The above mentioned comprehensive approach to HF and it’s proven improved clinical outcomes may also translate into economic savings. Methods: A total of 1982 Allegheny Health/Highmark (AHN) patients are on the above mentioned Care pathway, out of which 337 were identified (from May 2017 until Dec 2018) as possible matches to patients outside of the system (deemed as “Market”) with similar attributes such as clinical severity, comorbidities and index facility ie., tertiary vs. community hospitals. The above match was blinded and performed by an independent non clinical entity to maintain investigational integrity. Results: After placement on the pathway, patient cost defined as per member per month (PMPM) was less expensive than market by $357 primarily driven by 30% decrease in post discharge inpatient cost and 12% decrease in post-acute costs (see Fig 1). Conclusion: Economic benefit can be achieved in tandem with better clinical outcome via multifaceted CHF care.
Introduction: About half of HF hospitalizations result from a cardiovascular cause. Identifying patients who are more likely to experience a cardiovascular (CV) readmission (and those who are more likely to experience a non-cardiovascular readmission) could have important implications on developing effective strategies to reduce 30-day readmission. We sought to determine if a simple count of cardiac conditions could predict CV-specific 30-day readmission. Methods: Using the Nationwide Readmissions Database, we examined all discharges in January-November 2014 following a hospitalization with a principal diagnosis of HF. We created a count based on the presence of three common and easily identifiable cardiac conditions (coronary artery disease [CAD], atrial arrhythmia, and ventricular arrhythmia) using ICD-9-CM codes. We used multinomial logistic regression to determine if a count of cardiac conditions was independently associated with CV readmission or non-CV readmission (relative to no readmission), adjusting for age, sex, payer status, annual income, comorbidity burden (Elixhauser index), and hospital bed size and urban vs. rural location. Results: Among 380,075 patients, 51% had CAD, 43% had an atrial arrhythmia, and 5% had a ventricular arrhythmia. The 30-day all-cause readmission rate was 20%; 55% were from CV causes. CAD, atrial arrhythmia, and ventricular arrhythmia were each associated with increased risk for 30-day CV readmission. About 28% had 0 cardiac comorbidities, 47% had 1, 23% had 2, and 2% had 3. When adjusting for potential patient- and hospital-level confounders, cardiac comorbidity count was independently associated with CV readmission, and was not associated with non-CV readmission (Table). The association between cardiac comorbidity count and CVreadmission were largely similar across age strata and tertiles of comorbidity burden (Table). Conclusion: A simple cardiac comorbidity count (comprised of CAD, atrial arrhythmia, and ventricular arrhythmia) was significantly associated with 30-day CV readmissions. This count can be calculated at the patient’s bedside and may provide a simple strategy to identify HF patients who would benefit from strategies targeted specifically to reduce CV-readmissions. Table 1. Independent Association of Cardiac Comorbidity Count with CV Re admission
356 Depressive Symptoms Drive Fatigue Following Congestion in Heart Failure Jonathan P. Auld; University of Washington, Seattle, WA
355 A Simple Cardiac Comorbidity Count Predicts 30-Day Cardiovascular Readmissions Following Heart Failure Hospitalization Aayush Visaria1, Lauren Balkan2, Laura Pinheiro2, Joanna Bryan2, Samprit Banerjee2, Madeline R. Sterling2, Evelyn M. Horn2, Monika M. Safford2, Parag Goyal2; 1Rutgers New Jersey Medical School, Newark, NJ; 2Weill Cornell Medicine, New York, NY
Background: Physical and depressive symptoms in heart failure (HF) are drivers of quality of life and healthcare use. Intrathoracic impedance, an objective measure of pulmonary congestion in HF, has been associated with both physical and psychological symptoms. Little is known, however, about how intrathoracic impedance (OptivolÒ Index), and physical and psychological symptoms are inter-related. Objective: To understand the mechanisms by which an objective measure of congestion is related to physical or depressive symptoms. Methods: Adults with symptomatic HF and an Optivol device had congestion data (Optivol Index>60V threshold) collected over 180 days prior to completing surveys of physical symptoms (Functional Assessment of Chronic Illness Therapy-Fatigue Scale; HF Somatic Perception Scale Dyspnea and Early and Subtle Symptoms subscales) and depressive symptoms (9-item Patient Health Questionnaire). Symptoms associated with congestion were identified based on Pearson correlation (p value <0.10). Path analyses (bootstrapped) were used to test mediation models: Model 1: congestion events ( one in past 180 days vs. none) predicting depressive symptoms, mediated by physical symptoms; and Model 2: congestion events predicting physical symptoms, mediated by depressive symptoms. Models were adjusted for gender, left ventricular ejection fraction, and time with HF. Results: Participants (n=49) were mostly male (61%), on average 62 years old, with mainly non-ischemic (80%), NYHA Class III/IV HF (63%). Fatigue (r= 0.29) and depressive symptoms (r= 0.51) were the only symptoms correlated with congestion (p value <0.10). Multivariate regression showed that having a congestion event in the past 180 days was associated with more fatigue (7.35§23.23, p=0.044), and more depressive symptoms (6.85§9.66, p<0.001). Both mediation models showed excellent fit with the data. The model with fatigue as the mediator
352 Impact of Renal Dysfunction on Periprocedural Outcomes in Patients with Ischemic Cardiomyopathy Undergoing Elective Coronary Artery Bypass Graft (CABG) Aasim Afzal, Tariq Nisar, Aayla Jamil, Aaron Kluger, Joost Felius, Shelley Hall, Parag Kale; Baylor University Medical Center, Dallas, TX Background: Ischemic cardiomyopathy is associated with multiple comorbidities including diabetes, hypertension, hyperlipidemia, and kidney disease. Patients with end-stage renal disease (ESRD) and left ventricular systolic heart failure have a 2-year cumulative survival as low as 33%. Chronic kidney disease (CKD) dramatically increases the Society of Thoracic Surgeons (STS) risk score for CABG. Hypothesis: Patients with preoperative CKD undergoing elective revascularization with CABG for ischemic cardiomyopathy will have worse periprocedural outcomes. Methods: From the 2006-2014 National Inpatient Sample, we identified hospitalizations for systolic heart failure (ICD-9 codes 428.1, 428.X, 428.4X, or 428.9) undergoing CABG (ICD-9 procedure codes 36.1X). Those with acute myocardial infarction (code 410.X) were excluded. Patients were categorized into normal preoperative renal function, preoperative CKD stages 1-4 (diagnosis codes 585.1-4 or 585.9), and preoperative ESRD (diagnosis codes 585.5-6), and compared in terms of demographics, comorbidities, in-hospital mortality, length of stay (LOS), cost of care, and postoperative complications. Trends over time were assessed with the Cochran Armitage and Cuzick tests. Multivariate models were constructed with logistic and linear regression (gamma function) using NIS discharge weights and adjusted for age and comorbidities (hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking, and family history of myocardial infarction). Results: Over the study period, trends showed a decline in in-hospital mortality in normal preoperative renal function and CKD stages 1-4 (p<0.05) groups, but remained unchanged for the ESRD group (p=0.91). Patients with ESRD had greater in-hospital mortality (OR = 3.40; 95% confidence interval 3.04 3.80) than those with normal renal function. LOS remained unchanged in all groups, but patients with ESRD had an average of 7 days longer LOS (6.4 - 7.8) compared to those with normal renal function. Total charges increased over the study period, but hospitalization cost on average was $120,996 more for the ESRD group than patients with normal renal function. Patients with ESRD had increased risk of stroke (OR=2.31; 1.55-2.86), while patients with CKD stages 1-4 had increased odds of post-procedural renal failure (OR=1.84; 1.65-2.05) compared to
S129
the normal renal function group. Conclusions: Patient with ESRD undergoing CABG for ischemic cardiomyopathy continue to have elevated in-hospital mortality despite an overall improvement in the non ESRD cohorts.
353 Home for the Holidays Campaign to Reduce Seasonal Heart Failure Hospitalizations Tulay Aksoy, Jessica Dekhtyar, Linda Gillespie, Nadine Katz, Benjamin Koo, John Loehner, Andrea Porrovecchio, Jeffrey Weiss, Katherine E. Di Palo; Montefiore Medical Center, Bronx, NY Introduction: Heart failure (HF) is a progressive syndrome and previous studies have shown that HF patients are more likely to be hospitalized during colder winter months. These seasonal variations coincide with holidays and can cause an additional emotional burden on patients, family members, and caregivers. Historically, 1 out of 4 HF patients at our institution experienced multiple hospitalizations during this period compared to 1 out of 5 in all other months. Therefore, we created a Home for the Holidays campaign to engage interdisciplinary care teams (IDT) and patients. We hypothesized that these efforts, in conjunction with existing hospital readmission reduction program interventions, would reduce the 30-day all-cause HF readmission rate. Methods: A readmission rate goal of less than 15% was established for 23 nursing units across 3 hospital campuses within a large, urban academic health system. Units that achieved this goal received recognition and breakfast with senior executive health system leadership. A toolkit consisting of a low sodium holiday menu, education workbook and magnet advertising the post-discharge helpline were distributed in a tote bag to all patients identified with acute decompensated HF (ADHF). IDT members focused on self-care management and early symptom recognition with patients and caregivers, as well as timely follow-up appointments. Results: Between 2014 and 2017 the average 30-day all-cause HF readmission rate for the month of December was 24.3%. In December 2018, 235 patients were admitted for ADHF, 37 patients were subsequently readmitted within 30 days and the readmission rate was 15.7%. The Home for the Holidays campaign contributed to a 35.4% rate reduction (p= 0.046) and 9 units achieved the institutional goal of less than 15%. Conclusions: Implementation of the toolkit, along with enhanced counseling and post-discharge follow-up, successfully reduce HF hospital readmissions. Health systems can easily integrate a seasonal campaign to increase awareness and stimulate transitional care and educational activities to keep patients healthy and at home for the holidays.
354 Multifaceted Care Model for CHF Improves Health System and Patient Economic Outcome Azam Hadi1, Michaelle Callihan1, Samuel Neiswender2, Srinivas Murali1; 1Allegheny, Pittsburgh, PA; 2Allegheny/Highmark, Pittsburgh, PA Introduction: Inconsistent piece-meal care for a chronic multidimensional disease like CHF results in poor clinical outcomes, therefore a chronic disease Care model that provides multifaceted holistic chronic disease management in the post-acute
S130 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 setting, aligning a multidisciplinary dedicated heart care team to a narrow network of home/community service providers implementing evidence based protocols across the continuum; namely a Care pathway improves outcomes. Specifically, this pathway may include daily inpatient CHF identification and navigation as follows: Heart protocol implementation & training at exclusively partnered Skilled Nursing/LTAC/ Home Health after concerted CHF Education (at those facilities) of Nurse practitioners (32 hours) RN Aides (3 hours) and RN (6 hours) of evidence based curriculum.Participating in daily phone huddle along with daily telehealth from the partnered facilities and home health with daily reporting/monitoring of progress eg., vitals, diet, PT/OT progress, etc.Incorporating care of chronic comorbidities including Diabetes and COPD and working concomitantly with those Care pathways.Discharge planning under the supervision of central CRNP and multi-disciplinary team including physician follow-up < 7 days, medication reconciliation via Pharmacy, referral to Cardiac Rehab, etc.Intervention protocols at various touch points for high risk patients at home to prevent adverse outcomes and to abort exacerbation of disease. The above model and it’s pathways revealed improvement in clinical outcomes, particularly 30 day readmissions that were reported at the HFSA 2018 but the economic impact of such interventions are unknown. Hypothesis: The above mentioned comprehensive approach to HF and it’s proven improved clinical outcomes may also translate into economic savings. Methods: A total of 1982 Allegheny Health/Highmark (AHN) patients are on the above mentioned Care pathway, out of which 337 were identified (from May 2017 until Dec 2018) as possible matches to patients outside of the system (deemed as “Market”) with similar attributes such as clinical severity, comorbidities and index facility ie., tertiary vs. community hospitals. The above match was blinded and performed by an independent non clinical entity to maintain investigational integrity. Results: After placement on the pathway, patient cost defined as per member per month (PMPM) was less expensive than market by $357 primarily driven by 30% decrease in post discharge inpatient cost and 12% decrease in post-acute costs (see Fig 1). Conclusion: Economic benefit can be achieved in tandem with better clinical outcome via multifaceted CHF care.
Introduction: About half of HF hospitalizations result from a cardiovascular cause. Identifying patients who are more likely to experience a cardiovascular (CV) readmission (and those who are more likely to experience a non-cardiovascular readmission) could have important implications on developing effective strategies to reduce 30-day readmission. We sought to determine if a simple count of cardiac conditions could predict CV-specific 30-day readmission. Methods: Using the Nationwide Readmissions Database, we examined all discharges in January-November 2014 following a hospitalization with a principal diagnosis of HF. We created a count based on the presence of three common and easily identifiable cardiac conditions (coronary artery disease [CAD], atrial arrhythmia, and ventricular arrhythmia) using ICD-9-CM codes. We used multinomial logistic regression to determine if a count of cardiac conditions was independently associated with CV readmission or non-CV readmission (relative to no readmission), adjusting for age, sex, payer status, annual income, comorbidity burden (Elixhauser index), and hospital bed size and urban vs. rural location. Results: Among 380,075 patients, 51% had CAD, 43% had an atrial arrhythmia, and 5% had a ventricular arrhythmia. The 30-day all-cause readmission rate was 20%; 55% were from CV causes. CAD, atrial arrhythmia, and ventricular arrhythmia were each associated with increased risk for 30-day CV readmission. About 28% had 0 cardiac comorbidities, 47% had 1, 23% had 2, and 2% had 3. When adjusting for potential patient- and hospital-level confounders, cardiac comorbidity count was independently associated with CV readmission, and was not associated with non-CV readmission (Table). The association between cardiac comorbidity count and CVreadmission were largely similar across age strata and tertiles of comorbidity burden (Table). Conclusion: A simple cardiac comorbidity count (comprised of CAD, atrial arrhythmia, and ventricular arrhythmia) was significantly associated with 30-day CV readmissions. This count can be calculated at the patient’s bedside and may provide a simple strategy to identify HF patients who would benefit from strategies targeted specifically to reduce CV-readmissions. Table 1. Independent Association of Cardiac Comorbidity Count with CV Re admission
356 Depressive Symptoms Drive Fatigue Following Congestion in Heart Failure Jonathan P. Auld; University of Washington, Seattle, WA
355 A Simple Cardiac Comorbidity Count Predicts 30-Day Cardiovascular Readmissions Following Heart Failure Hospitalization Aayush Visaria1, Lauren Balkan2, Laura Pinheiro2, Joanna Bryan2, Samprit Banerjee2, Madeline R. Sterling2, Evelyn M. Horn2, Monika M. Safford2, Parag Goyal2; 1Rutgers New Jersey Medical School, Newark, NJ; 2Weill Cornell Medicine, New York, NY
Background: Physical and depressive symptoms in heart failure (HF) are drivers of quality of life and healthcare use. Intrathoracic impedance, an objective measure of pulmonary congestion in HF, has been associated with both physical and psychological symptoms. Little is known, however, about how intrathoracic impedance (OptivolÒ Index), and physical and psychological symptoms are inter-related. Objective: To understand the mechanisms by which an objective measure of congestion is related to physical or depressive symptoms. Methods: Adults with symptomatic HF and an Optivol device had congestion data (Optivol Index>60V threshold) collected over 180 days prior to completing surveys of physical symptoms (Functional Assessment of Chronic Illness Therapy-Fatigue Scale; HF Somatic Perception Scale Dyspnea and Early and Subtle Symptoms subscales) and depressive symptoms (9-item Patient Health Questionnaire). Symptoms associated with congestion were identified based on Pearson correlation (p value <0.10). Path analyses (bootstrapped) were used to test mediation models: Model 1: congestion events ( one in past 180 days vs. none) predicting depressive symptoms, mediated by physical symptoms; and Model 2: congestion events predicting physical symptoms, mediated by depressive symptoms. Models were adjusted for gender, left ventricular ejection fraction, and time with HF. Results: Participants (n=49) were mostly male (61%), on average 62 years old, with mainly non-ischemic (80%), NYHA Class III/IV HF (63%). Fatigue (r= 0.29) and depressive symptoms (r= 0.51) were the only symptoms correlated with congestion (p value <0.10). Multivariate regression showed that having a congestion event in the past 180 days was associated with more fatigue (7.35§23.23, p=0.044), and more depressive symptoms (6.85§9.66, p<0.001). Both mediation models showed excellent fit with the data. The model with fatigue as the mediator