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Patients Hospitalized for Heart Failure Have Difficulties Managing Medications Despite Reported Self-Confidence
The 17th Annual Scientific Meeting for cancer-therapy-associated cardiac abnormalities from 2008-present. A comprehensive review of patient records was performed, with documentation of baseline characteristics, cardiac imaging, cardiac medications, and clinical course. Results: 79 consecutive patients who had drops in their LVEF associated with cancer therapy were included. The most common malignancies were breast (46%) and hematologic (35%); 71% of patients were female, and the mean age was 52 +/- 13 years. The primary cancer therapeutics associated with LVEF drop included anthracyclines, trastuzumab, and tyrosine kinase inhibitors. The mean LVEF prior to cancer therapy was 60%, and post-cancer therapy was 40%. The most common cardiac interventions included beta-blockers (84%), ACE-inhibitors/angiotensin receptor blockers (83%); mean LVEF after cardiac intervention was 53%. 77% of the patients had LVEF recovery to $50%, and 68% of these patients had recovery within 6 months of starting cardiac therapy. 76% of patients were able to continue their planned cancer therapy. Conclusions: With appropriate cardiac intervention, the majority of patients with LVEF decline from cancer therapy can achieve LVEF recovery and complete their chemotherapy.
HFSA
S87
level, 68% frail (Fried frailty criteria), 23% with high probability of cognitive impairment (Mini-Cog). Ninety-one percent of subjects were confident in managing medications, though only 11% were able to complete MMAT without errors (Figure). Specifically, 93% were able to read pill bottle labels, 89% were able to open pill bottles, 18% could correctly allocate mock medications into pillbox, and 72% were able to locate correct slot. Of pill allocation failures, 48% failed based on comprehension, 28% failed based on logic, 17% failed due to clerical errors, and 7% refused to complete test. Conclusions: Self-perception and observed ability to manage medications are discordant in older adults hospitalized for HF. This may represent a root cause for downstream medication non-adherence. We describe a novel MMAT that has construct validity in adults hospitalized for HF and may be used in future investigations.
252 Participation in a Multi-Disciplinary Heart Failure Disease Management Program (HFDMP) Minimizes Risk of Aldosterone Antagonist-Induced Hyperkalemia Kristyn Mulqueen, Shawn Anderson, Tamarah Jungklaus, Samantha Malloy, Timothy Cleeton, Jesus Acosta, Jennifer Darago, Richard Schofield; North Florida/ South Georgia Veterans Health System, Gainesville, FL Introduction: Aldosterone antagonists (AA) have been shown to reduce mortality and morbidity in a number of large, randomized controlled trials. Clinical practice guidelines recommend AA therapy for patients with heart failure with reduced ejection fraction (HFrEF), even in those with mild symptoms; however, these agents are often underutilized. Although clinical trials showed relatively low rates of significant hyperkalemia with AA therapy, some observational studies suggest that hyperkalemia occurs more frequently in clinical practice. As a result, some providers may hesitate to prescribe AAs. Hypothesis: Evidence-based prescribing of AAs with appropriate monitoring results in rates of hyperkalemia similar to those seen with standard heart failure (HF) therapy without an AA. Methods: A retrospective review of HF patients followed in a multi-disciplinary Heart Failure Disease Management Program (HFDMP) was performed to compare the incidence of hyperkalemia in patients managed with HF pharmacotherapy with AA (AA therapy group) or without AA (standard therapy group). Inpatient and outpatient medical records were reviewed to identify episodes of hyperkalemia occurring while patients were enrolled in the HFDMP. Hyperkalemia was classified as clinical (K $ 6 mmol/L) or subclinical (6 mmol/L O K $ 5.5 mmol/L). Hyperkalemic events were excluded if the blood sample was hemolyzed. One hundred fifty patients were needed in each group to have 80% power to detect a difference in the rate of hyperkalemia, using expected rates of 15% in the AA therapy group and 2% in the standard therapy group. Results: A total of 300 patients were included in the study. Clinical hyperkalemia occurred in 5 (3.3%) patients in the AA therapy group and 6 (4%) patients in the standard therapy group (p50.76). Subclinical hyperkalemia occurred in 15 (10%) patients in the AA therapy group and 22 (15%) patients in the standard therapy group (p50.22). The observed rate of any hyperkalemia for patients on AA therapy and standard therapy was 13.3% and 18.7%, respectively (p50.21). Conclusions: We found no statistically significant difference in the rate of hyperkalemia between groups of HFDMP patients treated with AA compared with those receiving standard HF therapy. Appropriate patient selection, close laboratory monitoring and follow-up allow for the safe use of AA therapy in patients with HFrEF.
253 Patients Hospitalized for Heart Failure Have Difficulties Managing Medications Despite Reported Self-Confidence Erik H. Howell1, Alpana Senapati1, Eiran Z. Gorodeski2; 1Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic, Cleveland, OH Introduction: Medication non-adherence is prevalent and associated with poor outcomes. Root causes are not clearly understood. The ability of patients to manage their own medications is not routinely assessed at time of hospital discharge. We developed a novel medication management assessment tool (MMAT) and applied it to patients hospitalized for HF. Hypothesis: Patients hospitalized for HF have under recognized poor medication self-management skills. Methods: We prospectively enrolled inpatients transitioning from hospital-to-home after hospitalization for HF. Prior to discharge, MMAT was deployed under direct observation. MMAT involved a series of tasks focused on allocating mock medications into a weekly pillbox. Prior to testing subjects were asked “Do you feel confident managing your medications on a daily basis?” Subjects were then provided 5 pill bottles representing common HF medications, each filled with 30 mock pills. Four components were assessed pass/ fail: (1) ability to read pill bottle label, verbally stating medication name and instructions; (2) ability to open pill bottle; (3) ability to allocate pills into pillbox correctly; (4) ability to locate specific slot in pillbox. Failure to allocate pills correctly was further subdivided into four categories: (1) Failure in comprehension (no discernible method of allocating pills); (2) Failure in logic (method of allocating pills has repeated error); (3) Clerical errors (appropriate comprehension and logic but !25% of pills allocated incorrectly) and (4) Refusal to complete MMAT after initiation. Results: Of 94 subjects approached 56 consented. Mean age was 77 [range 66-92], 73% male, 64% Caucasian, 32% with HFPEF (LVEF$50%), 30% with low health literacy
254 Outpatient Ultrafiltration as an Alternative to Hospitalization for Mild to Moderate Decompensated Heart Failure Sitaramesh Emani1, Jennifer Host1, Tara L. Baxter1, Todd Yamokoski1, Matthew R. Potter2, Kyle Porter3, Garrie Haas1; 1The Ohio State University, Columbus, OH; 2The Ohio State University, Columbus, OH; 3The Ohio State University, Columbus, OH Background: We previously reported data suggesting feasibility and safety of an outpatient ultrafiltration (UF) protocol to treat mild-moderate acute decompensated heart failure (ADHF). In follow up, we tracked 30-day outcomes following outpatient UF with the hypothesis that outcomes would mirror those of ADHF hospitalizations. Furthermore, we propose that outpatient UF may be a cost-effective alternative to hospitalization in this highly selected population. Methods: We retrospectively analyzed the medical record of consecutive patients who underwent outpatient UF per our established protocol. Treatment characteristics and efficacy were recorded. Unplanned hospitalizations or emergency room visits were tracked for 30 days. Finally, the cost of each outpatient UF treatment was compared to the average cost of an ADHF admission. Results: A total of 37 treatment episodes were identified. Each episode met criteria of outpatient UF based on our previously presented criteria. Demographic data are shown in table 1. Weight decreased by 7.1 kg (95% CI 5.4, 8.8) and creatinine changed by 0.01 (CI -0.10, 0.11). The rate of unplanned admission or ER visits at 30 days postUF was 24% (CI 10, 44%), which is comparable to a national ADHF readmission rate of 27%. The average charge for outpatient UF was $25,500 per treatment ($11,100/ day), which is less than typical inpatient charges for an ADHF hospitalization at our institution (based on a national average length of stay of 6.4 days). Reimbursement for outpatient at present is highly variable based on payer source. Conclusions: Outpatient UF can serve as an alternative to inpatient admission for selected cases of Demographic Data Average Age
59.6 yrs
Male ICM HFpEF Daily furosemide equivalent Thiazide use Number of UF days/episode
78% 65% 11% 161.1 mg 38% 2.3
HFSA
S87
level, 68% frail (Fried frailty criteria), 23% with high probability of cognitive impairment (Mini-Cog). Ninety-one percent of subjects were confident in managing medications, though only 11% were able to complete MMAT without errors (Figure). Specifically, 93% were able to read pill bottle labels, 89% were able to open pill bottles, 18% could correctly allocate mock medications into pillbox, and 72% were able to locate correct slot. Of pill allocation failures, 48% failed based on comprehension, 28% failed based on logic, 17% failed due to clerical errors, and 7% refused to complete test. Conclusions: Self-perception and observed ability to manage medications are discordant in older adults hospitalized for HF. This may represent a root cause for downstream medication non-adherence. We describe a novel MMAT that has construct validity in adults hospitalized for HF and may be used in future investigations.
252 Participation in a Multi-Disciplinary Heart Failure Disease Management Program (HFDMP) Minimizes Risk of Aldosterone Antagonist-Induced Hyperkalemia Kristyn Mulqueen, Shawn Anderson, Tamarah Jungklaus, Samantha Malloy, Timothy Cleeton, Jesus Acosta, Jennifer Darago, Richard Schofield; North Florida/ South Georgia Veterans Health System, Gainesville, FL Introduction: Aldosterone antagonists (AA) have been shown to reduce mortality and morbidity in a number of large, randomized controlled trials. Clinical practice guidelines recommend AA therapy for patients with heart failure with reduced ejection fraction (HFrEF), even in those with mild symptoms; however, these agents are often underutilized. Although clinical trials showed relatively low rates of significant hyperkalemia with AA therapy, some observational studies suggest that hyperkalemia occurs more frequently in clinical practice. As a result, some providers may hesitate to prescribe AAs. Hypothesis: Evidence-based prescribing of AAs with appropriate monitoring results in rates of hyperkalemia similar to those seen with standard heart failure (HF) therapy without an AA. Methods: A retrospective review of HF patients followed in a multi-disciplinary Heart Failure Disease Management Program (HFDMP) was performed to compare the incidence of hyperkalemia in patients managed with HF pharmacotherapy with AA (AA therapy group) or without AA (standard therapy group). Inpatient and outpatient medical records were reviewed to identify episodes of hyperkalemia occurring while patients were enrolled in the HFDMP. Hyperkalemia was classified as clinical (K $ 6 mmol/L) or subclinical (6 mmol/L O K $ 5.5 mmol/L). Hyperkalemic events were excluded if the blood sample was hemolyzed. One hundred fifty patients were needed in each group to have 80% power to detect a difference in the rate of hyperkalemia, using expected rates of 15% in the AA therapy group and 2% in the standard therapy group. Results: A total of 300 patients were included in the study. Clinical hyperkalemia occurred in 5 (3.3%) patients in the AA therapy group and 6 (4%) patients in the standard therapy group (p50.76). Subclinical hyperkalemia occurred in 15 (10%) patients in the AA therapy group and 22 (15%) patients in the standard therapy group (p50.22). The observed rate of any hyperkalemia for patients on AA therapy and standard therapy was 13.3% and 18.7%, respectively (p50.21). Conclusions: We found no statistically significant difference in the rate of hyperkalemia between groups of HFDMP patients treated with AA compared with those receiving standard HF therapy. Appropriate patient selection, close laboratory monitoring and follow-up allow for the safe use of AA therapy in patients with HFrEF.
253 Patients Hospitalized for Heart Failure Have Difficulties Managing Medications Despite Reported Self-Confidence Erik H. Howell1, Alpana Senapati1, Eiran Z. Gorodeski2; 1Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic, Cleveland, OH Introduction: Medication non-adherence is prevalent and associated with poor outcomes. Root causes are not clearly understood. The ability of patients to manage their own medications is not routinely assessed at time of hospital discharge. We developed a novel medication management assessment tool (MMAT) and applied it to patients hospitalized for HF. Hypothesis: Patients hospitalized for HF have under recognized poor medication self-management skills. Methods: We prospectively enrolled inpatients transitioning from hospital-to-home after hospitalization for HF. Prior to discharge, MMAT was deployed under direct observation. MMAT involved a series of tasks focused on allocating mock medications into a weekly pillbox. Prior to testing subjects were asked “Do you feel confident managing your medications on a daily basis?” Subjects were then provided 5 pill bottles representing common HF medications, each filled with 30 mock pills. Four components were assessed pass/ fail: (1) ability to read pill bottle label, verbally stating medication name and instructions; (2) ability to open pill bottle; (3) ability to allocate pills into pillbox correctly; (4) ability to locate specific slot in pillbox. Failure to allocate pills correctly was further subdivided into four categories: (1) Failure in comprehension (no discernible method of allocating pills); (2) Failure in logic (method of allocating pills has repeated error); (3) Clerical errors (appropriate comprehension and logic but !25% of pills allocated incorrectly) and (4) Refusal to complete MMAT after initiation. Results: Of 94 subjects approached 56 consented. Mean age was 77 [range 66-92], 73% male, 64% Caucasian, 32% with HFPEF (LVEF$50%), 30% with low health literacy
254 Outpatient Ultrafiltration as an Alternative to Hospitalization for Mild to Moderate Decompensated Heart Failure Sitaramesh Emani1, Jennifer Host1, Tara L. Baxter1, Todd Yamokoski1, Matthew R. Potter2, Kyle Porter3, Garrie Haas1; 1The Ohio State University, Columbus, OH; 2The Ohio State University, Columbus, OH; 3The Ohio State University, Columbus, OH Background: We previously reported data suggesting feasibility and safety of an outpatient ultrafiltration (UF) protocol to treat mild-moderate acute decompensated heart failure (ADHF). In follow up, we tracked 30-day outcomes following outpatient UF with the hypothesis that outcomes would mirror those of ADHF hospitalizations. Furthermore, we propose that outpatient UF may be a cost-effective alternative to hospitalization in this highly selected population. Methods: We retrospectively analyzed the medical record of consecutive patients who underwent outpatient UF per our established protocol. Treatment characteristics and efficacy were recorded. Unplanned hospitalizations or emergency room visits were tracked for 30 days. Finally, the cost of each outpatient UF treatment was compared to the average cost of an ADHF admission. Results: A total of 37 treatment episodes were identified. Each episode met criteria of outpatient UF based on our previously presented criteria. Demographic data are shown in table 1. Weight decreased by 7.1 kg (95% CI 5.4, 8.8) and creatinine changed by 0.01 (CI -0.10, 0.11). The rate of unplanned admission or ER visits at 30 days postUF was 24% (CI 10, 44%), which is comparable to a national ADHF readmission rate of 27%. The average charge for outpatient UF was $25,500 per treatment ($11,100/ day), which is less than typical inpatient charges for an ADHF hospitalization at our institution (based on a national average length of stay of 6.4 days). Reimbursement for outpatient at present is highly variable based on payer source. Conclusions: Outpatient UF can serve as an alternative to inpatient admission for selected cases of Demographic Data Average Age
59.6 yrs
Male ICM HFpEF Daily furosemide equivalent Thiazide use Number of UF days/episode
78% 65% 11% 161.1 mg 38% 2.3