- Email: [email protected]
Pilot Program To Improve Self Management of Patients with Heart Failure by Redesigning Care Coordination
S108 Journal of Cardiac Failure Vol. 17 No. 8S August 2011 increasing nurses’ knowledge of HF SM principles and has increased nurses’ ability to use the TB method. Retention will be assessed in 3 months using the the same survey.
Table 1 (continued )
Laboratory Data Sodium Creatinine
348 Diabetes and Heart Failure: Does the Type of Anti-Diabetic Therapy Matter? Lazaros A. Nikolaidis, Swetang Shah, Laurie Russell, Alfred A. Bove; Cardiology, Temple University School of Medicine, Philadelphia, PA Diabetes mellitus (DM) and heart failure (HF) are frequent co-morbidities that adversely affect each other’s prognosis. Patients with both DM and HF are treated with a spectrum of therapies ranging from “diet only” to oral hypoglycemic (notwithstanding the glitazone limitations in advanced (NYHA III-IV) HF), insulin or combination. Although adequate DM control remains a desirable goal, there is no consensus about what type of anti-diabetic therapy is better suited for HF patients. We identified 160 patients with systolic LV dysfunction (LVEF ! 50%) and type II DM from our chronic HF clinic. We investigated the relationship between glycemic control, chronic therapy for HF and diabetes and hospitalization for acutely decompensated HF (ADHF) within the past 3 years. Demographically, the majority of our patients (66%) were African-Americans, 58% were male and 53% were non-ischemic. Baseline LVEF was 27 6 4% and baseline HgbA1c was 8.3 6 2 g/dl. Outpatient anti-DM therapy ranged from “diet only” (15%), to oral medicines only (35%), insulin only (40%) and insulin combined with oral medicines (10%). Insulin users had significantly higher HgbA1c than non-users (8.7 6 2.3 vs. 7.8 6 2.2 g/dl, P! 0.05) There were no significant baseline differences between the group hospitalized for ADHF (n564) and those who did not (n596) with regard to age, gender, race, baseline HgbA1c, baseline LVEF or cardiovascular therapies. The distribution of DM therapy however demonstrated different trends with insulin monotherapy (45% vs. 37%, pw 0.08) or diet-control only (22% vs. 12%, pw0.08) being more common and metformin use -among all oral anti-diabetic therapies- being less common (14% vs. 26%, pw 0.06) among patients with a history of ADHF hospitalization. In our predominantly African-American population of type II diabetic patients with advanced systolic dysfunction, there was a notable trend of metformin therapy associated with freedom from ADHF hospitalization, independent of HgbA1c control. These data are concordant with studies suggestive that metformin should not be withheld from diabetic patients with HF and support a plausible cardio-protective role.
349 Improved Survival with HeartMate II Left Ventricular Assist Device for Acute Cardiogenic Shock Susan Lien1, Ryan C. Nelson1, Scott McNitt1, H. Todd Massey1, Jeffrey D. Alexis1, Leway Chen1, Eugene Storozynsky1, Michael W. Fong2; 1Cardiology Division, Cardiac Surgery Division, University of Rochester Medical Center, Rochester, NY; 2 Cardiology Division, University of Southern California, Los Angeles, CA Background: Acute cardiogenic shock (aCS) is associated with high rates of morbidity and mortality despite advancements in therapy. The development of ventricular assist devices (VADs) has emerged as an effective option to rescue patients from circulatory collapse following myocardial infarction, acute myocarditis, or post-cardiotomy shock. The HeartMate II left ventricular assist device (HM-II LVAD) has not been formally studied for use in aCS. We hypothesized that survival with the HMII LVAD used as the primary mechanical assist device in aCS would be superior to other mechanical circulatory support (MCS) strategies. Methods: Single center retrospective review of patients who presented to the University of Rochester in aCS and received MCS between January 2001 and April 2010. Comparison was made to evaluate the primary use of the HM-II LVAD for aCS vs. other initial MCS options. A total of 107 patients received MCS in the form of LVAD or biventricular assist device for aCS; 16 received the HM-II LVAD and 91 patients received other initial MCS options. The primary outcomes included mortality at 30 days, 90 days, and 6 months, and survival to discharge. Results: Baseline characteristics are presented in Table 1. The etiology of aCS was predominately due to acute myocardial infarction or post-cardiotomy shock. Mortality at 30 days, 90 days, and 6 months was significantly lower in the HM-II LVAD group vs. the other MCS device group, and survival to hospital discharge was improved (Table 2). Table 1. - Clinical Characteristics
Age Female (%) Caucasian (%) BMI Clinical History Cardiac arrest (%) CAD (%) DM (%) Hemodynamics CI
HeartMate II (n516)
Other VADs (n591)
p-value
51.4 6 9.4 37.5 100 29.4 6 6.6
53.4 6 13.9 32.3 90 27.7 6 5.3
0.382 0.679 0.549 0.549
50 43.8 43.8
38.6 41.1 24.4
0.394 0.844 0.132
1.8 6 0.5
1.8 6 0.6
0.751 (continued)
HeartMate II (n516)
Other VADs (n591)
p-value
138.0 1.3 6 0.5
137.8 1.7 6 1.8
0.376 0.293
HeartMate II (n516)
Other VADs (n591)
p-value
6.2% 6.2% 6.2% 93.8%
43.3% 52.8% 61.6% 41.1%
0.005 0.001 !0.001 !0.001
Table 2. - Outcomes
Primary Outcomes 30d Mortality 90d Mortality 6m mortality Survival to Discharge
Conclusions: HM-II LVAD was associated with lower mortality compared to other strategies and is a good initial treatment option for patients in aCS who require MCS.
350 Electronic Identifiers Accurately Identify Inpatient Heart Failure Admissions Carrie Geisberg, Connie Lewis, Jack Starmer, Zachary Cox, Thomas DiSalvo, Douglas Sawyer, Daniel Lenihan; Cardiovascular Medicine, Vanderbilt University, Nashville, TN Nationally heart failure (HF) remains a leading cause of hospital admissions. Accurate early identification, diagnosis, and treatment are essential to reduce length of stay, readmission rates, improving outcomes measures and quality of life. Bundled electronic medical record indicators collected at the time of admission to the hospital are one strategy that might improve initiation of integrated physician order sets, as well as HF disease education initiatives. Using the electronic medical record (EMR) system, 3-patient data sets (n5366) were radomly generated from emergency room, cardiac telemetry floor, and general hospital admissions from an academic medical center over a combined period of 7-months. Data was collected to test the performance of specific electronic identifiers from a customized electronic dashboard using: BNP (b-type natriuretic peptide) ordered, BNP O500 (pg/ml), IV diuretic use, documentation of HF in the patient’s electronic problem list, and a history of HF from previous ICD-9 financial data in a logistic regression model. A confirmed diagnosis of HF was assigned in 24.9% of patients by a physician’s review of the medical record using history, physical exam, laboratory and radiology data. A BNP ordered, IV diuretic use, or a history of HF from patient’s electronic problem list increased the probability of confirmed diagnosis of HF (81.3%, 88.1%, and 89.3%respectively). A BNP O500 (pg/ml) was of little utility in identifying HF patients among a diverse population of admission to a large medical center due to low number of patient identified (15.3%). When history of HF from patient’s electronic problem list or BNP ordered was added to IV diuretic use there was additive predictive value in accurate confirmation of HF diagnosis (97.3%, 95.5% respectively) (table 1).
HF admissions n5366
ROC
Sensitivity (%)
Specificity (%)
Probability of HF diagnosis (%)
BNP O 500 (pg/ml)* BNP ordered* IV Diuretic* Hx of HF* BNP ordered & IV diuretic* Hx of HF & IV diuretic*
0.90 0.79 0.86 0.76 0.92 0.90
89.3 68.3 80.0 55.8 90.8 85.8
86.8 89.1 92.5 95.4 84.5 88.5
55.5 81.3 88.1 89.3 95.5 97.3
* p-value significant The electronic identifiers of BNP ordered, IV diuretic use, and history of HF from electronic problem list, accurately identifies patients with a confirmed diagnosis of HF regardless of location in the hospital. Use of this EMR system to prompt HF order sets, teaching from a multidisciplinary team, and and educational strategies may improve HF outcomes.
351 Pilot Program To Improve Self Management of Patients with Heart Failure by Redesigning Care Coordination Jessica Shaw1, Dan O’Neal2, Frances Zarella3, Kris Siddharthan2, Britta Neugaard1; 1 Quality Management, James A Haley VA, Tampa, FL; 2Research Service, James A Haley VA, Tampa, FL; 3Nursing Service, James A Haley VA, Tampa, FL Introduction: The prevalence of HF is projected to be 5.8 million in 2011. The Veterans Health Administration readmits more than half of those discharged with a HF
The 15th Annual Scientific Meeting
HFSA
S109
diagnosis within 180 days. The unnecessary utilization of health care resources justified tests of change to improve self-management of HF. We tested a behavioral element of health care: will better disease-specific knowledge lead to successful self management of HF? Methods: This study assessed outcomes in the self-management of HF among admitted HF patients given intensive education and care coordination compared to usual care. Study population comprised hospitalized patients with HF discharged to their homes and without cognitive deficits. Patients randomly admitted cardiology teams and general medicine teams formed the intervention group; all other HF patients formed the usual care group. During their hospitalization, intervention patients received enhanced education and earlier scheduled primary care appointments compared to the control group, who had standard HF education. Within 2-4 days of discharge, study patients received a follow-up phone call to enhance care coordination and assess patient self-management of heart failure. Data were analyzed using Fisher ‘s exact test and t-tests. Mean, standard deviation, and proportions were used to characterize the study sample, using a p-value !0.05 for statistical significance. Results: The study contained 40 HF patients with 20 in each study group. Study participants were 96.97% male, 72.73% white, 81.82% non-Hispanic, average age 65.6 years, and 60.6% had a history of smoking. Intervention patients were more likely to have a scale at home, weigh themselves every day, and record their weight (p!0.05). Intervened patients were also 1.69 times more likely than control patients to understand the adverse consequences of a diet high in sodium (p50.08). Conclusion: This health system’s first step in evidence based redesign of care coordination for HF patients examined enhanced inpatient care coordination. Patients receiving more intensive education knew more about their disease and were better able to self-manage their weight compared to those receiving standard care. The results of this study, in addition to qualitative findings from study participants’ focus groups, will help us further to tailor interventions to the patients’ explicit needs.
requirements for a CHFN HF clinic are at least one physician and one nurse who have specialized expertise in HF diagnosis and management. Eighteen CHFN clinics, all of whom had more than 1,000 staff/patient interactions, had a total of 32 physicians and 50 nurses/allied staff who provided care to 17,956 patients over a mean of 7.6 yrs. On average, a physician saw 561 unique patients during this period. The minimum clinic staff complement was 1 physician + 1 nurse/allied staff and the maximum was 3 physicians + 8 nurses/allied staff with a staff mean of 1.8 physicians and 2.8 nurses/allied staff per clinic. The clinic visits averaged 7.4 visits/patient with a range from 3.2 to 12.5 visits/patient. As the individual clinics represent academic, community, and private practices, the challenges and expectations for the breadth of services will differ. In this real world scenario where funding and resources may also vary, approximately 2 physicians and 3 nurses/allied staff per center provided 7-8 visits per patient. This may provide a base for the planning of new HF clinics. However, in this cohort of centers, each individual clinic defined the services that they could deliver and these data do not include the contributions of other complementary specialists and the role of the patient’s family doctor.
352
Introduction: Heart Failure Society of America and American College of Cardiology/ American Heart Association (ACC/AHA) guidelines support use of ultrafiltration (UF) as a treatment for patients with heart failure who present with volume overload [1] [2]. Studies have shown reduced length of hospital stay [3] and reduced readmission rates [4] with ultrafiltration in comparison to standard therapy. Hypothesis: Early initiation of UF therapy may reduce length of hospital stay. Methods: Data were extracted by retrospective chart review of admissions with primary diagnosis of decompensated heart failure including right and left ventricular failure and requiring UF. Institutional Review Board exemption was granted. All UF treatments were prescribed and managed by the Heart Failure Management Program practitioners at St Luke’s Hospital and Health Network, Bethlehem, PA, using Aquapheresis by the Aquadex system between December 2008 and November 2010. Results: One hundred eighty UF therapies provided data, mean age 6 standard deviation [SD] was 73.7 6 11.1 years); 124 (68.9%) were aged O70 years and 103 (57.2%) were male. Among the 180 UF therapies, data was compared between those initiated within the first 24 hours of admission (101) vs. those initiated between 24 and 72 hours (34). UF therapies initiated after 72 hours were excluded. Both groups were demographically similar with 61% males and mean age of 74 years. Multiple parameters including serum creatinine, BUN, electrolytes, UF duration, UF volume, change in weight, length of hospital stay and readmission rates were compared. The mean length of stay 6 standard deviation [SD] for early UF (within 24 hours) was 5.5 +/- 5.0 days in comparison to 12.2 +/- 11.4 days for later UF (24 to 72 hours). Statistical analysis using Welch’s unpaired t test showed the difference to be statistically significant (P50.002). Conclusion: Among patients who qualify for ultrafiltration therapy, early initiation reduces length of hospital stay.
An Evaluation of Pharmacist-Led Heart Failure Clinic in Tan Tock Seng Hospital Kai Xin Ong1, Hwei Khien Lee1, Daniel Yeo2; 1Outpatient Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore; 2Cardiology, Tan Tock Seng Hospital, Singapore, Singapore Background: With the advances in pharmacologic and surgical therapy of Heart Failure over the years, coupled with management by a pharmacist-involved multidisciplinary team, the mortality and morbidity of patients have greatly reduced. Objective: The Pharmacist-led Heart Failure Clinic (HFCP) has been established since 2005 with the aim of optimizing the doses of ACE-I/ARB and BB to their respective target doses. The purpose of this retrospective study is to evaluate the effect of the pharmacist-led Heart Failure clinic in reducing hospitalization and mortality rates. Methods: All Heart Failure patients recruited into HFCP between Jan 2009 e December 2009 were included in this study. Patients were separated into control and HFCP group. The control group comprises of patients who had defaulted or lost to follow-up while those in HFCP group have had their ACEI/ARB and /or BB optimized to target or maximum tolerable dose. The readmission and mortality rates were assessed 6 months after recruitment. Results: There were 171 and 181 patients in the control and HFCP group respectively. There were 23.6% lesser heart failure related readmission rates in HFCP group as compared to the control group. However, there were 2 heart failure related deaths in HFCP group while one death was reported in the control group. Conclusion: Patients, who were on regular follow-up with the Pharmacist in the Heart Failure Clinic, had lower readmission rates due to higher possibility of optimization of ACEI/ARB and BB doses.
353 Specialized Heart Failure Outpatient Clinics: What Staff Are Required, What Is Their Workload, and Can These Data Facilitate the Planning of New Heart Failure Clinics? Malcolm Arnold, Anne Marie Kaan, Jonathan Howlett, Andrew Ignaszewski, MarieHelene LeBlanc, Peter Liu, Haddad Hassam, Miroslav Rajda, Shelley Zieroth, Michael Chan; London Health Sciences Center, London, Canada; St Paul’s Hospital, Vancouver, Canada; Foothills Hospital, Calgary, Canada; St Paul’s, Hospital, Vancouver, Canada; Institute, de Cardiologie de Quebec, Quebec City, Canada; University Health Network, Toronto, Canada; Ottawa Heart Institute, Ottawa, Canada; Halifax Infirmary, Halifax, Canada; St Boniface Hospital, Winnipeg, Canada; Royal Alexandra Hospital, Edmonton, Canada Outpatient Heart Failure (HF) clinics are recommended in national guidelines to implement multidisciplinary care and ensure consistent follow-up. Studies have demonstrated their effectiveness to provide personalized education, optimize medications and improve clinical outcomes. However, resources to provide these services can vary considerably resulting in different clinic models based on feasibility and fiscal realities. We analyzed the number of physicians, nurses and allied health care professionals in clinics of the Canadian Heart Failure Network (CHFN) to determine whether the staff to patient ratio was similar among the clinics. The minimum
354 Early Ultrafiltration May Reduce Length of Hospital Stay for Decompensated Heart Failure Santh V.S. Silparshetty1, Hyma V. Polimera1, Mahesh Aradhya1, Deepakraj Gajanana1, Ellen Amedeo2, Prasanna Sugathan2; 1Internal Medicine, Saint Luke’s Hospital and Health Network, Bethlehem, PA; 2Cardiology, Saint Luke’s Hospital and Health Network, Bethlehem, PA
355 Prevalence and Clinical Correlates of Hemoconcentration during Hospitalization for Acute Decompensated Heart Failure Carlos Davila, Alex Reyentovich, Stuart D. Katz; Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, NY Background: Hemoconcentration (as evidenced by increased hemoglobin, albumin, and/or total protein levels over time) is a surrogate marker of reduced plasma volume in response to effective diuretic therapy in patients with intravascular volume overload. The prevalence and clinical correlates of hemoconcentration in hospitalized patients with acute decompensated heart failure (ADHF) have not been previously described. Methods and Results: We retrospectively reviewed paired values of hemoglobin, albumin, and total protein at admission and discharge to identify evidence of hemoconcentration in 310 subjects hospitalized with ADHF (mean age 79 y, mean ejection fraction 46%). Subjects with hemoconcentration (n5112) received higher doses of loop diuretics and demonstrated greater weight loss during the hospitalization when compared with subjects without hemoconcentration (median loop diuretic dose 180 (150) vs. 160 (130) mg, p50.03; mean weight loss 2.7 6 3.5 vs. 1.4 6 2.5 kg, p!0.001). Worsening renal function (serum creatinine increase O 0.3 mg/dl) occurred during the hospitalization in 58 subjects (19%). Hemoconcentration was associated with increased risk of worsening renal function during the hospitalization (odds ratio 1.95, 95% CI 1.09-3.48, p50.024), but risk of in-hospital mortality
Table 1 (continued )
Laboratory Data Sodium Creatinine
348 Diabetes and Heart Failure: Does the Type of Anti-Diabetic Therapy Matter? Lazaros A. Nikolaidis, Swetang Shah, Laurie Russell, Alfred A. Bove; Cardiology, Temple University School of Medicine, Philadelphia, PA Diabetes mellitus (DM) and heart failure (HF) are frequent co-morbidities that adversely affect each other’s prognosis. Patients with both DM and HF are treated with a spectrum of therapies ranging from “diet only” to oral hypoglycemic (notwithstanding the glitazone limitations in advanced (NYHA III-IV) HF), insulin or combination. Although adequate DM control remains a desirable goal, there is no consensus about what type of anti-diabetic therapy is better suited for HF patients. We identified 160 patients with systolic LV dysfunction (LVEF ! 50%) and type II DM from our chronic HF clinic. We investigated the relationship between glycemic control, chronic therapy for HF and diabetes and hospitalization for acutely decompensated HF (ADHF) within the past 3 years. Demographically, the majority of our patients (66%) were African-Americans, 58% were male and 53% were non-ischemic. Baseline LVEF was 27 6 4% and baseline HgbA1c was 8.3 6 2 g/dl. Outpatient anti-DM therapy ranged from “diet only” (15%), to oral medicines only (35%), insulin only (40%) and insulin combined with oral medicines (10%). Insulin users had significantly higher HgbA1c than non-users (8.7 6 2.3 vs. 7.8 6 2.2 g/dl, P! 0.05) There were no significant baseline differences between the group hospitalized for ADHF (n564) and those who did not (n596) with regard to age, gender, race, baseline HgbA1c, baseline LVEF or cardiovascular therapies. The distribution of DM therapy however demonstrated different trends with insulin monotherapy (45% vs. 37%, pw 0.08) or diet-control only (22% vs. 12%, pw0.08) being more common and metformin use -among all oral anti-diabetic therapies- being less common (14% vs. 26%, pw 0.06) among patients with a history of ADHF hospitalization. In our predominantly African-American population of type II diabetic patients with advanced systolic dysfunction, there was a notable trend of metformin therapy associated with freedom from ADHF hospitalization, independent of HgbA1c control. These data are concordant with studies suggestive that metformin should not be withheld from diabetic patients with HF and support a plausible cardio-protective role.
349 Improved Survival with HeartMate II Left Ventricular Assist Device for Acute Cardiogenic Shock Susan Lien1, Ryan C. Nelson1, Scott McNitt1, H. Todd Massey1, Jeffrey D. Alexis1, Leway Chen1, Eugene Storozynsky1, Michael W. Fong2; 1Cardiology Division, Cardiac Surgery Division, University of Rochester Medical Center, Rochester, NY; 2 Cardiology Division, University of Southern California, Los Angeles, CA Background: Acute cardiogenic shock (aCS) is associated with high rates of morbidity and mortality despite advancements in therapy. The development of ventricular assist devices (VADs) has emerged as an effective option to rescue patients from circulatory collapse following myocardial infarction, acute myocarditis, or post-cardiotomy shock. The HeartMate II left ventricular assist device (HM-II LVAD) has not been formally studied for use in aCS. We hypothesized that survival with the HMII LVAD used as the primary mechanical assist device in aCS would be superior to other mechanical circulatory support (MCS) strategies. Methods: Single center retrospective review of patients who presented to the University of Rochester in aCS and received MCS between January 2001 and April 2010. Comparison was made to evaluate the primary use of the HM-II LVAD for aCS vs. other initial MCS options. A total of 107 patients received MCS in the form of LVAD or biventricular assist device for aCS; 16 received the HM-II LVAD and 91 patients received other initial MCS options. The primary outcomes included mortality at 30 days, 90 days, and 6 months, and survival to discharge. Results: Baseline characteristics are presented in Table 1. The etiology of aCS was predominately due to acute myocardial infarction or post-cardiotomy shock. Mortality at 30 days, 90 days, and 6 months was significantly lower in the HM-II LVAD group vs. the other MCS device group, and survival to hospital discharge was improved (Table 2). Table 1. - Clinical Characteristics
Age Female (%) Caucasian (%) BMI Clinical History Cardiac arrest (%) CAD (%) DM (%) Hemodynamics CI
HeartMate II (n516)
Other VADs (n591)
p-value
51.4 6 9.4 37.5 100 29.4 6 6.6
53.4 6 13.9 32.3 90 27.7 6 5.3
0.382 0.679 0.549 0.549
50 43.8 43.8
38.6 41.1 24.4
0.394 0.844 0.132
1.8 6 0.5
1.8 6 0.6
0.751 (continued)
HeartMate II (n516)
Other VADs (n591)
p-value
138.0 1.3 6 0.5
137.8 1.7 6 1.8
0.376 0.293
HeartMate II (n516)
Other VADs (n591)
p-value
6.2% 6.2% 6.2% 93.8%
43.3% 52.8% 61.6% 41.1%
0.005 0.001 !0.001 !0.001
Table 2. - Outcomes
Primary Outcomes 30d Mortality 90d Mortality 6m mortality Survival to Discharge
Conclusions: HM-II LVAD was associated with lower mortality compared to other strategies and is a good initial treatment option for patients in aCS who require MCS.
350 Electronic Identifiers Accurately Identify Inpatient Heart Failure Admissions Carrie Geisberg, Connie Lewis, Jack Starmer, Zachary Cox, Thomas DiSalvo, Douglas Sawyer, Daniel Lenihan; Cardiovascular Medicine, Vanderbilt University, Nashville, TN Nationally heart failure (HF) remains a leading cause of hospital admissions. Accurate early identification, diagnosis, and treatment are essential to reduce length of stay, readmission rates, improving outcomes measures and quality of life. Bundled electronic medical record indicators collected at the time of admission to the hospital are one strategy that might improve initiation of integrated physician order sets, as well as HF disease education initiatives. Using the electronic medical record (EMR) system, 3-patient data sets (n5366) were radomly generated from emergency room, cardiac telemetry floor, and general hospital admissions from an academic medical center over a combined period of 7-months. Data was collected to test the performance of specific electronic identifiers from a customized electronic dashboard using: BNP (b-type natriuretic peptide) ordered, BNP O500 (pg/ml), IV diuretic use, documentation of HF in the patient’s electronic problem list, and a history of HF from previous ICD-9 financial data in a logistic regression model. A confirmed diagnosis of HF was assigned in 24.9% of patients by a physician’s review of the medical record using history, physical exam, laboratory and radiology data. A BNP ordered, IV diuretic use, or a history of HF from patient’s electronic problem list increased the probability of confirmed diagnosis of HF (81.3%, 88.1%, and 89.3%respectively). A BNP O500 (pg/ml) was of little utility in identifying HF patients among a diverse population of admission to a large medical center due to low number of patient identified (15.3%). When history of HF from patient’s electronic problem list or BNP ordered was added to IV diuretic use there was additive predictive value in accurate confirmation of HF diagnosis (97.3%, 95.5% respectively) (table 1).
HF admissions n5366
ROC
Sensitivity (%)
Specificity (%)
Probability of HF diagnosis (%)
BNP O 500 (pg/ml)* BNP ordered* IV Diuretic* Hx of HF* BNP ordered & IV diuretic* Hx of HF & IV diuretic*
0.90 0.79 0.86 0.76 0.92 0.90
89.3 68.3 80.0 55.8 90.8 85.8
86.8 89.1 92.5 95.4 84.5 88.5
55.5 81.3 88.1 89.3 95.5 97.3
* p-value significant The electronic identifiers of BNP ordered, IV diuretic use, and history of HF from electronic problem list, accurately identifies patients with a confirmed diagnosis of HF regardless of location in the hospital. Use of this EMR system to prompt HF order sets, teaching from a multidisciplinary team, and and educational strategies may improve HF outcomes.
351 Pilot Program To Improve Self Management of Patients with Heart Failure by Redesigning Care Coordination Jessica Shaw1, Dan O’Neal2, Frances Zarella3, Kris Siddharthan2, Britta Neugaard1; 1 Quality Management, James A Haley VA, Tampa, FL; 2Research Service, James A Haley VA, Tampa, FL; 3Nursing Service, James A Haley VA, Tampa, FL Introduction: The prevalence of HF is projected to be 5.8 million in 2011. The Veterans Health Administration readmits more than half of those discharged with a HF
The 15th Annual Scientific Meeting
HFSA
S109
diagnosis within 180 days. The unnecessary utilization of health care resources justified tests of change to improve self-management of HF. We tested a behavioral element of health care: will better disease-specific knowledge lead to successful self management of HF? Methods: This study assessed outcomes in the self-management of HF among admitted HF patients given intensive education and care coordination compared to usual care. Study population comprised hospitalized patients with HF discharged to their homes and without cognitive deficits. Patients randomly admitted cardiology teams and general medicine teams formed the intervention group; all other HF patients formed the usual care group. During their hospitalization, intervention patients received enhanced education and earlier scheduled primary care appointments compared to the control group, who had standard HF education. Within 2-4 days of discharge, study patients received a follow-up phone call to enhance care coordination and assess patient self-management of heart failure. Data were analyzed using Fisher ‘s exact test and t-tests. Mean, standard deviation, and proportions were used to characterize the study sample, using a p-value !0.05 for statistical significance. Results: The study contained 40 HF patients with 20 in each study group. Study participants were 96.97% male, 72.73% white, 81.82% non-Hispanic, average age 65.6 years, and 60.6% had a history of smoking. Intervention patients were more likely to have a scale at home, weigh themselves every day, and record their weight (p!0.05). Intervened patients were also 1.69 times more likely than control patients to understand the adverse consequences of a diet high in sodium (p50.08). Conclusion: This health system’s first step in evidence based redesign of care coordination for HF patients examined enhanced inpatient care coordination. Patients receiving more intensive education knew more about their disease and were better able to self-manage their weight compared to those receiving standard care. The results of this study, in addition to qualitative findings from study participants’ focus groups, will help us further to tailor interventions to the patients’ explicit needs.
requirements for a CHFN HF clinic are at least one physician and one nurse who have specialized expertise in HF diagnosis and management. Eighteen CHFN clinics, all of whom had more than 1,000 staff/patient interactions, had a total of 32 physicians and 50 nurses/allied staff who provided care to 17,956 patients over a mean of 7.6 yrs. On average, a physician saw 561 unique patients during this period. The minimum clinic staff complement was 1 physician + 1 nurse/allied staff and the maximum was 3 physicians + 8 nurses/allied staff with a staff mean of 1.8 physicians and 2.8 nurses/allied staff per clinic. The clinic visits averaged 7.4 visits/patient with a range from 3.2 to 12.5 visits/patient. As the individual clinics represent academic, community, and private practices, the challenges and expectations for the breadth of services will differ. In this real world scenario where funding and resources may also vary, approximately 2 physicians and 3 nurses/allied staff per center provided 7-8 visits per patient. This may provide a base for the planning of new HF clinics. However, in this cohort of centers, each individual clinic defined the services that they could deliver and these data do not include the contributions of other complementary specialists and the role of the patient’s family doctor.
352
Introduction: Heart Failure Society of America and American College of Cardiology/ American Heart Association (ACC/AHA) guidelines support use of ultrafiltration (UF) as a treatment for patients with heart failure who present with volume overload [1] [2]. Studies have shown reduced length of hospital stay [3] and reduced readmission rates [4] with ultrafiltration in comparison to standard therapy. Hypothesis: Early initiation of UF therapy may reduce length of hospital stay. Methods: Data were extracted by retrospective chart review of admissions with primary diagnosis of decompensated heart failure including right and left ventricular failure and requiring UF. Institutional Review Board exemption was granted. All UF treatments were prescribed and managed by the Heart Failure Management Program practitioners at St Luke’s Hospital and Health Network, Bethlehem, PA, using Aquapheresis by the Aquadex system between December 2008 and November 2010. Results: One hundred eighty UF therapies provided data, mean age 6 standard deviation [SD] was 73.7 6 11.1 years); 124 (68.9%) were aged O70 years and 103 (57.2%) were male. Among the 180 UF therapies, data was compared between those initiated within the first 24 hours of admission (101) vs. those initiated between 24 and 72 hours (34). UF therapies initiated after 72 hours were excluded. Both groups were demographically similar with 61% males and mean age of 74 years. Multiple parameters including serum creatinine, BUN, electrolytes, UF duration, UF volume, change in weight, length of hospital stay and readmission rates were compared. The mean length of stay 6 standard deviation [SD] for early UF (within 24 hours) was 5.5 +/- 5.0 days in comparison to 12.2 +/- 11.4 days for later UF (24 to 72 hours). Statistical analysis using Welch’s unpaired t test showed the difference to be statistically significant (P50.002). Conclusion: Among patients who qualify for ultrafiltration therapy, early initiation reduces length of hospital stay.
An Evaluation of Pharmacist-Led Heart Failure Clinic in Tan Tock Seng Hospital Kai Xin Ong1, Hwei Khien Lee1, Daniel Yeo2; 1Outpatient Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore; 2Cardiology, Tan Tock Seng Hospital, Singapore, Singapore Background: With the advances in pharmacologic and surgical therapy of Heart Failure over the years, coupled with management by a pharmacist-involved multidisciplinary team, the mortality and morbidity of patients have greatly reduced. Objective: The Pharmacist-led Heart Failure Clinic (HFCP) has been established since 2005 with the aim of optimizing the doses of ACE-I/ARB and BB to their respective target doses. The purpose of this retrospective study is to evaluate the effect of the pharmacist-led Heart Failure clinic in reducing hospitalization and mortality rates. Methods: All Heart Failure patients recruited into HFCP between Jan 2009 e December 2009 were included in this study. Patients were separated into control and HFCP group. The control group comprises of patients who had defaulted or lost to follow-up while those in HFCP group have had their ACEI/ARB and /or BB optimized to target or maximum tolerable dose. The readmission and mortality rates were assessed 6 months after recruitment. Results: There were 171 and 181 patients in the control and HFCP group respectively. There were 23.6% lesser heart failure related readmission rates in HFCP group as compared to the control group. However, there were 2 heart failure related deaths in HFCP group while one death was reported in the control group. Conclusion: Patients, who were on regular follow-up with the Pharmacist in the Heart Failure Clinic, had lower readmission rates due to higher possibility of optimization of ACEI/ARB and BB doses.
353 Specialized Heart Failure Outpatient Clinics: What Staff Are Required, What Is Their Workload, and Can These Data Facilitate the Planning of New Heart Failure Clinics? Malcolm Arnold, Anne Marie Kaan, Jonathan Howlett, Andrew Ignaszewski, MarieHelene LeBlanc, Peter Liu, Haddad Hassam, Miroslav Rajda, Shelley Zieroth, Michael Chan; London Health Sciences Center, London, Canada; St Paul’s Hospital, Vancouver, Canada; Foothills Hospital, Calgary, Canada; St Paul’s, Hospital, Vancouver, Canada; Institute, de Cardiologie de Quebec, Quebec City, Canada; University Health Network, Toronto, Canada; Ottawa Heart Institute, Ottawa, Canada; Halifax Infirmary, Halifax, Canada; St Boniface Hospital, Winnipeg, Canada; Royal Alexandra Hospital, Edmonton, Canada Outpatient Heart Failure (HF) clinics are recommended in national guidelines to implement multidisciplinary care and ensure consistent follow-up. Studies have demonstrated their effectiveness to provide personalized education, optimize medications and improve clinical outcomes. However, resources to provide these services can vary considerably resulting in different clinic models based on feasibility and fiscal realities. We analyzed the number of physicians, nurses and allied health care professionals in clinics of the Canadian Heart Failure Network (CHFN) to determine whether the staff to patient ratio was similar among the clinics. The minimum
354 Early Ultrafiltration May Reduce Length of Hospital Stay for Decompensated Heart Failure Santh V.S. Silparshetty1, Hyma V. Polimera1, Mahesh Aradhya1, Deepakraj Gajanana1, Ellen Amedeo2, Prasanna Sugathan2; 1Internal Medicine, Saint Luke’s Hospital and Health Network, Bethlehem, PA; 2Cardiology, Saint Luke’s Hospital and Health Network, Bethlehem, PA
355 Prevalence and Clinical Correlates of Hemoconcentration during Hospitalization for Acute Decompensated Heart Failure Carlos Davila, Alex Reyentovich, Stuart D. Katz; Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, NY Background: Hemoconcentration (as evidenced by increased hemoglobin, albumin, and/or total protein levels over time) is a surrogate marker of reduced plasma volume in response to effective diuretic therapy in patients with intravascular volume overload. The prevalence and clinical correlates of hemoconcentration in hospitalized patients with acute decompensated heart failure (ADHF) have not been previously described. Methods and Results: We retrospectively reviewed paired values of hemoglobin, albumin, and total protein at admission and discharge to identify evidence of hemoconcentration in 310 subjects hospitalized with ADHF (mean age 79 y, mean ejection fraction 46%). Subjects with hemoconcentration (n5112) received higher doses of loop diuretics and demonstrated greater weight loss during the hospitalization when compared with subjects without hemoconcentration (median loop diuretic dose 180 (150) vs. 160 (130) mg, p50.03; mean weight loss 2.7 6 3.5 vs. 1.4 6 2.5 kg, p!0.001). Worsening renal function (serum creatinine increase O 0.3 mg/dl) occurred during the hospitalization in 58 subjects (19%). Hemoconcentration was associated with increased risk of worsening renal function during the hospitalization (odds ratio 1.95, 95% CI 1.09-3.48, p50.024), but risk of in-hospital mortality