Faculty Bibliography

BACKGROUND: Heart failure is among the most common reasons for hospitalizations in the United States. Recent data from Medicare suggest that the number of hospitalizations with a primary diagnosis of heart failure has declined over the past decade. However, heart failure may increase hospitalization rates for related comorbidities and individuals with heart failure are commonly admitted for other reasons. Using a nationally representative sample of hospital admissions, we studied trends in hospitalizations with both a primary and a secondary diagnosis of heart failure. METHODS: We evaluated trends in heart failure hospitalizations from 2001 to 2009 using the Nationwide Inpatient Sample (NIS), the largest all-payer inpatient database in the United States. We included hospitalizations with an International Classification of Diseases, Ninth Revision discharge diagnosis codes of 402.X1, 404.X1, 404.X3, 428.XX in any position; these codes in the primary position are used by The Centers for Medicare & Medicaid Services for reporting heart failure quality measures. Admissions were categorized as either primary heart failure hospitalization, if heart failure was the primary discharge code, or heart failure associated hospitalization, if heart failure was listed as a secondary diagnosis. National estimates of heart failure hospitalizations were calculated using the sampling weights and stratified sample design of the NIS. Yearly hospitalization rateswere determined by dividing the number of hospitalizations by the United States population in a given year. Population estimates were obtained from the United States Census Bureau. RESULTS: The total number of heart failure hospitalizations in the United States increased from 3,900,305 in 2001 to 4,398,376 in 2006 and then decreased to 4,253,937 in 2009. The number of primary heart failure admissions decreased from 1,139,607 in 2001 to 1,087,913 in 2009, while the number of heart failure associated hospitalizations increased from 2,760,698 to 3,166,024 over !

BACKGROUND: Diabetes is associated with increased risk of mortality in heart failure. We examined the association of diabetes with expenditures, hospitalizations, and procedures among Medicare beneficiaries with heart failure during the last 6 months of life. METHODS AND RESULTS: In a 5% national Medicare sample, the prevalence of diabetes was 41.7% among 16,613 beneficiaries who died in 2007 with a diagnosis of heart failure. Diabetes was associated with higher expenditures during the last 6 months of life (mean $39,042 vs $29,003; P < .001), even after adjusting for covariates, including age, sex, race, geographic location, comorbidities, and preceding hospitalizations (cost ratio 1.08, 95% CI 1.05-1.12). For both diabetic and nondiabetic adults, more than one-half of Medicare expenditures were related to hospitalization costs (mean $22,516 vs $15,721; P < .001). Compared with their counterparts without diabetes, beneficiaries with diabetes had higher rates of hospitalization (adjusted incidence rate ratio 1.09, 95% CI 1.05-1.12) and days spent in the intensive care unit. CONCLUSIONS: Comorbid diabetes was common in heart failure and associated with higher expenditures, much of which was driven by increased rates of hospitalizations. Programs that focus on prevention of hospitalizations may reduce the substantial costs associated with heart failure near the end of life.

BACKGROUND: Although hospice use may be increasing among heart failure patients, its association with both cost and intensity of care in this population has not been well examined. OBJECTIVE: To assess the association of hospice care with resource utilization among a national sample of Medicare beneficiaries with heart failure during the last 6 months of life. METHODS: We performed a cross-sectional analysis of the 5% sample of Medicare claims data. Negative binomial regression models were used to compare expenditures, hospitalization rates, and intensive care unit (ICU) days between hospice and nonhospice beneficiaries. We used Poisson regression models to compare utilization of certain procedures between hospice and nonhospice beneficiaries. RESULTS: Among 16613 Medicare beneficiaries who died with heart failure in 2007, 6436 (38.7%) received hospice care during the last 6 months of life. The mean total medical expenditures were $31,793 (SD 25,691) among decedents with hospice care, in comparison to $34,067 (SD 40,561) among decedents without hospice care. However, after adjustments for covariates, hospice care was associated with 4% higher expenditures (cost ratio, 1.04; 95% confidence interval, CI: 1.01-1.07). Hospice use was associated with reduced hospitalizations (adjusted incidence rate ratio, 0.87, 95% CI: 0.84-0.89), ICU days (adjusted incidence rate ratio, 0.68, 95% CI: 0.63-0.73), and procedures, including cardiac catheterization, noninvasive ventilation, and mechanical ventilation. CONCLUSIONS: Despite lower rates of hospitalization, ICU days, and invasive procedures, hospice care was not associated with reduced expenditures in heart failure. Financial savings related to reduced intensive medical care seems to be offset by the expenditures related to hospice care itself.

BACKGROUND: Urgent, unplanned hospital readmissions are increasingly being used to gauge the quality of care. We reviewed urgent readmissions to determine which were potentially avoidable and compared rates of all-cause and avoidable readmissions. METHODS: In a multicentre, prospective cohort study, we reviewed all urgent readmissions that occurred within six months among patients discharged to the community from 11 teaching and community hospitals between October 2002 and July 2006. Summaries of the readmissions were reviewed by at least four practising physicians using standardized methods to judge whether the readmission was an adverse event (poor clinical outcome due to medical care) and whether the adverse event could have been avoided. We used a latent class model to determine whether the probability that each readmission was truly avoidable exceeded 50%. RESULTS: Of the 4812 patients included in the study, 649 (13.5%, 95% confidence interval [CI] 12.5%-14.5%) had an urgent readmission within six months after discharge. We considered 104 of them (16.0% of those readmitted, 95% CI 13.3%-19.1%; 2.2% of those discharged, 95% CI 1.8%-2.6%) to have had a potentially avoidable readmission. The proportion of patients who had an urgent readmission varied significantly by hospital (range 7.5%-22.5%; chi(2) = 92.9, p < 0.001); the proportion of readmissions deemed avoidable did not show significant variation by hospital (range 1.2%-3.7%; chi(2) = 12.5, p < 0.25). We found no association between the proportion of patients who had an urgent readmission and the proportion of patients who had an avoidable readmission (Pearson correlation 0.294; p = 0.38). In addition, we found no association between hospital rankings by proportion of patients readmitted and rankings by proportion of patients with an avoidable readmission (Spearman correlation coefficient 0.28, p = 0.41). INTERPRETATION: Urgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions with a potentially avoidable readmission.

BACKGROUND: Albuminuria has been associated with cardiovascular risk, but the relationship of high-normal albuminuria to subsequent heart failure has not been well established. STUDY DESIGN: Prospective observational study, the Atherosclerosis Risk in Communities (ARIC) Study. SETTING & PARTICIPANTS: 10,975 individuals free from heart failure were followed up from the fourth ARIC Study visit (1996-1998) through January 2006. PREDICTOR: Urinary albumin-creatinine ratio (UACR), analyzed continuously and categorically as optimal (<5 mg/g), intermediate-normal (5-9 mg/g), high-normal (10-29 mg/g), microalbuminuria (30-299 mg/g), and macroalbuminuria (>/=300 mg/g). OUTCOMES & MEASUREMENTS: Incident heart failure was defined as a heart failure-related hospitalization or death. Cox proportional hazard models were used to calculate the HR of heart failure after adjustment for age, race, sex, estimated glomerular filtration rate (eGFR), and other cardiovascular risk factors. RESULTS: Individuals were followed up for a median of 8.3 years and experienced 344 heart failure events. Compared with normal UACR, albuminuria was associated with a progressively increased risk of heart failure from intermediate-normal (adjusted HR, 1.54; 95% CI, 1.12-2.11) and high-normal UACR (adjusted HR, 1.91; 95% CI, 1.38-2.66) to microalbuminuria (adjusted HR, 2.49; 95% CI, 1.77-3.50) and macroalbuminuria (adjusted HR, 3.47; 95% CI, 2.10-5.72). Results were similar in secondary analyses of participants censored at the time of coronary heart disease event and along a range of eGFRs. LIMITATIONS: UACR was measured as a single random sample. CONCLUSIONS: Albuminuria is associated with subsequent heart failure, even in individuals with few cardiovascular risk factors and UACR within the normal range. Our results suggest that the association between albuminuria and heart failure may not be mediated fully by ischemic heart disease or kidney disease, measured using eGFR.

BACKGROUND: A substantial portion of the public health burden of heart failure is due to hospitalizations, many of which are for causes other than cardiovascular disease. We assessed whether left ventricular (LV) systolic dysfunction was associated with increased risk of both cardiovascular and noncardiovascular hospitalizations in a community sample of African Americans. METHODS: African American participants from the Jackson, MS, site of the Atherosclerosis Risk in Communities (ARIC) study who underwent echocardiography were followed for 12 years. Hospitalization rates among individuals with and without LV systolic dysfunction were compared using negative binomial regression. RESULTS: Among 2,416 participants with echocardiograms, LV systolic dysfunction was found in 61 (2.5%). Participants with LV dysfunction experienced 366 hospitalizations, a rate of 1.27 per person-year, compared with 0.25 per person-year among individuals without LV dysfunction. The incidence rate ratio adjusted for demographics, comorbidities, and other risk factors was 3.11 (95% CI 2.22-4.35). The adjusted rate ratios were 4.76 (95% CI 2.90-7.20) for cardiovascular and 2.67 (95% CI 1.82-3.90) for noncardiovascular diagnoses, with similar findings in the subset of individuals with asymptomatic LV dysfunction. The percentage attributable risks for hospitalizations were 87% and 74% for cardiovascular and noncardiovascular causes (79% and 63% after adjustment). CONCLUSIONS: African American individuals with LV dysfunction are at an increased risk of hospitalization due to a wide range of causes, with noncardiovascular hospitalizations accounting for nearly half the increased risk. To the extent that estimates of risk focus on cardiovascular morbidity, they may underestimate the true health burden of LV dysfunction.

OBJECTIVE: This study sought to investigate an association of HbA1c (A1C) with incident heart failure among individuals without diabetes and compare it to fasting glucose. RESEARCH DESIGN AND METHODS: We studied 11,057 participants of the Atherosclerosis Risk in Communities (ARIC) Study without heart failure or diabetes at baseline and estimated hazard ratios of incident heart failure by categories of A1C (<5.0, 5.0-5.4 [reference], 5.5-5.9, and 6.0-6.4%) and fasting glucose (<90, 90-99 [reference], 100-109, and 110-125 mg/dl) using Cox proportional hazards models. RESULTS: A total of 841 cases of incident heart failure hospitalization or deaths (International Classification of Disease, 9th/10th Revision, 428/I50) occurred during a median follow-up of 14.1 years (incidence rate 5.7 per 1,000 person-years). After the adjustment for covariates including fasting glucose, the hazard ratio of incident heart failure was higher in individuals with A1C 6.0-6.4% (1.40 [95% CI, 1.09-1.79]) and 5.5-6.0% (1.16 [0.98-1.37]) as compared with the reference group. Similar results were observed when adjusting for insulin level or limiting to heart failure cases without preceding coronary events or developed diabetes during follow-up. In contrast, elevated fasting glucose was not associated with heart failure after adjustment for covariates and A1C. Similar findings were observed when the top quartile (A1C, 5.7-6.4%, and fasting glucose, 108-125 mg/dl) was compared with the lowest quartile (<5.2% and <95 mg/dl, respectively). CONCLUSIONS: Elevated A1C (> or =5.5-6.0%) was associated with incident heart failure in a middle-aged population without diabetes, suggesting that chronic hyperglycemia prior to the development of diabetes contributes to development of heart failure.

OBJECTIVE: To examine the association between severe mental illness (SMI) and quality of care in heart failure. METHODS: We conducted a cohort study between 2001 and 2004 of disabled Maryland Medicaid participants with heart failure. Quality measures and clinical outcomes were compared for individuals with and without SMI. RESULTS: Of 1801 individuals identified with heart failure, 341 had comorbid SMI. SMI was not associated with differences in quality measures, including left ventricular assessment [adjusted relative risk (aRR) 0.99; 95% CI 0.91-1.07], utilization of angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) (aRR 1.04; 95% CI 0.92-1.17), or beta-blocker use (aRR 1.13; 95% CI 0.99-1.29). During the study period, 52.2% of individuals in the cohort filled a prescription for an ACE inhibitor or ARB and 45.5% filled a beta-blocker prescription. Individuals with and without SMI had similar rates of clinical outcomes, including hospitalizations, readmissions, and mortality. Both medication interventions were associated with improved mortality. CONCLUSIONS: In this sample of disabled Medicaid recipients with heart failure, persons with SMI received similar quality of care as those without SMI. Both groups had low rates of beneficial medical treatments. Quality improvement programs should consider how best to target these vulnerable populations.

In the era of "comparative effectiveness" research, each of the major stakeholders in healthcare-payors, patients, providers, and government-face a similar challenge. When making a decision about whether a new device, drug, or a diagnostic modality should be considered for use or coverage, what choices are best supported by the evidence? Medical evidence is defined by randomized controlled trials and by observational studies that vary greatly in their design, the accuracy of their analyses, and the relevance of their conclusions and recommendations. Hence, key decision makers increasingly rely on systematic reviews and meta-analyses to facilitate the interpretation and application of research evidence. Knowing how to evaluate meta-analyses and understanding the potential pitfalls of the method are crucial for those involved in designing drug benefits. The authors highlight the process, strengths, and weaknesses of meta-analysis and explain how to judge the value of the results.