Dunlay, Shannon M.

Background Sepsis is associated with an elevated risk of late cardiovascular events among hospital survivors. Methods and Results We included OptumLabs Data Warehouse patients from 2009 to 2019 who survived a medical/nonsurgical hospitalization lasting at least 2 nights. The association between sepsis during hospitalization, based on explicit and implicit discharge International Classification of Diseases, Ninth Revision ( ICD‐9 )/ Tenth Revision ( ICD‐10 ) diagnosis codes, with subsequent death and rehospitalization was analyzed using Kaplan–Meier survival analysis and multivariable Cox proportional‐hazards models. The study population included 2 258 464 survivors of nonsurgical hospitalization (5 396 051 total patient‐years of follow‐up). A total of 808 673 (35.8%) patients had a sepsis hospitalization, including implicit sepsis only in 448 644, explicit sepsis only in 124 841, and both in 235 188. Patients with sepsis during hospitalization had an elevated risk of all‐cause mortality (adjusted hazard ratio [HR], 1.27 [95% CI, 1.25–1.28]; P <0.001), all‐cause rehospitalization (adjusted HR, 1.38 [95% CI, 1.37–1.39]; P <0.001), and cardiovascular hospitalization (adjusted HR, 1.43 [95% CI, 1.41–1.44]; P <0.001), especially heart failure hospitalization (adjusted HR, 1.51 [95% CI, 1.49–1.53]). Patients with implicit sepsis had higher risk than those with explicit sepsis. A sensitivity analysis using the first hospitalization yielded concordant results for cardiovascular hospitalization (adjusted HR, 1.78 [95% CI, 1.76–1.78]; P <0.001), as did a propensity‐weighted analysis (adjusted HR, 1.52 [95% CI, 1.50–1.54]; P <0.001). Conclusions Survivors of sepsis hospitalization are at elevated risk of early and late post‐discharge death as well as cardiovascular and non‐cardiovascular rehospitalization. This hazard spans the spectrum of cardiovascular events and may suggest that sepsis is an important cardiovascular risk factor.

Abstract Background Preoperative risk scores facilitate patient selection, but postoperative risk scores may offer valuable information for predicting outcomes. We hypothesized that the postoperative Sequential Organ Failure Assessment (SOFA) score would predict mortality after left ventricular assist device (LVAD) implantation. Methods We retrospectively reviewed data from 294 continuous‐flow LVAD implantations performed at Mayo Clinic Rochester during 2007 to 2015. We calculated the EuroSCORE, HeartMate‐II Risk Score, and RV Failure Risk Score from preoperative data and the APACHE III and Post Cardiac Surgery (POCAS) risk scores from postoperative data. Daily, maximum, and mean SOFA scores were calculated for the first 5 postoperative days. The area under receiver‐operator characteristic curves (AUC) was calculated to compare the scoring systems' ability to predict 30‐day, 90‐day, and 1‐year mortality. Results For the entire cohort, mortality was 5% at 30 days, 10% at 90 days, and 19% at 1 year. The Day 1 SOFA score had better discrimination for 30‐day mortality (AUC 0.77) than the preoperative risk scores or the APACHE III and POCAS postoperative scores. The maximum SOFA score had the best discrimination for 30‐day mortality (AUC 0.86), and the mean SOFA score had the best discrimination for 90‐day mortality (AUC 0.82) and 1‐year mortality (AUC 0.76). Conclusions We observed that postoperative mean and maximum SOFA scores in LVAD recipients predict short‐term and intermediate‐term mortality better than preoperative risk scores do. However, because preoperative and postoperative risk scores each contribute unique information, they are best used in concert to predict outcomes after LVAD implantation.

Background: Some patients with heart failure (HF) will go on to develop advanced HF, characterized by severe HF symptoms despite attempts to optimize medical therapy. The goals of this study were to examine the risk of developing advanced HF in patients with newly diagnosed HF, identify risk factors for developing advanced HF, and evaluate the impact of advanced HF on outcomes. Methods: This was a population-based, retrospective cohort study of Olmsted County, Minnesota, residents with a new clinical diagnosis of HF between 2007 and 2017. Risk factors for the development of advanced HF (2018 European Society of Cardiology criteria) were examined using cause-specific Cox proportional hazard regression models. The associations of development of advanced HF with risks of hospitalization and mortality were examined using the Andersen-Gill and Cox models, respectively. Results: There were 4597 residents with incident HF from 2007 to 2017. The cumulative incidence of advanced HF was 11.5% (95% CI, 10.5%–12.5%) at 6 years after incident HF diagnosis overall and was 14.4% (95% CI, 12.3%–16.9%), 11.4% (95% CI, 8.9%–14.6%), and 11.7% (95% CI, 10.3%–13.2%) in patients with incident HF with reduced, mildly reduced, and preserved ejection fraction, respectively. Key demographics, comorbidities, and echocardiographic characteristics were independently associated with the development of advanced HF. Development of advanced HF was associated with increased risks of all-cause hospitalization (adjusted hazard ratio, 3.0 [95% CI, 2.7–3.4]; P <0.001), HF hospitalization (hazard ratio, 10.2 [95% CI, 8.7–12.1]), all-cause mortality (hazard ratio, 5.0 [95% CI, 4.5–5.6]; P <0.001), and cardiovascular mortality (hazard ratio, 7.8 [95% CI, 6.7–9.1]). Conclusions: In this population-based study, development of advanced HF was common and was associated with markedly increased morbidity and mortality.

Background: Recent studies have suggested that patient activation, or having the knowledge, skills and confidence to manage one’s own health, has a substantial impact on patient behaviors and health outcomes. However, the role of activation in patients with heart failure is unknown. Methods: We prospectively recruited Southeastern Minnesota residents hospitalized with acute decompensated heart failure (ADHF) from January 2014 through July 2015. Activation was measured by face-to-face questionnaire using the Patient Activation Measure (PAM) and patients were categorized into four activation levels (lowest to highest activation) per PAM guidelines. Logistic regression was used to examine the association between activation level and discharge location and early post-discharge outcomes. Results: Among the 302 patients enrolled, the mean age was 77.3 years, 57.3% were men, and 46.8% had preserved ejection fraction. Median (25th-75th percentile) length of stay was 4 (3-7) days and 7 (2.3%) patients died prior to discharge. Among survivors, 73.3% discharged to home, while the remainder went to skilled nursing facilities (23.0%), assisted living facilities (2.0%) or other arrangements (1.4%). The 30-day mortality rate was 7.0% and the 30-day readmission rate was 21.2%. The number (%) of patients in each activation category from highest to lowest was 9 (3.0%), 121 (40.1%), 122 (40.4%), and 50 (16.6%). Patients with lower activation were older, less educated, had worse overall and financial satisfaction, and worse health literacy. They more often discharged to skilled nursing facilities and had higher 30-day mortality, though 30-day readmission did not differ by activation (Figure). Adjusting for age, patients in the lowest activation level were at 3.1-fold increased odds of discharging to a skilled nursing facility and 6.0-fold increased odds of dying within 30 days of hospital discharge compared with patients in the highest two activation levels. Conclusions: Patients hospitalized with ADHF with lower activation are less satisfied, have worse health literacy, more often require skilled care and are at increased risk for early post-discharge mortality. Activation is easy to measure, identifies a high-risk subgroup, and is potentially modifiable.

Background: Heart failure (HF) is a clinical syndrome with an overall poor prognosis, but the clinical trajectory is often unpredictable in individuals. There has been an impetus to promote iterative patient-provider discussions regarding preferences for end of life (EOL) care and advanced care planning. However, very little is known regarding provider preferences or their personal confidence addressing EOL care with their patients with HF. To address these gaps in knowledge, we surveyed clinicians at three practice sites in a large integrated health system. Methods: Physicians, nurse practitioners (NP), and physician assistants (PA) at Mayo Clinic (Rochester, Minnesota) and its surrounding health system were asked to participate in an electronic survey in October 2013. Clinicians surveyed included tertiary care HF specialists (Tertiary Care Cardiology), cardiologists and NP/PAs practicing in a community setting (Community Cardiology), and primary care clinicians (Primary Care). Results: A total of 95 clinicians completed the survey (52.5% response rate), including 50 physicians and 45 NP/PAs. Clinicians reported discussing prognosis and EOL wishes when their patient’s health status was worsening, but only 12% reported annual discussions as advocated by the American Heart Association. In total 52% of providers reported one or more reasons that they hesitate to discuss EOL care with their patients, including provider discomfort (11%), perception of patient (21%) or family (12%) unreadiness to have the discussion, fear of destroying hope (9%), or a lack of time (8%). Tertiary Care (63%) and Community Cardiology (58%) clinicians were more likely to attribute responsibility for having EOL discussions to the HF cardiologist, while 66% of Primary Care providers felt it was their responsibility. Tertiary and Community Cardiology clinicians were more likely to have referred patients to Palliative Medicine within the last year than Primary Care (89% vs. 21%, p<0.001). Overall, 30% of those surveyed reported low or very low confidence levels in initiating prognosis or EOL discussions, enrolling patients in hospice, or providing EOL care, with lower confidence among those with fewer years of clinical experience. The majority of clinicians expressed a high level of interest in further skills acquisition on these topics. Conclusion: There is tremendous variability in the way that clinicians view and approach advanced care discussions with their patients with HF; varying provider perception and lack of provider confidence may contribute. Despite this variability, most clinicians are interested in further development and skills acquisition. Addressing the learning needs of providers is an important next step toward enhancing the EOL care of patients with HF.

Background: While implantation of left ventricular assist devices (LVAD) improves survival and quality of life in patients with advanced heart failure, very little is known about healthcare resource utilization, including hospital readmissions, post-LVAD. Methods: Administrative claims data from a large, national US health plan were used to identify privately insured and Medicare Advantage patients that received an LVAD (ICD-9-CM code 37.66) and survived to hospital discharge from January 1, 2006 through 31 August 31, 2013, and had at least six months coverage pre-LVAD. The individuals covered by this health plan, about 88 million in years 2003 to 2013, are geographically dispersed across the United States, with greatest representation in the South and Midwest census regions. Reasons for subsequent readmissions were categorized according to the AHRQ Clinical Classifications Software and risk factors for readmission analyzed using multiple failure Cox regression analysis. Patients were censored at the time of heart transplantation or end of coverage through November 30, 2013. Results: In total, 857 patients received an LVAD, of whom 693 (81%) survived to hospital discharge without undergoing heart transplantation (mean age 56 years, 77% male). After a median follow-up of 0.69 (interquartile range [IQR]: 0.31, 1.50) years, 1,659 readmissions occurred among 509 patients. Over this period, patients spent a median of 10.5 days (IQR: 0 -40 days) per followup year hospitalized. The number of readmissions per patient varied widely (0 to 20 per person), with 184 (26.6%) patients experiencing no readmissions, while 112 (16.2%) had 5 or more readmissions during follow-up. The most common reasons for readmission were device complications (291 readmissions in 155 patients), heart failure (246 readmissions in 135 patients), gastrointestinal bleeding (90 readmissions in 52 patients), and arrhythmia (88 readmissions in 55 patients). Readmission risk was higher in patients who had longer initial length of stay and more comorbid conditions. Discussion: There is tremendous variability in the readmission burden experienced post-LVAD, with some patients experiencing no readmissions while others are repeatedly hospitalized. LVAD therapy introduces a unique set of problems that often prompt readmission including device complications and gastrointestinal bleeding.

Background: The dominant healthcare payment model in the US, fee-for-service, provides incentives to deliver costlier care for heart failure and disincentives to deliver higher quality care. One proposed method to align cost and quality incentives is to impose financial penalties on providers when patients are readmitted within 30 days after a heart failure hospitalization. We hypothesized that this strategy might not lower overall costs, because lower readmission costs might be offset by higher non-readmission post-acute care costs. Methods: We studied cost to Medicare from 2008-09 for all heart failure hospitalizations (MS-DRG 291, 292, or 293) in the 15 healthcare delivery systems participating in the High Value Health Collaborative. We categorized costs for the 30, 90, and 180 days after the day of admission for first heart failure hospitalization in the study period into acute care costs (inpatient care, outpatient facility costs with 3 day look back window, part B professional fees), inpatient readmission cost, and non-readmission post-acute care costs (outpatient facility fee, sub-acute rehab, inpatient rehab, long term care, home health care, part B professional fees). Results: Using the most common MS DRG (DRG 292) as an example, across the 15 healthcare systems, we found wide variation in median total costs for the 30- ($6487-$11565), 90- ($8049-$18918), and 180- ($9844-$24752) day time frames. For the 30-day time frame, readmission costs ($700 - $2684) and non-readmission post-acute care costs ($477 - $6398) also showed wide variation. The Figure is a plot of these two costs, with bubbles sized to reflect the number of cases for the hospital system (30-day time frame); results were comparable for 90 and 180 days. Contrary to our hypothesis, we found no inverse relationship between readmission costs and non-readmission post-acute care costs. These data do not account for possible differences in case mix and in geographic differences in labor and facility costs. Conclusions: Non-readmission post-acute costs for heart failure are unrelated to readmission costs but were greater than readmission costs in a number of healthcare deliver systems, raising questions about the overall value to the healthcare systems of an exclusive focus on readmission as a strategy for reducing the costs of heart failure.

Background: Echocardiography is an important component of the assessment of patients with heart failure (HF). However, its longitudinal use after initial HF diagnosis has not been evaluated. Methods: We studied patterns of echocardiogram use after HF diagnosis among a random sample of validated incident HF cases in Olmsted County, Minnesota, from 1987 to 2006. Results: Among 1472 HF patients (mean age 76.0 years, 45% male), 4817 echocardiograms were obtained over a mean follow-up of 5.1 years. The majority were transthoracic (n=3952, 82%), with fewer transesophageal (n=604, 13%) and stress (n=250, 5%) studies obtained. Most patients died during follow-up (n=1126, 76%), and thus had their entire lifetime after HF diagnosis captured. The number of echocardiograms per person ranged from 0-38 (Figure) with a median (25 th , 75 th percentile) of 2 (1, 4). The mean rate of echocardiograms obtained per 10 years of follow-up was 6.4, and increased over time with mean echocardiograms per 10 years follow-up of 4.9, 5.9, 7.2, and 7.8 for persons diagnosed from 1987-1991, 1992-96, 1997-2001, and 2002-06, respectively (p for trend <0.001). Men had echocardiograms more frequently than women (7.2 vs. 5.7 per 10 person years follow-up, p<0.001). Patients who were younger at diagnosis had more frequent echocardiography with rates of 7.1, 6.8, and 5.2 per 10 years follow-up for those who were <70 years, 70-79 years, and 80 years or older at diagnosis (p for trend <0.001). Conclusions: Most patients have multiple echocardiograms performed after HF diagnosis, and echocardiography use in patients with HF has increased over time. Men and younger patients have higher rates of use after HF diagnosis.

Background: Heart failure (HF) with improved ejection fraction (HFiEF) is defined as a new subset in addition to the subsets of HF with reduced EF (≤40%; HFrEF) and HF with preserved EF (>40%). The characteristics and outcomes of patients with ischemic HFiEF after coronary revascularization are unknown. Methods and Results: We identified 1,816 patients with coronary artery diseases and reduced EF (≤40%) in a large hospital in China, who underwent either coronary artery bypass graft surgery (n=1,126) or percutaneous coronary intervention with drug eluting stent (n=687) from January 2005 to December 2014. All patients had EF reassessment during follow-up. The improvement of EF peaked at 3 months and persisted for more than one year after revascularization. Thus, 589 patients who had EF reassessment between 3 to 12 months after revascularization were included in the definitions of HFiEF and HFrEF patient cohort and subsequent survival analysis. 367 (62.3%) patients had EF >40% which constituted HFiEF cohort while 222 (37.7%) patients with EF≤40% constituted HFrEF cohort. Using stepwise logistic regression, we identified preoperative EF (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.11; P =0.006), left ventricular end-systolic diameter (OR, 0.93; 95% CI, 0.91-0.95; P =0.000) and history of myocardial infarction (OR, 0.61; 95% CI, 0.42-0.88; P =0.008) were associated with being in HFiEF group. Using Cox proportional hazard models, HFiEF patients had lower risk of all-cause mortality (hazard ratios [HR], 0.39; 95% CI, 0.23-0.68; P =0.001), sudden cardiac death (HR, 0.32; 95% CI, 0.14-0.75; P =0.009) and death due to HF (HR, 0.13; 95% CI, 0.03-0.52; P =0.004) compared to HFrEF patients. Nonproportional outcome of composite end points (i.e., combination of all-cause mortality, HF hospitalization and repeat revascularization) between HFiEF and HFrEF groups was detected by using the Schoenfeld residuals. By using flexible parametric model, patients with HFiEF had similar risk of composite end points in the first 5 years (HR, 0.84; 95% CI, 0.53-1.31; P =0.433), but significantly lower risk during years 6 to 11(HR, 0.12; 95% CI, 0.03-0.56; P =0.007). In the HFiEF group, the risk of death were age (HR, 1.07; 95% CI, 1.02-1.12; P =0.008), current smoking (HR, 5.62; 95% CI, 1.93-18.18; P =0.002) and history of myocardial infarction (HR, 2.89; 95% CI, 1.05-7.93; P =0.039). By contrast, in the HFrEF group, the risk factors were moderate or severe mitral regurgitation (HR, 1.81; 95% CI, 1.06-3.11; P =0.031) and estimated glomerular filtration rate (HR, 0.97; 95% CI, 0.95-0.99; P=0.014). Conclusions: Patients with ischemic HFiEF have distinct clinical characteristics and favorable outcomes. Our data support HFiEF as a distinct HF category in ischemic HF patients after revascularization therapy.

Introduction: Some patients with heart failure (HF) will go on to develop advanced HF, characterized by severe HF symptoms despite attempts to optimize medical therapy. Our understanding of advanced HF at a population level remains limited. The goals of this study were to determine the risk of developing advanced HF in patients with newly diagnosed HF, identify risk factors for developing advanced HF, and evaluate the impact of advanced HF on outcomes. Methods: This was a population-based, retrospective cohort study of Olmsted County, Minnesota residents with a new clinical diagnosis of HF between 2007-2017. The primary outcome was development of advanced HF, defined using the 2018 European Society of Cardiology Criteria. Risk factors for development of advanced HF from the time of incident HF diagnosis were examined using cause-specific Cox proportional hazard regression models. The associations of development of advanced HF with risks of hospitalization and mortality were examined using Andersen-Gill and Cox models, respectively, with advanced HF treated as a time dependent covariate. Results: There were 4597 residents with incident HF from 2007 to 2017. The cumulative incidence of advanced HF was 6.0%, 9.1%, and 11.5% at 2, 4, and 6 years after incident HF diagnosis. Characteristics independently associated with development of advanced HF included older age, male sex, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, lower serum sodium, worse right ventricular function, left atrial enlargement, higher estimated filling pressures, and higher right ventricular systolic pressure (p<0.05 for each). Development of advanced HF was associated with increased risks of all-cause hospitalization (adjusted HR 3.00; 95% CI 2.65-3.41, p<0.001), HF hospitalization (HR 10.24, 95% CI 8.67-12.10), all-cause mortality (HR 5.00, 95% CI 4.46-5.59, p<0.001), and cardiovascular mortality (HR 7.84, 95% CI 6.74-9.12). Conclusions: In this population-based study, clinical, laboratory and echocardiographic characteristics at the time of incident HF diagnosis were associated with future risk of advanced HF. Development of advanced HF was associated with markedly increased morbidity and mortality.