Wellness in Sickness and Health (The W.I.S.H. Project): Advance Care Planning Preferences and Experiences Among Elderly Latino Patients

Objective: To assess advance care planning (ACP) preferences, experiences, and comfort in discussing end-of-life (EOL) care among elderly Latinos.

Methods: Patients aged 60 and older from the Los Angeles County and University of Southern California (LAC+USC) Medical Center Geriatrics Clinic (n = 41) participated in this intervention. Trained staff conducted ACP counseling with participants in their preferred language, which included: (a) pre-counseling survey about demographics and EOL care attitudes, (b) discussion of ACP and optional completion of an advance directive (AD), and (c) post-session survey.

Results: Patients were primarily Spanish speaking with an average of 2.7 chronic medical conditions. Most had not previously documented (95%) or discussed (76%) EOL wishes. Most were unaware they had control over their EOL treatment (61%), but valued learning about EOL options (83%). Post-counseling, 85% reported comfort discussing EOL goals compared to 66% pre-session, and 88% elected to complete an AD. Nearly half of patients reported a desire to discuss EOL wishes sooner.

Conclusions: Elderly Latino patients are interested in ACP, given individualized, culturally competent counseling in their preferred language.

Clinical Implications: Patients should be offered the opportunity to discuss and document EOL wishes at all primary care appointments, regardless of health status. Counseling should be completed in the patient’s preferred language, using culturally competent materials, and with family members present if this is the patient’s preference. Cultural-competency training for providers could enhance the impact of EOL discussions and improve ACP completion rates for Latino patients.     

Opiniones: End‐of‐Life Care Preferences and Planning of Older Latinos

OBJECTIVES: To measure end‐of‐life (EOL) care preferences and advance care planning (ACP) in older Latinos and to examine the relationship between culture‐based attitudes and extent of ACP. DESIGN: Cross‐sectional interview. SETTING: Twenty‐two senior centers in greater Los Angeles. PARTICIPANTS: One hundred forty‐seven Latinos aged 60 and older. MEASUREMENTS: EOL care preferences, extent of ACP, attitudes regarding patient autonomy, family‐centered decision‐making, trust in healthcare providers, and health and sociodemographic characteristics. RESULTS: If seriously ill, 84% of participants would prefer medical care focused on comfort rather than care focused on extending life, yet 47% had never discussed such preferences with their family or doctor, and 77% had no advance directive. Most participants favored family‐centered decision making (64%) and limited patient autonomy (63%). Greater acculturation, education, and desire for autonomy were associated with having an advance directive (P‐values <.03). Controlling for sociodemographic characteristics, greater acculturation (adjusted odds ratio (AOR)=1.6, 95% confidence interval (CI)=1.1–2.4) and preferring greater autonomy (AOR=1.6, 95% CI=1.1–2.3) were independently associated with having an advance directive. CONCLUSIONS: The majority of older Latinos studied preferred less‐aggressive, comfort‐focused EOL care, yet few had documented or communicated this preference. This discrepancy places older Latinos at risk of receiving high‐intensity care inconsistent with their preferences.     

Improvements in advance care planning in the Veterans Affairs System: results of a multifaceted intervention

BACKGROUND: Advance care planning (ACP) aims to guide health care in the event of decisional incapacity. Interventions to promote ACP have had limited effectiveness. We conducted an educational and motivational intervention in Department of Veterans Affairs outpatient clinics to increase ACP use and proxy and health care provider understanding of patients' preferences and values. METHODS: We recruited 23 providers and up to 14 of each of their patients; the patients were randomized to the control or intervention group. Eligibility criteria included a preexisting relationship with the provider, age 55 years or older, chronic health condition(s), and no recorded advance directive. The intervention group (n = 119) received an ACP workbook, motivational counseling by social workers, and cues to providers to discuss ACP. The control group (n = 129) received an advance directive booklet. RESULTS: The intervention patients reported more ACP discussions with their providers (64% vs 38%; P<.001). Living wills were filed in the medical record twice as often in the intervention group (48% vs 23%; P<.001). Provider-patient dyads in the intervention group had higher agreement scores than the control group for treatment preferences, values, and personal beliefs (58% vs 48%, 57% vs 46%, and 61% vs 47%, respectively; P<.01 for all comparisons). The agreement scores for the proxy-patient dyads did not differ between groups for treatment preferences and values, but were higher in the intervention than the control group for personal beliefs (67% vs 56%). CONCLUSION: This intervention demonstrates mixed results and highlights the ongoing challenges of helping health care providers and potential proxy decision makers represent patient preferences and values.     

The Association of Digital Health Application Use With Heart Failure Care and Outcomes: Insights From CONNECT-HF

BackgroundIt is unknown whether digital applications can improve guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF).Methods and ResultsCare Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure trial (CONNECT-HF) included an optional, prospective ancillary study of a mobile health application among patients hospitalized due to HFrEF. Digital users were matched to nonusers from the usual-care group. Coprimary outcomes included change in opportunity-based composite HF quality scores and HF rehospitalization or all-cause mortality. Among 2431 patients offered digital applications across the United States, 1526 (63%) had limited digital access or insufficient data, 425 (17%) were digital users, and 480 (20%) declined use. Digital users were similar in age to those who declined use (mean 58 vs 60 years; P = 0.031). Digital users (n = 368) vs matched nonusers (n = 368) had improved composite HF quality scores (48.0% vs 43.6%; + 4.76% [3.27–6.24]; P = 0.001) and composite clinical outcomes (33.0% vs 39.6%; HR 0.76 [0.59–0.97]; P = 0.027).ConclusionsAmong participants in the CONNECT-HF trial, use of digital applications was modest but was associated with higher HF quality-of-care scores, including use of GDMT and better clinical outcomes. Although cause and effect cannot be determined from this study, the application of technology to guide GDMT use and dosing among patients with HFrEF warrants further investigation.     

A New Standard for Advance Care Planning (ACP) Conversations in the Hospital: Results from a Delphi Panel

BackgroundFewer than half of the US population has an advance healthcare directive. Hospitalizations offer a key opportunity for clinicians to engage patients in advance care planning (ACP) conversations. Guidelines suggest screening for the presence of “serious illness” but do not further specify how to prioritize the 12.4 million patients hospitalized each year.ObjectiveTo establish a normative standard for prioritizing hospitalized patients for ACP conversations.Design and SettingA modified Delphi study, with three iterative rounds of online surveys.ParticipantsMulti-disciplinary group of US-based clinicians with research and practical expertise in ACP.Main MeasuresIndirect and direct elicitation of short-term and 1-year risk of mortality that prompt experts to prioritize ACP conversations for hospitalized adults.Main resultsFifty-seven of 108 (52%) candidate panelists completed round 1, and 47 completed rounds 2 and 3. Panelists were primarily physicians (84%), with significant experience (mean years 23 [SD 9.8]), who either taught (55%) and/or performed research about ACP (55%). In round 1, > 70% of panelists agreed that all hospitalized adults ≥ 65 years should have an ACP conversation before discharge, but disagreed about the timing and content of the conversation. By round 3, > 70% of participants agreed that patients with either high (> 10%) short-term or high (≥ 34%) 1-year risk of mortality should have a goals of care conversation (i.e., focused on preferences for near-term treatment), while patients with low (≤ 10%) short-term and low (< 19%) 1-year risk of mortality warranted an ACP conversation (i.e., focused on preferences for future care) before discharge.LimitationsUse of case vignettes to elicit clinician judgment; response rate.ConclusionsPanelists agreed that clinicians should have an ACP conversation with all hospitalized adults over 65 years in an ACP conversation, adjusting the content and timing of the conversation conditional on the patient’s risk of short-term and 1-year mortality.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06150-0) contains supplementary material, which is available to authorized users.KEY WORDS: advance care planning, Delphi survey, physician performance

Numerous stakeholders recommend advance care planning (ACP) to improve the quality of care that patients receive as they approach the end-of-life.^1–3 Hospitalizations offer one opportunity for clinicians to initiate ACP conversations with patients.⁴ However, high-quality conversations, which allow patients to reveal (or potentially construct) their preferences, require clinicians to have the communication skills, the willingness to engage in emotionally complex interactions, and the time necessary to facilitate this process.^5–8 Guidelines suggest screening patients to prioritize those with near-term mortality or morbidity risk based on the presence of “serious illness,” defined as the presence of a condition that carries a high risk of mortality or impacts quality of life.⁴ In the absence of a quantifiable definition of this term, the surprise question (which requires the treating clinician to consider whether or not he/she would be surprised if the patient died in the next year) has been widely promoted.^{9, 10} Pooled results of two different meta-analyses, however, suggest poor to modest accuracy of the surprise question for predicting death at 12 months.^{10, 11} Efforts to improve the quality of care for patients at the end-of-life therefore require better strategies to screen and prioritize patients for ACP conversations.The objective of this study was to establish a consensus-based normative standard for risk of mortality that should prompt hospitalists to have an ACP conversation with their patients. Recognizing that people, even experts, struggle with probability-based judgments, we embedded a behavioral experiment within a Delphi process, sequentially presenting experts with cases selected from across the distribution of mortality risk and observing their judgments as the sampling frame changed. We hypothesized that experts would be more likely to recommend an immediate ACP conversation as the risk of mortality increased.     

Mind the gap: Opportunities for improving end-of-life care for patients with advanced heart failure

BACKGROUND:

Patients with advanced heart failure (HF) experience progressive symptoms, decreased quality of life, and more frequent hospitalizations as they approach the end of life (EOL). Understanding patient perspectives and preferences regarding EOL issues is necessary to identify key opportunities for improving care.

OBJECTIVE:

To identify, from the patient’s perspective, the major opportunities for improving EOL care for patients hospitalized because of advanced HF.

METHODS:

A cross-sectional survey of patient perspectives regarding EOL care was administered via interview of 106 hospitalized patients who had advanced HF in five tertiary care centres across Canada. The study compared which aspects of EOL care patients rated as ‘extremely important’ and their level of satisfaction with these aspects of EOL care to identify key opportunities for improvement of care.

RESULTS:

The greatest opportunities for improvement in EOL care were reducing the emotional and physical burden on family, having an adequate plan of care following discharge, effective symptom relief and opportunities for honest communication. The three most important issues ranked by patients were avoidance of life support if there was no hope for a meaningful recovery, communication of information by the doctor and avoidance of burden for the family.

CONCLUSIONS:

Advanced care planning that seamlessly bridges hospital and home must be standard care for patients who have advanced HF. Components must include coordination of care, caregiver support, comprehensive symptom management, and effective communication regarding HF and EOL issues.     

Advance Care Planning Program and the Knowledge and Attitude Concerning Palliative Care

Objectives: The study aimed to evaluate the effects of an advance care planning (ACP) program on knowledge and attitudes concerning palliative care, and decisions regarding DNR orders in the older residents in a long-term care institution.

Methods: A quasi-experimental design was used. Participants were cognitively unimpaired older residents in a long-term care institution in Taiwan. The experimental group (n = 29) received the intervention including an individual interview using an ACP handbook and a group patient education; whereas the control group (n = 28) received the group patient education only.

Results: There were significant positive effects of the ACP program on understanding of DNR and palliative care, willingness to sign a DNR order, and knowledge of and attitude towards palliative care; however, there was no significant effect on willingness to receive palliative care. Six participants signed the DNR order after the intervention compared to none in the control group.

Conclusions: The ACP program can improve knowledge and attitudes towards palliative care in older residents in long-term care institutions.

Clinical Implications: The ACP program could incorporate multiple components, including individual interview using ACP handbook and group patient education, and address knowledge and attitudes towards palliative care.     

Polypharmacy in Palliative Care for Advanced Heart Failure: The PAL-HF Experience

BackgroundPalliative care (PC) in advanced heart failure (HF) aims to improve symptoms and quality of life (QOL), in part through medication management. The impact of PC on polypharmacy (>5 medications) remains unknown.Methods and ResultsWe explored patterns of polypharmacy in the Palliative Care in HF (PAL-HF) randomized controlled trial of standard care vs interdisciplinary PC in advanced HF (N = 150). We describe differences in medication counts between arms at 2, 6, 12, and 24 weeks for HF (12 classes) and PC (6 classes) medications. General linear mixed models were used to evaluate associations between treatment arm and polypharmacy over time. The median age of the patients was 72 years (interquartile range 62–80 years), 47% were female, and 41% were Black. Overall, 48% had ischemic etiology, and 55% had an ejection fraction of 40% or less. Polypharmacy was present at baseline in 100% of patients. HF and PC medication counts increased in both arms, with no significant differences in counts by drug class at any time point between arms.ConclusionsIn a trial of patients with advanced HF considered eligible for PC, polypharmacy was universal at baseline and increased during follow-up with no effect of the palliative intervention on medication counts relative to standard care.     

Do-not-resuscitate orders and readmission among elderly patients with heart failure in Pennsylvania: An observational study, 2011 - 2014

BackgroundReadmissions for patients with heart failure (HF) continues to be a target of value-based purchasing initiatives. Do-not-resuscitate (DNR) orders—one part of advance care planning (ACP)—have been shown to be related to other patient outcomes but has not been explored as a risk factor for HF readmission.ObjectivesExamine the association between DNR and 30-day readmissions among elderly patients with HF admitted to hospitals in Pennsylvania.MethodsData included hospital discharges from 2011 to 2014 of patients 65+ years with a primary diagnosis of HF. Logistic regression was used to model the relationship between DNR and 30-day readmission.ResultsAmong 107,806 patients, 20.9% were readmitted within 30 days. After controlling for covariates, patients with HF who had a DNR were less likely to be readmitted to the hospital (OR=0.85, 95% CI: 0.80–0.91, p<0.001).ConclusionsDocumentation of a DNR may inform efforts to reduce readmissions among elderly patients with HF.     

Low Skepticism and Positive Attitudes About Advance Care Planning Among African Americans: a National,Mixed Methods Cohort Study

BackgroundAfrican Americans have low engagement in advance care planning (ACP). This has been attributed to healthcare distrust and skepticism about ACP. A better understanding of these attitudes is needed to address health disparities related to end-of-life care.ObjectiveTo explore the ACP-related values and beliefs of diverse African American communities across the USA and then the perceived value of an inexpensive end-of-life conversational game.DesignProspective, convergent, mixed methods cohort study involving fifteen underserved, African American communities across the USA.ParticipantsOf the 428 who attended events at purposively sampled sites, 90% consented to the research; 37% participated in one of 15 focus groups (n = 141).InterventionAn end-of-life conversation game, played in groups of 4–6.Main MeasuresThe validated, 7-item ACP values and beliefs questionnaire (scaled 7 = least skeptical, 49 = most skeptical) was administered pre-game. Post-game focus groups explored perceptions about ACP and the intervention.Key ResultsParticipants had positive attitudes (low skepticism) about ACP with a median score of 12.00 (7.00, 20.00). Values and beliefs did not significantly differ by geographical region; however, rural areas were observed to be slightly more skeptical than urban areas (median score 14.00 vs. 11.00, p = 0.002). Themes from focus groups converged with survey data showing participants valued the ACP process and consider further engagement in ACP to be worthwhile. Subthemes emphasized the need for and value of ACP.ConclusionsSkepticism about ACP may contribute to low rates of ACP engagement in underserved African American communities. The positive attitudes uncovered in our study either negate previous findings or suggest reduced skepticism.Trial RegistrationThis study has been registered at clinicaltrials.gov ({"type":"clinical-trial","attrs":{"text":"NCT03456921","term_id":"NCT03456921"}}NCT03456921)Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06224-z) contains supplementary material, which is available to authorized users.Key words: advance care planning, End-of-life care, Underserved communities, Health disparities     

Association of the induction of a self-care management system with 1-year outcomes in patients hospitalized for heart failure

BackgroundTo perform self-care in patients with heart failure (HF), we developed and implemented a new HF point self-care system, which was characterized by 1) the way weight and HF symptoms were scored (“Heart Failure Points”) and 2) the timing of consultations defined for both patients and health care providers. We examined the association between the induction of the new system and 1-year outcomes in patients hospitalized for HF.MethodsWe retrospectively enrolled 569 consecutive patients into our study who were admitted for HF treatment at our hospital: 275 patients between November 2011 and October 2013 (before the induction of the self-management system) and 294 patients between November 2015 and October 2017 (after the induction). We sought to compare the clinical outcomes between patients using the self-management system and those not using the system after propensity-score (PS) matching. The primary outcome measure was a composite of all-cause death or HF rehospitalization.ResultsThe cumulative 1-year incidence of the primary outcome measure in the use group (n = 153) was significantly lower than that in the non-use group (n = 153) (24.5% vs. 34.9%, respectively; p = 0.031; hazard ratio: 0.62; 95% confidence interval: 0.40?0.96), mainly due to a reduction in HF hospitalization.ConclusionsThe induction of the new self-care system was associated with better 1-year outcomes in patients hospitalized for HF. This system may help patients with HF to achieve more efficient self-care.     

Lung Ultrasound for Heart Failure Diagnosis in Primary Care

BackgroundLung ultrasound (LUS) is useful for diagnosing pulmonary congestion, but its value in primary care remains unclear. We investigated whether LUS improved diagnostic accuracy in outpatients with heart failure (HF) suspicion.Methods and resultsLUS was performed on 2 anterior (A), 2 lateral (L), and 2 posterior (P) areas per hemithorax. An area was positive when ≥3 B-lines were observed. Two diagnostic criteria were used: for LUS-C1, 2 positive areas of 4 (A-L) on each hemithorax; and for LUS-C2, 2 positive areas of 6 (A-L-P) on each hemithorax. A cardiologist blinded to LUS validated HF diagnosis. 162 patients were included (age 75.6 ± 9.4 years, 70.4% women). Both LUS criteria, alone and combined with other HF diagnostic criteria, were accurate for identifying HF. LUS-C2 outperformed LUS-C1, showing remarkable specificity (0.99) and positive predictive value (0.92). LUS-C2, together with Framingham criteria, N-terminal pro-B-type natriuretic peptide, and electrocardiogram, added diagnostic value (area under the receiver operating characteristic curves 0.90 with LUS-C2 vs 0.84 without; P = .006). In the absence of N-terminal pro-B-type natriuretic peptide, LUS-C2 significantly reclassified one-third of patients above Framingham criteria and electrocardiogram (net reclassification improvement 0.65, 95% confidence interval 0.04–1.1).ConclusionsLUS was accurate enough to rule-in HF in a primary care setting. The accuracy of diagnostic workup for HF in primary care is enhanced by incorporating LUS, irrespective NT-proBNP availability.     

Heart Failure Outcomes and Benefits of NT-proBNP-Guided Management in the Elderly: Results From the Prospective, Randomized ProBNP Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) Study

BackgroundElderly patients with heart failure (HF) have a worse prognosis than younger patients. We wished to study whether elders benefit from natriuretic peptide-guided HF care in this single-center study.Methods and ResultsA total of 151 patients with HF resulting from left ventricular systolic dysfunction (LVSD) were treated with HF treatment by standard-of-care (SOC) management or guided by N-terminal pro-B type natriuretic peptide (NT-proBNP) values (with a goal to lower NT-proBNP ≤1000 pg/mL) over 10 months. The primary end point for this post-hoc analysis was total cardiovascular events in 2 age categories (<75 and ≥75 years). In those ≥75 years of age (n = 38), NT-proBNP values increased in the SOC arm (2570 to 3523 pg/mL, P = .01), but decreased in the NT-proBNP–guided arm (2664 to 1418 pg/mL, P = .001). Elderly patients treated with SOC management had the highest rate of cardiovascular events, whereas the elderly with NT-proBNP management had the lowest rate of cardiovascular events (1.76 events per patient versus 0.71 events per patient, P = .03); the adjusted logistic odds for cardiovascular events related to NT-proBNP–guided care for elders was 0.24 (P = .008), whereas in those <75 years (n = 113), the adjusted logistic odds for events following NT-proBNP–guided care was 0.61 (P = .10).ConclusionsNatriuretic peptide–guided HF care was well tolerated and resulted in substantial improvement in cardiovascular event rates in elders (Clinical Trials.Gov #00351390).     

In-Hospital Management of Sleep Apnea During Heart Failure Hospitalization: A Randomized Controlled Trial

BackgroundObstructive sleep apnea (OSA) is associated with increased mortality and readmissions in patients with heart failure (HF). The effect of in-hospital diagnosis and treatment of OSA during decompensated HF episodes remains unknown.Methods and ResultsA single-site, randomized, controlled trial of hospitalized patients with decompensated HF (n = 150) who were diagnosed with OSA during the hospitalization was undertaken. All participants received guideline-directed therapy for HF decompensation. Participants were randomized to an intervention arm which received positive airway pressure (PAP) therapy during the hospitalization (n = 75) and a control arm (n = 75). The primary outcome was discharge left ventricular ejection fraction (LVEF). The LVEF changed in the PAP arm from 25.5 ± 10.4 at baseline to 27.3 ± 11.9 at discharge. In the control group, LVEF was 27.3 ± 11.7 at baseline and 28.8 ± 10.5 at conclusion. There was no significant effect on LVEF of in-hospital PAP compared with controls (P = .84) in the intention-to-treat analysis. The on-treatment analysis in the intervention arm showed a significant increase in LVEF in participants who used PAP for ≥3 hours per night (n = 36, 48%) compared with those who used it less (P = .01). There was a dose effect with higher hours of use associated with more improvement in LVEF. Follow-up of readmissions at 6 months after discharge revealed a >60% decrease in readmissions for patients who used PAP ≥3 h/night compared with those who used it <3 h/night (P < .02) and compared with controls (P < .04).ConclusionsIn-hospital treatment with PAP was safe but did not significantly improve discharge LVEF in patients with decompensated HF and newly diagnosed OSA. An exploratory analysis showed that adequate use of PAP was associated with higher discharge LVEF and decreased 6 months readmissions.     

De Novo vs Acute-on-Chronic Presentations of Heart Failure-Related Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry

BackgroundHeart failure-related cardiogenic shock (HF-CS) accounts for an increasing proportion of cases of CS in contemporary cardiac intensive care units. Whether the chronicity of HF identifies distinct clinical profiles of HF-CS is unknown.Methods and ResultsWe evaluated admissions to cardiac intensive care units for HF-CS in 28 centers using data from the Critical Care Cardiology Trials Network registry (2017–2020). HF-CS was defined as CS due to ventricular failure in the absence of acute myocardial infarction and was classified as de novo vs acute-on-chronic based on the absence or presence of a prior diagnosis of HF, respectively. Clinical features, resource use, and outcomes were compared among groups. Of 1405 admissions with HF-CS, 370 had de novo HF-CS (26.3%), and 1035 had acute-on-chronic HF-CS (73.7%). Patients with de novo HF-CS had a lower prevalence of hypertension, diabetes, coronary artery disease, atrial fibrillation, and chronic kidney disease (all P < 0.01). Median Sequential Organ Failure Assessment (SOFA) scores were higher in those with de novo HF-CS (8; 25th–75th: 5–11) vs acute-on-chronic HF-CS (6; 25th–75th: 4–9, P < 0.01), as was the proportion of Society of Cardiovascular Angiography and Intervention (SCAI) shock stage E (46.1% vs 26.1%, P < 0.01). After adjustment for clinical covariates and preceding cardiac arrest, the risk of in-hospital mortality was higher in patients with de novo HF-CS than in those with acute-on-chronic HF-CS (adjusted hazard ratio 1.36, 95% confidence interval 1.05–1.75, P = 0.02).ConclusionsDespite having fewer comorbidities, patients with de novo HF-CS had more severe shock presentations and worse in-hospital outcomes. Whether HF disease chronicity is associated with time-dependent compensatory adaptations, unique pathobiological features and responses to treatment in patients presenting with HF-CS warrants further investigation.     

Epidemiology of Acute Heart Failure in Critically Ill Patients With COVID-19: An Analysis From the Critical Care Cardiology Trials Network

BackgroundAcute heart failure (HF) is an important complication of coronavirus disease 2019 (COVID-19) and has been hypothesized to relate to inflammatory activation.MethodsWe evaluated consecutive intensive care unit (ICU) admissions for COVID-19 across 6 centers in the Critical Care Cardiology Trials Network, identifying patients with vs without acute HF. Acute HF was subclassified as de novo vs acute-on-chronic, based on the absence or presence of prior HF. Clinical features, biomarker profiles and outcomes were compared.ResultsOf 901 admissions to an ICU due to COVID-19, 80 (8.9%) had acute HF, including 18 (2.0%) with classic cardiogenic shock (CS) and 37 (4.1%) with vasodilatory CS. The majority (n = 45) were de novo HF presentations. Compared to patients without acute HF, those with acute HF had higher cardiac troponin and natriuretic peptide levels and similar inflammatory biomarkers; patients with de novo HF had the highest cardiac troponin levels. Notably, among patients critically ill with COVID-19, illness severity (median Sequential Organ Failure Assessment, 8 [IQR, 5–10] vs 6 [4–9]; P = 0.025) and mortality rates (43.8% vs 32.4%; P = 0.040) were modestly higher in patients with vs those without acute HF.ConclusionsAmong patients critically ill with COVID-19, acute HF is distinguished more by biomarkers of myocardial injury and hemodynamic stress than by biomarkers of inflammation.     

Full-Time Cardiac Intensive Care Unit Staffing by Heart Failure Specialists and its Association with Mortality Rates

BackgroundCardiac intensive care units (CICUs) serve medically complex patients with multiorgan dysfunction. Whether a CICU that is staffed full time by heart failure (HF) specialists is associated with decreased mortality is unclear.Methods and ResultsA retrospective review of consecutive CICU admissions from January 1, 2012, to December 31, 2016, was performed. In January 2014, the CICU changed from an open unit staffed by any cardiologist to a closed unit managed by HF specialists. Patients’ baseline characteristics were determined, and a multivariate regression analysis was performed to ascertain mortality rates in the CICU. Baseline severity of illness was higher in the closed/HF specialist CICU model (P< 0.001). Death occurred in 101 of 1185 patients admitted to the CICU (8.5%) in the open-unit model and in 139 of 2163 patients (6.4%) admitted to the closed/HF specialist model (absolute risk reduction 2.1%, 95% confidence interval [CI] 0.1–4.0%; P = 0.01). The transition from an open to a closed/HF specialist model was associated with a lower overall CICU mortality rate (odds ratio [OR] 0.63; 95% CI 0.43–0.93). Prespecified interaction with a mechanical circulatory support device and unit model showed that treatment with such a device was associated with lower mortality rates in the closed/HF specialist model of a CICU (OR 0.6; 95% CI 0.18–0.78; P for interaction <0.01).ConclusionTransition to a closed unit model staffed by a dedicated HF specialist is associated with lower CICU mortality rates.     

How Well Does the Surprise Question Predict 1-year Mortality for Patients Admitted with COPD?

BackgroundPatients with chronic obstructive pulmonary disease (COPD) often receive burdensome care at end-of-life (EOL) and infrequently complete advance care planning (ACP). The surprise question (SQ) is a prognostic tool that may facilitate ACP.ObjectiveTo assess how well the SQ predicts mortality and prompts ACP for COPD patients.DesignRetrospective cohort study.SubjectsPatients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018.Main MeasuresEmergency department (ED) and inpatient clinicians answered, “Would you be surprised if this patient died in the next 30 days (ED)/one year (inpatient)?” The primary outcome measure was the accuracy of the SQ in predicting 30-day and 1-year mortality. The secondary outcome was the correlation between SQ and ACP (palliative care consultation, documented goals-of-care conversation, change in code status, or completion of ACP document).Key ResultsThe 30-day SQ had a high specificity but low sensitivity for predicting 30-day mortality: sensitivity 12%, specificity 95%, PPV 11%, and NPV 96%. The 1-year SQ demonstrated better accuracy for predicting 1-year mortality: sensitivity 47%, specificity 75%, PPV 35%, and NPV 83%. After multivariable adjustment for age, sex, and prior 6-month admissions, 1-year SQ+ responses were associated with greater odds of 1-year mortality (OR 2.38, 95% CI 1.39–4.08) versus SQ-. One-year SQ+ patients were more likely to have a goals-of-care conversation (25% vs. 11%, p < 0.01) and complete an advance directive or POLST (46% vs. 23%, p < 0.01). After multivariable adjustment, SQ+ responses to the 1-year SQ were associated with greater odds of ACP receipt (OR 2.67, 95% CI 1.64–4.36).ConclusionsThe 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06512-8.Key Words: prognostication, goals-of-care, advance care planning, surprise question, chronic obstructive pulmonary disease     

Prospective evaluation of beta-blocker use at the time of hospital discharge as a heart failure performance measure: results from OPTIMIZE-HF

BackgroundThe objective of this study was to prospectively evaluate beta-blocker use at hospital discharge as an indicator of quality of care and outcomes in patients with heart failure (HF).Methods and ResultsData from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry for patients hospitalized with HF from 259 hospitals were prospectively collected and analyzed. HF medication contraindications, intolerance, and use at hospital discharge were assessed, along with 60- to 90-day follow-up data in a prespecified cohort. There were 20,118 patients with left ventricular systolic dysfunction. At discharge, 90.6% of patients were eligible to receive beta-blockers, and 83.7% were eligible to receive an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Eligible patients discharged with beta-blockers were significantly more likely to be treated at follow-up than those not discharged with beta-blockers (93.1% vs 30.5%; P < .0001). Discharge use of beta-blockers in eligible patients was associated with a significant reduction in the adjusted risk of death (hazard ratio: 0.48; 95% confidence interval: 0.32–0.74; P < .001) and death/rehospitalization (odds ratio: 0.74; 95% confidence interval: 0.55–0.99; P = .04), although we cannot completely exclude the possibility of residual confounding.ConclusionsDischarge beta-blocker use in HF appeared to be well tolerated, improved treatment rates, and was associated with substantially lower postdischarge mortality risk. These data provide additional evidence that supports beta-blocker use at hospital discharge in eligible patients as an HF performance measure.