Health-related quality of life as a predictor of hospital readmission and death among patients with heart failure

BACKGROUND: We sought to examine the relationship between health-related quality of life (HRQL) and a first emergency rehospitalization and mortality in patients with heart failure (HF) having a wide variation in ventricular ejection fraction and functional status. METHODS: Prospective study conducted with 394 patients admitted for HF-related emergencies at 4 Spanish hospitals. Baseline HRQL was measured with a generic questionnaire, the Medical Outcomes Study 36-item Short Form Survey (SF-36), and with an HF-specific instrument, the Minnesota Living With Heart Failure (MLWHF) questionnaire. Cox proportional hazards models were used to calculate hazard ratios (HRs) for hospitalization and death on the basis of HRQL scores. RESULTS: During a median follow-up of approximately 6 months, 138 patients (35.0%) underwent a first emergency rehospitalization and 70 (17.8%) died. After adjustment for biomedical, psychosocial, and health care variables, the frequency of hospital readmission was higher in patients with worse scores on the SF-36 physical functioning (HR, 1.65; 95% confidence interval [CI], 1.11-2.44; P = .01), general health (HR, 1.73; 95% CI, 1.19-2.52; P = .003), and mental health (HR, 1.65; 95% CI, 1.10-2.47; P = .02) subscales. Results were similar for the mortality end point. For the MLWHF questionnaire, worse overall and worse physical and emotional summary scores were associated with higher mortality. CONCLUSIONS: Worse HRQL is associated with hospital readmission and death in patients with HF. The magnitude of this association, for both physical and mental HRQL components, is comparable to that for other well-known predictors of hospital readmission and death, such as personal history of diabetes, previous hospitalizations, and treatment with angiotensin-converting enzyme inhibitors.     

Impact of atrial fibrillation on mortality and readmission in older adults hospitalized with heart failure

BACKGROUND: Atrial fibrillation is common in older adults with heart failure. It is known to adversely affect outcomes. AIM: To examine the associations of atrial fibrillation with 4-year mortality and 30-day readmission in older adults hospitalized with heart failure. METHODS: Patients were Medicare beneficiaries 65 years of age and older discharged with a primary diagnosis of heart failure. Baseline data were obtained by retrospective chart reviews and data on mortality and readmission were obtained from Medicare administrative files. Presence of atrial fibrillation was confirmed using electrocardiogram during hospital admission. Using Cox proportional hazards models we estimated bivariate and multivariable (adjusted for various patient and care covariates) hazards ratios (HR) and 95% confidence intervals (CI) for 4-year mortality and 30-day readmission of patients with atrial fibrillation compared with those without. RESULTS: Patients (n=944) had a mean age (+/-S.D.) of 79 (+/-7) years, 61% were women, 18% African-Americans, 25% had atrial fibrillation by admission electrocardiogram, 64% died within 4 years, and 8% were readmitted. Patients with atrial fibrillation had a 52% increased risk of 4-year mortality (adjusted HR=1.52; 95%CI=1.11-2.07). Atrial fibrillation was also associated with higher risk of readmission (unadjusted HR=1.64; 95%CI=1.01-2.68). However, the association lost its statistical significance after adjustment for various patient and care variables (adjusted HR=2.09; 95%CI=0.94-4.65). CONCLUSION: Presence of atrial fibrillation was associated with significant increased risk of long-term mortality in older adults hospitalized with heart failure and was associated with a non-significant higher risk of hospital readmission.     

The prognostic importance of anemia in patients with heart failure

Physiologic studies have suggested that anemia could adversely affect the cardiovascular condition of patients with heart failure. Yet, the prognostic importance of this treatable condition is not well established by epidemiologic studies. We sought to determine the prognostic value of hematocrit level in a cohort of elderly patients hospitalized with heart failure.We studied a consecutive sample of 2281 patients aged 65 years or older who had been admitted with a principal discharge diagnosis of heart failure. Multivariate Cox proportional hazards regression was conducted to test whether hematocrit level was an independent predictor of 1-year mortality and of hospital readmission.The mean (+/- SD) age of the patients was 79 +/- 8 years; 58% (n = 1324) were women. Their median hematocrit was 38% (25th to 75th percentile, 33% to 42%). Lower hematocrits were associated with a higher mortality. After adjusting for demographic and clinical factors, each 1% lower hematocrit was associated with a 2% greater 1-year mortality (P = 0.007). Compared with patients with a hematocrit >42%, those with a hematocrit < or =27% had a 40% greater 1-year mortality (hazard ratio [HR] = 1.40; 95% confidence interval [CI]: 1.02 to 1.92; P = 0.04). This increased risk was similar to that conferred by traditional risk factors, including a left ventricular ejection fraction < or =20% (HR = 1.50; 95% CI: 1.20 to 1.86). Lower hematocrits were also associated with a greater risk of hospital readmission.Anemia is associated with an increased risk of death and rehospitalization in older patients with heart failure. Whether anemia is a direct cause of worse outcomes, or a marker for other causal factors, is not known.     

The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators

PURPOSE: Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals.PATIENTS AND METHODS: This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a "usual care" control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge.RESULTS: Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of -1.1 days (95% confidence interval [CI]: -2.9 to 0.7 days, P = 0.18) and in hospital charges of -$817 (95% CI: -$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life.CONCLUSIONS: The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay.     

Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial

OBJECTIVES: To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure. DESIGN: Randomized, controlled trial with follow-up through 52 weeks postindex hospital discharge. SETTING: Six Philadelphia academic and community hospitals. PARTICIPANTS: Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure. INTERVENTION: A 3-month APN-directed discharge planning and home follow-up protocol. MEASUREMENTS: Time to first rehospitalization or death, number of rehospitalizations, quality of life, functional status, costs, and satisfaction with care. RESULTS: Mean age of patients (control n=121; intervention n=118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank chi(2)=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.001). CONCLUSION: A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes.     

Randomized trial of an education and support intervention to prevent readmission of patients with heart failure.

OBJECTIVES: We determined the effect of a targeted education and support intervention on the rate of readmission or death and hospital costs in patients with heart failure (HF). BACKGROUND: Disease management programs for patients with HF including medical components may reduce readmissions by 40% or more, but the value of an intervention focused on education and support is not known. METHODS: We conducted a prospective, randomized trial of a formal education and support intervention on one-year readmission or mortality and costs of care for patients hospitalized with HF. RESULTS: Among the 88 patients (44 intervention and 44 control) in the study, 25 patients (56.8%) in the intervention group and 36 patients (81.8%) in the control group had at least one readmission or died during one-year follow-up (relative risk = 0.69, 95% confidence interval [CI]: 0.52, 0.92; p = 0.01). The intervention was associated with a 39% decrease in the total number of readmissions (intervention group: 49 readmissions; control group: 80 readmissions, p = 0.06). After adjusting for clinical and demographic characteristics, the intervention group had a significantly lower risk of readmission compared with the control group (hazard ratio = 0.56, 95% CI: 0.32, 0.96; p = 0.03) and hospital readmission costs of $7,515 less per patient. CONCLUSIONS: A formal education and support intervention substantially reduced adverse clinical outcomes and costs for patients with HF.     

Outcomes in heart failure patients with preserved ejection fraction: mortality,readmission, and functional decline

OBJECTIVES: We evaluated the six-month clinical trajectory of patients hospitalized for heart failure (HF) with preserved ejection fraction (EF), as the natural history of this condition has not been well established. We compared mortality, hospital readmission, and changes in functional status in patients with preserved versus depressed EF. BACKGROUND: Although the poor prognosis of HF with depressed EF has been extensively documented, there are only limited and conflicting data concerning clinical outcomes for patients with preserved EF. METHODS: We prospectively evaluated 413 patients hospitalized for HF to determine whether EF >or=40% was an independent predictor of mortality, readmission, and the combined outcome of functional decline or death. RESULTS: After six months, 13% of patients with preserved EF died, compared with 21% of patients with depressed EF (p = 0.02). However, the rates of functional decline were similar among those with preserved and depressed EF (30% vs. 23%, respectively; p = 0.14). After adjusting for demographic and clinical covariates, preserved EF was associated with a lower risk of death (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.26 to 0.90; p = 0.02), but there was no difference in the risk of readmission (HR 1.01, 95% CI 0.72 to 1.43; p = 0.96) or the odds of functional decline or death (OR 1.01, 95% CI 0.59 to 1.72; p = 0.97). CONCLUSIONS: Heart failure with preserved EF confers a considerable burden on patients, with the risk of readmission, disability, and symptoms subsequent to hospital discharge, comparable to that of HF patients with depressed EF.     

Preliminary data on the potential usefulness of B-type natriuretic peptide levels in predicting outcome after hospital discharge in patients with heart failure

PURPOSE: Among patients admitted for treatment of heart failure, we aimed to evaluate the value of B-type natriuretic peptide levels in predicting subsequent death or hospital readmission. SUBJECTS AND METHODS: We observed and followed 50 consecutive patients admitted with decompensated heart failure. B-type natriuretic peptide levels were measured using an immunofluorometric assay at admission and at discharge. We followed patients for 6 months and ascertained readmissions for cardiovascular causes and death. RESULTS: Forty-three patients were discharged. There were 20 events during follow-up (15 readmissions and 5 deaths). Mean (+/- SD) B-type natriuretic peptide levels decreased during the initial hospitalization, from 619 +/- 491 pg/mL to 328 +/- 314 pg/mL (P <0.001) among patients who were event free during follow-up, whereas declines were less marked among patients with hospital readmission or death (from 779 +/- 608 pg/mL to 643 +/- 465 pg/mL, P = 0.08). Among the 7 patients with in-hospital increases in B-type natriuretic peptide level, 6 had events, compared with 14 of the 36 patients whose levels declined (P = 0.04). An increase in B-type natriuretic peptide levels during hospital stay was associated with an increased event rate (hazard ratio [HR] = 3.3; 95% confidence interval [CI]: 1.3 to 8.8). Patients whose B-type natriuretic peptide level at discharge was above the median (321 pg/mL) had a somewhat higher rate of dying or being readmitted (HR = 2.3; 95% CI: 0.9 to 5.8). CONCLUSION: These preliminary results in a small number of patients suggest that changes in B-type natriuretic peptide levels, as well as predischarge levels, are related to hospital readmission and death within 6 months.     

Telehome monitoring in patients with cardiac disease who are at high risk of readmission

Patients with chronic conditions are heavy users of the health care system. There are opportunities for significant savings and improvements to patient care if patients can be maintained in their homes. A randomized control trial tested the impact of 3 months of telehome monitoring on hospital readmission, quality of life, and functional status in patients with heart failure or angina. The intervention consisted of video conferencing and phone line transmission of weight, blood pressure, and electrocardiograms. Telehome monitoring significantly reduced the number of hospital readmissions and days spent in the hospital for patients with angina and improved quality of life and functional status in patients with heart failure or angina. Patients found the technology easy to use and expressed high levels of satisfaction. Telehealth technologies are a viable means of providing home monitoring to patients with heart disease at high risk of hospital readmission to improve their self-care abilities.     

Correlates of Early Hospital Readmission or Death in Patients With Congestive Heart Failure

Among patients with heart failure who survive an admission to the hospital, those who are readmitted or die soon after discharge may warrant special attention. Therefore, we prospectively followed 257 patients admitted nonelectively to an urban university hospital, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph, who were discharged alive. Through survey of patients and families, review of the hospital computer system, and a search of the National Death Index, we recorded death and hospital readmission. Within 60 days of discharge, 13 patients (5%) died and 82 (32%) died or were readmitted to the hospital. Using Cox proportional-hazards modeling, the multivariable correlates of readmission or death were single marital status (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.3 to 3.3), Charlson Comorbidity Index score (HR 1.3 per point to maximum 4 points, 95% CI 1.1 to 1.6), admission systolic blood pressure of ≤100 mm Hg (HR 2.8, 95% CI 1.6 to 5.0), and absence of new ST-T-wave changes on the initial electrocardiogram (HR 1.9, 95% CI 1.1 to 3.3). Self-reported patient compliance and clinical instability at discharge were not correlates. Almost all patients stratified by these factors had at least a 25% risk of readmission or death. Our independent correlates of readmission or death support the importance of both medical and social factors in the pathway to clinical decline. However, we could not reliably identify a truly low-risk group. Interventions to decrease early readmission or death among patients with heart failure should target both medical management and the adequacy of social support, and probably need to be applied to all admitted patients.

To determine correlates of early readmission or death, we prospectively followed 257 patients admitted to an urban university hospital with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph. Single marital status, increasing comorbidity, relative hypotension, and absence of new ST-T-wave changes on initial electrocardiogram were the correlates, but we could not reliably identify a truly low-risk group.     

Effects of previous influenza vaccination on subsequent readmission and mortality in elderly patients hospitalized with pneumonia

PURPOSE: To determine the effect of influenza vaccination on mortality and hospital readmission rates following discharge of elderly patients admitted with pneumonia. METHODS: We reviewed the medical records of 12,566 randomly selected Medicare beneficiaries hospitalized for pneumonia from October 1 through December 31, 1998, to assess mortality and hospital readmission rates from the date of discharge through the influenza season, May 1, 1999. Patients were grouped based on vaccination status: before hospitalization, during hospitalization, or unknown (no evidence of vaccination). RESULTS: Severity-adjusted mortality rates were 22.4% (95% confidence interval [CI]: 14.4% to 29.7%) for the vaccination before hospitalization group, 26.4% (95% CI: 20.4% to 31.9%) for the in-hospital vaccination group, and 29.4% (95% CI: 28.1% to 30.6%) for the unknown vaccination status group. Patients vaccinated before hospitalization had significantly lower mortality than did patients with unknown vaccination status (hazard ratio [HR] = 0.65; 95% CI: 0.59 to 0.70; P <0.0001). Adjusted readmission rates were 42.6% (95% CI: 40.0% to 45.1%) for the vaccination before hospitalization group, 40.0% (95% CI: 33.2% to 46.1%) for the in-hospital vaccination group, and 44.8% (95% CI: 43.3% to 46.4%) for the unknown vaccination status group. Patients vaccinated before hospitalization had significantly lower readmission rates than patients with unknown vaccination status (HR = 0.92; 95% CI: 0.87 to 0.98; P = 0.009). CONCLUSION: Influenza vaccination before hospitalization was effective in decreasing subsequent mortality and hospital readmission in elderly patients with pneumonia.     

A systematic review and meta-analysis of studies comparing readmission rates and mortality rates in patients with heart failure

BACKGROUND: Heart failure is the leading cause of hospitalization and readmission in many hospitals worldwide. We performed a meta-analysis to evaluate the effectiveness of multidisciplinary heart failure management programs on hospital admission rates. METHODS: We identified studies through an electronic search and mortality using 8 distinct methods. Eligible studies met the following criteria: (1) randomized controlled clinical trials of adult inpatients hospitalized for heart failure enrolled either at the time of discharge or within 1 week after discharge; (2) heart failure-specific patient education intervention coupled with a postdischarge follow-up assessment; and (3) unplanned readmission reported. Four reviewers independently assessed each study for eligibility and quality, achieving a weighted kappa of 0.73 for eligibility and 0.77 for quality. For each study we calculated the relative risk for readmissions and mortality for patients receiving enhanced education relative to patients receiving usual care. RESULTS: A total of 529 citation titles were identified, of which 8 randomized trials proved eligible. The pooled relative risk for hospital readmission rates using a random-effects model was 0.79 (95% confidence interval, 0.68-0.91; P<.001; heterogeneity P = .25). There was no apparent effect on mortality (relative risk, 0.98; 95% confidence interval, 0.72-1.34; P = .90; heterogeneity P = .20). Data were insufficient to meaningfully pool intervention effects on quality of life or compliance. CONCLUSION: This systematic review suggests that specific heart failure-targeted interventions significantly decrease hospital readmissions but do not affect mortality rates.     

Differences in mortality of black and white patients enrolled in the program of all-inclusive care for the elderly

OBJECTIVES: To examine the relationship between race and mortality in frail community-dwelling older people with access to a program providing comprehensive access and coordination of services. DESIGN: A longitudinal cohort study. SETTING: Twelve nationwide demonstration sites of the Program of All-Inclusive Care for the Elderly (PACE) from 1990 to 1996. PACE provides comprehensive medical and long-term care services for nursing home-eligible older people who live in the community. PARTICIPANTS: Two thousand two white patients and 859 black patients. MEASUREMENTS: Patients were followed after enrollment until death or the end of the follow-up period. Time from enrollment to death was measured with adjustment of the Cox proportional hazards model for comorbid conditions, functional status, site, and other demographic characteristics. RESULTS: Black patients were younger than white patients (mean age 77 vs 80, P <.001) but had worse functional status (mean activity of daily living (ADL) score 6.5 vs 7.2, P <.001) on enrollment. Survival for black and white patients was 88% and 86% at 1 year, 67% and 61% at 3 years, and 51% and 42% at 5 years, respectively (unadjusted hazard ratio (HR) for black patients = 0.77; 95% confidence interval (CI) = 0.67-0.89). After adjustment for baseline comorbid conditions, functional status, site, and demographic characteristics, black patients still had a lower mortality rate (HR = 0.77; 95% CI =.65-0.93). The survival advantage for black patients did not emerge until about 1 year after PACE enrollment (HR for first year after enrollment = 0.97; 95% CI = 0.72-1.31; HR after first year = 0.67; 95% CI = 0.54-0.85, P-value for time interaction <.001). During the first year of enrollment, black patients were more likely to improve and less likely to decline in ADL function than white patients (P <.001). CONCLUSION: In PACE, a system providing access to and coordination of comprehensive medical and long-term care services for frail older people, black patients have a lower mortality rate than white patients. This survival advantage, which emerges approximately 1 year after PACE enrollment, may be related to the comprehensive access and coordination of services provided by the PACE program.     

Hyponatremia and long-term mortality in survivors of acute ST-elevation myocardial infarction

BACKGROUND: Hyponatremia, a marker of neurohormonal activation, is a common electrolyte disorder among patients with acute ST-elevation myocardial infarction. The long-term prognostic value of hyponatremia during the acute phase of infarction is not known. METHODS: We studied 978 patients with acute ST-elevation myocardial infarction and without a history of heart failure who survived the index event. During the hospital stay, sodium levels were obtained on admission and at 24, 48, and 72 hours. The median duration of follow-up after hospital discharge was 31 months (range, 9-61 months). RESULTS: Hyponatremia, defined as a mean serum sodium level less than 136 mEq/L, was present during admission in 108 patients (11.0%). In a multivariable Cox proportional hazards model adjusting for other potential clinical predictors of mortality and for left ventricular ejection fraction, hyponatremia during admission remained an independent predictor of postdischarge death (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.3-3.2; P = .002). Hyponatremia during admission was also independently associated with postdischarge readmission for heart failure (HR, 1.6; 95% CI, 1.1-2.6; P = .04). When serum sodium level was used as a continuous variable, the adjusted HR for death or heart failure was 1.12 for every 1-mEq/L decrease (95% CI, 1.07-1.18; P<.001). CONCLUSION: Hyponatremia in the early phase of ST-elevation myocardial infarction is a predictor of long-term mortality and admission for heart failure after hospital discharge, independent of other clinical predictors of adverse outcome and left ventricular ejection fraction.     

Atrial fibrillation, ischaemic heart disease, and the risk of death in patients with heart failure.

AIMS: Atrial fibrillation (AF) is a risk factor for death in patients with a myocardial infarction, but highly variable results are reported in patients with heart failure. We studied the prognostic impact of AF in heart failure patients with and without ischaemic heart disease. METHODS AND RESULTS: During a period of 2 years, 3587 patients admitted to hospital because of heart failure were included in this study. All patients were examined by echocardiography and the presence of AF was recorded. Follow-up was available for 8 years. Twenty four percent of those discharged alive from hospital had AF. After 4 and 8 years of follow-up, mortality was higher in patients with AF than in patients without, 56 vs. 52% and 77 vs. 73%, respectively. Cox multivariable regression analysis showed a small but significant importance of AF for long-term mortality [hazard ratio (HR) 1.12, 95% confidence limits (CI), 1.02-1.23, P=0.018]. There was a significant interaction between the importance of AF and the presence of ischaemic heart disease (P=0.034). In patients with AF at the time of discharge and ischaemic heart disease, HR was 1.25 (95% CI: 1.09-1.42) and P<0.001; in patients with AF at discharge and without ischaemic heart disease, HR was 1.01 (95% CI: 0.88-1.16) and P=0.88. CONCLUSION: AF is associated with increased risk of death only in patients with ischaemic heart disease. This finding may explain the variable results of studies of the prognosis associated with AF in heart failure.     

Multicenter randomised trial on home-based telemanagement to prevent hospital readmission of patients with chronic heart failure

BACKGROUND: Chronic heart failure (CHF) remains a common cause of disability, death and hospital admission. Several investigations support the usefulness of programs of disease management for improving clinical outcomes. However, the effect of home-based telemanagement programs on the rate of hospital readmission is still unclear and the cost-effectiveness ratio of such programs is unknown. The aim of the study was to determine whether a home-based telemanagement (HBT) programme in CHF patients decreased hospital readmissions and hospital costs in comparison with the usual care (UC) follow-up programme over a one-year period. METHODS AND RESULTS: Four hundred-sixty CHF patients (pts), aged 57+/-10 years were randomised to two management strategies: 230 pts to HBT programme and 230 pts to UC programme. The HBT pts received a portable device, transferring, by telephone, a one-lead trace to a receiving station where a nurse was available for interactive teleconsultation. The UC pts were referred to their primary care physicians and cardiologists. The primary objective of the study was one-year hospital readmission for cardiovascular reasons. During one-year follow-up 55 pts (24%) in HBT group and 83 pts (36%) in UC group had at least one readmission (RR=0.56; 95% CI: 0.38-0.82; p=0.01). After adjusting for clinical and demographic characteristics, the HBT group had a significantly lower risk of readmission compared with the UC group (HR=0.50, 95% CI: 0.34-0.73; p=0.01). The intervention was associated with a 36% decrease in the total number of hospital readmissions (HBT group: 91 readmissions; UC group: 142 readmissions) and a 31% decrease in the total number of episodes of hemodynamic instability (101 in HBT group vs 147 in UC group). The rate of hearth failure-related readmission was 19% (43 pts) in HBT group and 32% (73 pts) in UC group (RR=0.49, 95% [CI]: 0.31-0.76; p=0.0001). No significant difference was found on cardiovascular mortality between groups. Mean cost for hospital readmission was significantly lower in HBT group (euro 843+/-1733) than in UC group (euro 1298+/-2322), (-35%, p<0.01). CONCLUSIONS: This study suggests that one-year HBT programme reduce hospital readmissions and costs in CHF patients.     

Comorbidity Significantly Affects Clinical Outcome After Cardiac Resynchronization Therapy Regardless of Ventricular Remodeling

BackgroundThe influence of comorbid conditions on ventricular remodeling, functional status, and clinical outcome after cardiac resynchronization therapy (CRT) is insufficiently elucidated.Methods and ResultsThe influence of different comorbid conditions on left ventricular remodeling, improvement in New York Heart Association (NYHA) functional class, hospitalizations for heart failure, and all-cause mortality after CRT implantation was analyzed in 172 consecutive patients (mean age 71 ± 9 y), implanted from October 2008 to April 2011 in a single tertiary care hospital. During mean follow-up of 18 ± 9 months, 21 patients died and 57 were admitted for heart failure. Left ventricular remodeling and improvement in NYHA functional class were independent from comorbidity burden. However, diabetes mellitus (hazard ratio [HR] 3.45, 95% confidence interval [CI] 1.24–9.65) and chronic kidney disease (HR 3.11, 95% CI 1.10–8.81) were predictors of all-cause mortality, and the presence of chronic obstructive pulmonary disease (HR 1.89, 95% CI 1.02–3.53) was independently associated with heart failure admissions. Importantly, those 3 comorbid conditions had an additive negative impact on survival and heart failure admissions, even in patients with reverse left ventricular remodeling.ConclusionsReverse ventricular remodeling and improvement in functional status after CRT implantation are independent from comorbidity burden. However, comorbid conditions remain important predictors of all-cause mortality and heart failure admissions.