Readmissions after Hospitalization for Heart Failure,Acute Myocardial Infarction,or Pneumonia among Young and Middle-Aged Adults: A Retrospective Observational Cohort Study

Background

Patients aged ≥65 years are vulnerable to readmissions due to a transient period of generalized risk after hospitalization. However, whether young and middle-aged adults share a similar risk pattern is uncertain. We compared the rate, timing, and readmission diagnoses following hospitalization for heart failure (HF), acute myocardial infarction (AMI), and pneumonia among patients aged 18–64 years with patients aged ≥65 years.

Methods and Findings

We used an all-payer administrative dataset from California consisting of all hospitalizations for HF (n = 206,141), AMI (n = 107,256), and pneumonia (n = 199,620) from 2007–2009. The primary outcomes were unplanned 30-day readmission rate, timing of readmission, and readmission diagnoses. Our findings show that the readmission rate among patients aged 18–64 years exceeded the readmission rate in patients aged ≥65 years in the HF cohort (23.4% vs. 22.0%, p<0.001), but was lower in the AMI (11.2% vs. 17.5%, p<0.001) and pneumonia (14.4% vs. 17.3%, p<0.001) cohorts. When adjusted for sex, race, comorbidities, and payer status, the 30-day readmission risk in patients aged 18–64 years was similar to patients ≥65 years in the HF (HR 0.99; 95%CI 0.97–1.02) and pneumonia (HR 0.97; 95%CI 0.94–1.01) cohorts and was marginally lower in the AMI cohort (HR 0.92; 95%CI 0.87–0.96). For all cohorts, the timing of readmission was similar; readmission risks were highest between days 2 and 5 and declined thereafter across all age groups. Diagnoses other than the index admission diagnosis accounted for a substantial proportion of readmissions among age groups <65 years; a non-cardiac diagnosis represented 39–44% of readmissions in the HF cohort and 37–45% of readmissions in the AMI cohort, while a non-pulmonary diagnosis represented 61–64% of patients in the pneumonia cohort.

Conclusion

When adjusted for differences in patient characteristics, young and middle-aged adults have 30-day readmission rates that are similar to elderly patients for HF, AMI, and pneumonia. A generalized risk after hospitalization is present regardless of age. Please see later in the article for the Editors'' Summary     

Hospital Readmissions of Patients with Heart Failure: The Impact of Hospital and Primary Care Organizational Factors in Northern Italy

BackgroundPrimary health care is essential for an appropriate management of heart failure (HF), a disease which is a major clinical and public health issue and a leading cause of hospitalization. The aim of this study was to evaluate the impact of different organizational factors on readmissions of patients with HF.MethodsThe study population included elderly resident in the Local Health Authority of Bologna (Northern Italy) and discharged with a diagnosis of HF from January to December 2010. Unplanned hospital readmissions were measured in four timeframes: 30 (short-term), 90 (medium-term), 180 (mid-long-term), and 365 days (long-term). Using multivariable multilevel Poisson regression analyses, we investigated the association between readmissions and organizational factors (discharge from a cardiology department, general practitioners’ monodisciplinary organizational arrangement, and implementation of a specific HF care pathway).ResultsThe 1873 study patients had a median age of 83 years (interquartile range 77–87) and 55.5% were females; 52.0% were readmitted to the hospital for any reason after a year, while 20.1% were readmitted for HF. The presence of a HF care pathway was the only factor significantly associated with a lower risk of readmission for HF in the short-, medium-, mid-long- and long-term period (short-term: IRR [incidence rate ratio]=0.57, 95%CI [confidence interval]=0.35–0.92; medium-term: IRR=0.70, 95%CI=0.51–0.96; mid-long-term: IRR=0.79, 95%CI=0.64–0.98; long-term: IRR=0.82, 95%CI=0.67–0.99), and with a lower risk of all-cause readmission in the short-term period (IRR=0.73, 95%CI=0.57–0.94).ConclusionOur study shows that the HF care specific pathway implemented at the primary care level was associated with lower readmission rate for HF in each timeframe, and also with lower readmission rate for all causes in the short-term period. Our results suggest that the engagement of primary care professionals starting from the early post-discharge period may be relevant in the management of patients with HF.     

Common Variants for Heart Failure

Heart failure (HF) is a common disease with high morbidity and mortality; however, none of thedrugs available are now entirely optimal for the treatment of HF. In addition to various clinical diseases andenvironment influences, genetic factors also contribute to the development and progression of HF. Identifyingthe common variants for HF by genome-wide association studies will facilitate the understanding ofpathophysiological mechanisms underlying HF. This review summarizes the recently identified commonvariants for HF risk and outcome and discusses their implications for the clinic therapy.     

Support for Sustainable Development Policy Decisions A Case Study from Highway Maintenance

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http://dx.doi.org/10.1065/lca2006.04.009

Goal, Scope and Method

logy. This paper describes a case study carried out as part of a wider programme to provide support for environmental decision-making in the highway maintenance programme of a local government body: Surrey County Council (SCC). UK local authorities are required to demonstrate that sustainable development principles are addressed in service provision, by improving environmental, economic or social wellbeing and improving public consultation. A methodological approach was developed to meet these requirements by using life cycle assessment (LCA) and multi-criteria decision analysis (MCDA) through the process of decision conferencing.

Results

In projects requiring strategic decisions, difficulties arise in identifying relevant sustainable development criteria and in evaluating maintenance options against these criteria where the context for decision-making is complex and characterised by uncertainty, where multiple public policy objectives compete and a number of decision-makers and key players are affected by the outcome. Clearly, a structured process is needed to engage such stakeholders in the decision process, utilising quantitative and qualitative information. The approach described proved to be capable of fulfilling these requirements.

Conclusions

and Recommendations. The approach of combining LCA with MCDA through decision conferencing is capable of further development to support other strategic decision-making activities. However, this illustrative case study has revealed a need for methodological developments in LCA for local, project-level decisions.

     

Autophagy and Heart Failure: A Possible Role for Homocysteine

Autophagy is a process used for intracellular digestion of organelles and proteins and has special relevance to the long-lived cardiomyocytes in heart disease. The pathway for autophagy and all its mediators remain to be elucidated, but involve such proteins as Atg, Beclin-1, LAMP-2, BH3, Bcl2, PI3K Kinase as well as a plethora of others. It is still not entirely clear whether autophagy is destructive or beneficial to the cell; evidence suggests that the answer is case-specific. For instance, autophagy appears to preserve cell life under cases of ischemia in I/R injury, but is detrimental during reperfusion. High levels of homocysteine (Hcy), a sulfur-containing amino acid, have been shown to be an independent risk factor for chronic heart failure. There are several links to induction and repression of autophagy and Hcy; the following connections to Hcy and autophagy have been made: intracellular nitrous oxide production, intracellular calcium production, and reactive oxygen species production. Further work remains to be elucidated concerning the specific mechanisms under which autophagy occurs and possible Hcy-mediated connections. Moreover, the therapeutic implications might be of some promise to patients.     

Heart Failure Re-Admission: Measuring the Ever Shortening Gap between Repeat Heart Failure Hospitalizations

Many quality-of-care and risk prediction metrics rely on time to first rehospitalization even though heart failure (HF) patients may undergo several repeat hospitalizations. The aim of this study is to compare repeat hospitalization models. Using a population-based cohort of 40,667 patients, we examined both HF and all cause re-hospitalizations using up to five years of follow-up. Two models were examined: the gap-time model which estimates the adjusted time between hospitalizations and a multistate model which considered patients to be in one of four states; community-dwelling, in hospital for HF, in hospital for any reason, or dead. The transition probabilities and times were then modeled using patient characteristics and number of repeat hospitalizations. We found that during the five years of follow-up roughly half of the patients returned for a subsequent hospitalization for each repeat hospitalization. Additionally, we noted that the unadjusted time between hospitalizations was reduced ∼40% between each successive hospitalization. After adjustment each additional hospitalization was associated with a 28 day (95% CI: 22-35) reduction in time spent out of hospital. A similar pattern was seen when considering the four state model. A large proportion of patients had multiple repeat hospitalizations. Extending the gap between hospitalizations should be an important goal of treatment evaluation.     

Quantifying Policy Options for Reducing Future Coronary Heart Disease Mortality in England: A Modelling Study

Aims

To estimate the number of coronary heart disease (CHD) deaths potentially preventable in England in 2020 comparing four risk factor change scenarios.

Methods and Results

Using 2007 as baseline, the IMPACT_SEC model was extended to estimate the potential number of CHD deaths preventable in England in 2020 by age, gender and Index of Multiple Deprivation 2007 quintiles given four risk factor change scenarios: (a) assuming recent trends will continue; (b) assuming optimal but feasible levels already achieved elsewhere; (c) an intermediate point, halfway between current and optimal levels; and (d) assuming plateauing or worsening levels, the worst case scenario. These four scenarios were compared to the baseline scenario with both risk factors and CHD mortality rates remaining at 2007 levels. This would result in approximately 97,000 CHD deaths in 2020. Assuming recent trends will continue would avert approximately 22,640 deaths (95% uncertainty interval: 20,390-24,980). There would be some 39,720 (37,120-41,900) fewer deaths in 2020 with optimal risk factor levels and 22,330 fewer (19,850-24,300) in the intermediate scenario. In the worst case scenario, 16,170 additional deaths (13,880-18,420) would occur. If optimal risk factor levels were achieved, the gap in CHD rates between the most and least deprived areas would halve with falls in systolic blood pressure, physical inactivity and total cholesterol providing the largest contributions to mortality gains.

Conclusions

CHD mortality reductions of up to 45%, accompanied by significant reductions in area deprivation mortality disparities, would be possible by implementing optimal preventive policies.     

General and Family Practice: Estrogen Replacement Therapy for Reducing Cardiovascular Disease

The Council on Scientific Affairs of the California Medical Association presents the following inventory of items of progress in general and family practice. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, and scholars to stay abreast of these items of progress in general and family practice that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on General and Family Practice of the California Medical Association, and the summaries were prepared under its direction.     

Societal LCA Methodology and Case Study (12 pp)

Background, Aim and Scope Societal assessment is advocated as one of the three pillars in the evaluation of, and movement toward, sustainability. As is the case with the well established LCA, and the emerging LCC, societal life cycle assessment should be developed in such as way as to permit relative product comparisons, rather than absolute analyses. The development of societal life cycle assessment is in its infancy, and important concepts require clarification including the handling of the more than two hundred social indicators. Therefore, any societal life cycle assessment methodology must explain why it is midpoint- or endpoint-based as well as its reasons to be complimentary with, or included within, life cycle assessment. Materials and Methods: A geographically specific midpoint based societal life cycle assessment methodology, which employs labour hours as an intermediate variable in the calculation has been developed and evaluated against an existing LCA comparing two detergents. The methodology is based on using an existing life cycle inventory and, therefore, has identical system boundaries and functional units to LCA. The societal life cycle assessment methodology, much like LCA, passes from inventory, through characterisation factors, to provide an ultimate result. In analogy to economics and cost estimation, societal life cycle assessment combines, into its statistics, both data as well as estimates, some of which are correlated to elements of the LCI. It focuses on the work hours required to meet basic needs.A geographically specific midpoint based societal life cycle assessment methodology, which employs labour hours as an intermediate variable in the calculation has been developed and evaluated against an existing LCA comparing two detergents. The methodology is based on using an existing life cycle inventory and, therefore, has identical system boundaries and functional units to LCA. The societal life cycle assessment methodology, much like LCA, passes from inventory, through characterisation factors, to provide an ultimate result. In analogy to economics and cost estimation, societal life cycle assessment combines, into its statistics, both data as well as estimates, some of which are correlated to elements of the LCI. It focuses on the work hours required to meet basic needs. Results: The societal life cycle assessment of an appended case study indicates that Detergent 2 generates, relative Detergent 1, approximately 20% less employment in Russia, 35% less in France, and approximately five times more in Canada and South Africa, the latter derived from its higher aluminium content. There is essentially no difference in the employment in the use country (Switzerland) nor in Morocco, where some of the waste disposal was assumed to take place. Discussion: Given that housing is more affordable, in terms of shelter units per labour hour, in South Africa, compared to Europe, it is, therefore, of no surprise that Detergent 2 provides a societal benefit in terms of housing. Detergent 2 does, however, result in dematerialization, in that its environmental impact is lower (LCI). Therefore, as less resources are employed and labour required, in extraction, production and transport, the societal benefits in health care, education and necessities, a grouped variable, are lower for Detergent 2. This is despite the employment shift away from Europe and to less 'developed' regions. Conclusions: The assessment of societal impacts involves several hundred specific indicators. Therefore, aggregation is, if not impossible, at least heavily value laden and, therefore, not recommended. The impact of a societal action, derived from a product purchase or otherwise, is also highly local. Given this, societal life cycle assessment, carried through to the midpoints, and based on an existing LCI, has been developed as a methodology. The results, for an existing LCA-detergent case, illustrate that societal life cycle assessment provides a means to investigate how policy and policy makers can be linked to sustainable development. The sensitivity analyses also clarify the decisions in regards to product improvement. Recommendations and Perspectives: The goal of societal life cycle assessment is not to make decisions, but rather to point out tradeoffs to decision- or policy-makers. This case, and the methodology that it is based on, permit such a comparison. Substituting Detergent 2 for Detergent 1 reduces resource use at the expense of an increase in atmospheric and terrestrial emissions. Access to housing is improved, though at the expense of education, health care and necessities. As a recommendation, one would look at the fact that the majority of indicators are superior for Detergent 2 relative to Detergent 1and seek to improve the aqueous emissions in Detergent 2 via a change in the formulation. An energy or fossil fuel substitution at the site of production could also improve the societal benefits in terms of education and health care. While societal life cycle assessment remains in its infancy, a methodology does exist. The field can, therefore, be viewed in a similar way to LCA in the early 1990s, with a need to validate, consolidate and, ultimately, built toward a standard. The contribution is aimed at contributing to such a discussion and therefore proposes that a societal life cycle assessment be LCI-derived, geographically specific, based on mid-points, and use employment as an intermediate variable.     

Barriers to Advance Care Planning in Cancer,Heart Failure and Dementia Patients: A Focus Group Study on General Practitioners' Views and Experiences

Background

The long-term and often lifelong relationship of general practitioners (GPs) with their patients is considered to make them the ideal initiators of advance care planning (ACP). However, in general the incidence of ACP discussions is low and ACP seems to occur more often for cancer patients than for those with dementia or heart failure.

Objective

To identify the barriers, from GPs'' perspective, to initiating ACP and to gain insight into any differences in barriers between the trajectories of patients with cancer, heart failure and dementia.

Method

Five focus groups were held with GPs (n = 36) in Flanders, Belgium. The focus group discussions were transcribed verbatim and analyzed using the method of constant comparative analysis.

Results

Three types of barriers were distinguished: barriers relating to the GP, to the patient and family and to the health care system. In cancer patients, a GP''s lack of knowledge about treatment options and the lack of structural collaboration between the GP and specialist were expressed as barriers. Barriers that occured more often with heart failure and dementia were the lack of GP familiarity with the terminal phase, the lack of key moments to initiate ACP, the patient''s lack of awareness of their diagnosis and prognosis and the fact that patients did not often initiate such discussions themselves. The future lack of decision-making capacity of dementia patients was reported by the GPs as a specific barrier for the initiation of ACP.

Conclusion

The results of our study contribute to a better understanding of the factors hindering GPs in initiating ACP. Multiple barriers need to be overcome, of which many can be addressed through the development of practical guidelines and educational interventions.     

心血管老化和心力衰竭

老年人心血管系统的老化是很明显的,动脉硬化改变了后负荷以及左心室的形状.尽管左心室的心脏收缩功能仍然能够维持,但是左心室的舒张功能则大大改变.运动时老年人的心血管功能产生明显的改变,老年人可以通过运动训练改善心血管功能.老化引起心血管结构和功能改变,从而降低心脏疾病出现的阈值.对老年人在运动或休息时心血管结构和功能的改变进行了综述.     

Heart Failure and Neonatal Hypocalcaemia

Six infants had congestive heart failure for which no cause could be found apart from a low serum calcium. All except one recovered completely and had normal chest x-ray appearances and E.C.G.s on discharge from hospital. Necropsy on the infant who died shoed engorgement and dilation of the right side of the heart and a small ductus but no other abnormalities. It is suggested that hypocalcaemia should be considered as a possible cause of heart failure in infants, especially when oedema is prominent.     

Psychiatric Treatment: General Implications and Lessons From Recent Court Decisions in California

The California legislature enacted tight constraints on the use of psychosurgery and electroconvulsive therapy in 1974. In April 1976 a State Court of Appeals declared part of the law to be unconstitutional. In doing so, the court enunciated several principles for regulating medical procedures. It affirmed the inherent police powers which permit the state to safeguard the public, especially incompetent, involuntary or confined persons, with respect to intrusive and hazardous medical procedures and to procedures which affect thought or feeling. Although limited to legislation concerning two psychiatric procedures, the court''s decision, and subsequently enacted legislation governing these procedures, has implications for other medical procedures and for other parts of the nation.     

An Integrated Mitochondrial ROS Production and Scavenging Model: Implications for Heart Failure

It has been observed experimentally that cells from failing hearts exhibit elevated levels of reactive oxygen species (ROS) upon increases in energetic workload. One proposed mechanism for this behavior is mitochondrial Ca²⁺ mismanagement that leads to depletion of ROS scavengers. Here, we present a computational model to test this hypothesis. Previously published models of ROS production and scavenging were combined and reparameterized to describe ROS regulation in the cellular environment. Extramitochondrial Ca²⁺ pulses were applied to simulate frequency-dependent changes in cytosolic Ca²⁺. Model results show that decreased mitochondrial Ca²⁺uptake due to mitochondrial Ca²⁺ uniporter inhibition (simulating Ru360) or elevated cytosolic Na⁺, as in heart failure, leads to a decreased supply of NADH and NADPH upon increasing cellular workload. Oxidation of NADPH leads to oxidation of glutathione (GSH) and increased mitochondrial ROS levels, validating the Ca²⁺ mismanagement hypothesis. The model goes on to predict that the ratio of steady-state [H₂O₂]_m during 3Hz pacing to [H₂O₂]_m at rest is highly sensitive to the size of the GSH pool. The largest relative increase in [H₂O₂]_m in response to pacing is shown to occur when the total GSH and GSSG is close to 1 mM, whereas pool sizes below 0.9 mM result in high resting H₂O₂ levels, a quantitative prediction only possible with a computational model.