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Heart failure readmissions, and more.

Thirty-day heart failure readmissions unchanged between 2004 and 2006

Hospital readmissions for heart failure hovered around 24% in 2004, 2005 and 2006, virtually unchanged from previous years, a study found.

Researchers used 2004-2006 Medicare data to identify fee-for-service patients admitted and discharged with a diagnosis of heart failure between Jan. 1, 2004 and Dec. 31, 2006. The main outcome was patient readmission to the hospital for any reason within 30 days of discharge after an index heart failure hospitalization. The study was published in the January Circulation: Heart Failure.

The data comprised 570,996 heart failure hospitalizations among 4,728 hospitals in 2004, 544,550 hospitalizations among 4,694 hospitals in 2005, and 501,234 hospitalizations among 4,674 hospitals in 2006. The average patient age was 80.1 years, and a majority of patients had multiple chronic diseases. Unadjusted, hospital-specific 30-day all-cause readmission rates were 23% in 2004, 23.3% in 2005, and 22.9% in 2006. The mean risk-standardized readmission rates were 23.7% in 2004, 23.9% in 2005 and 23.8% in 2006—statistically different (P<0.001), but not clinically significant, the authors noted. Annual estimates of between-hospital variation in patient risk of readmission were also similar (0.021 for 2004, 0.024 for 2005 and 0.025 for 2006).

There's been no regional or national improvement in readmission rates after heart failure hospitalization in recent years, the authors said. The data also suggest little variability between hospitals in managing transitions of care among patients discharged after heart failure hospitalization, they said. Observed hospital performance is likely a function of the current fee-for-service payment system, the authors added, which rewards patient volume over outcomes. “Readmitting nearly a quarter of patients after HF hospitalization within 30 days is not likely to represent optimal care for patients and suggests there is substantial room and a clear opportunity for improvement…,” they wrote.

H1N1 in California adds to growing knowledge about flu's presentation

A study of H1N1 influenza in California showed that, as reported around the world, the strain presents in younger patients and obese patients and that clinicians should give antiviral treatment regardless of when symptoms begin.

In the California case series, reported in the Nov. 4, 2009 Journal of the American Medical Association, there were 1,088 cases of hospitalization or death due to H1N1 infection from April 23 to August 11, with most cases occurring in June and July.

Among them, 118 patients (11%) died. Of the deaths, eight (7%) were children younger than 18 years. Among fatal cases, the median time from onset of symptoms to death was 12 days (range, 1 to 88 days). Ten patients died at home, in the emergency department, or within 24 hours after hospital admission. Infants had the highest hospitalization rates and those 50 years or older had the highest death rates once hospitalized. The most common causes of death were viral pneumonia and acute respiratory distress syndrome.

Among all 1,088 cases, 340 (31%) were admitted to intensive care units, and of the 297 intensive care cases with available information, 193 (65%) required mechanical ventilation. Of the 884 cases with available information, 701 (79%) received antiviral treatment, including 496 patients (71%) with established risk factors for severe influenza. Three hundred fifty-seven patients (51%) received treatment within 48 hours of symptom onset. The mean time from hospital admission to initiation of antiviral treatment was 1.5 days (range, 0 to 34 days).

Among all 1,088 cases, 344 (32%) were children younger than 18 years. The median age was 27 years (range, less than 1 year to 92 years). The median time from onset of symptoms to hospitalization was two days (range, 0 to 31 days). The most common symptoms included fever, cough and shortness of breath. A subset of cases also presented with altered mental status due to respiratory distress and hypoxia. The median length of hospitalization among all cases was four days (range, 1 to 74 days)

Forty-six patients (4%) had secondary bacterial infection, defined by isolation of bacteria from either a sterile site or a lower respiratory tract specimen in conjunction with new infiltrate on chest radiograph. The most common pathogens identified were Streptococcus pneumoniae, Staphylococcus aureus, gram-negative rods, and group A streptococcus. Of the 833 patients who had chest radiographs, 547 (66%) had infiltrates suggestive of pneumonia or acute respiratory distress syndrome.

Of the 268 adults aged 20 years or older with known body mass index (BMI), 156 (58%) were obese (BMI ≥30 kg/m2). Of these, 67 (43%) were morbidly obese (BMI ≥40 kg/m2). One hundred three (66%) of the 156 adult obese cases had underlying conditions associated with influenza complications, including 67 with chronic lung disease (65%, including 41 with asthma), 40 with cardiac disease (39%), 28 with immunosuppression (27%), 31 with diabetes mellitus (30%), and 12 with renal disease (12%).

Four hundred ten (66%) of 618 cases evaluated were positive for influenza A by hospital rapid antigen testing; 34% (208) were false-negative.

“Clinicians should be wary of excluding a diagnosis of pandemic 2009 influenza A (H1N1) infection based solely on nonmolecular testing,” the authors wrote. “One-fifth of hospitalized cases never received antiviral treatment, and about half received treatment more than 48 hours after onset of symptoms. Recent evidence suggests that even if initiated late, antiviral treatment can reduce mortality, and current national guidelines recommend that all hospitalized patients with pandemic 2009 influenza A (H1N1) infection should be treated with a neuraminidase inhibitor at standard dosing (75 mg every 12 hours) as soon as possible, regardless of when symptoms started.”