Use of Outpatient Intravenous Diuretic Therapy Among Patients With Heart Failure in the United States

Introduction: Select centers have published local experiences with outpatient (OP) intravenous (IV) diuretic clinics to treat worsening heart failure (HF) and prevent hospitalization. Little is known regarding widespread use of this care strategy in contemporary US practice, including the potential impact of the COVID-19 pandemic. Method(s): Inpatient (IP) and OP claims from Optum (April 2018-March 2021) were utilized to identify instances where patients with HF with reduced ejection fraction (HFrEF) received >=1 administration of IV diuretic. Episodes of care were categorized into hierarchical mutually exclusive groups defined by intensity of care setting, including IP hospitalization, critical care (without IP hospitalization), emergency department (without IP hospitalization), observation unit, nursing facility, and outpatient clinic. Analyses were stratified across pre-pandemic (4/2018-3/2019, 4/2019-3/2020) and COVID-19 pandemic periods (4/2020-3/2021). Result(s): Among 302,397 patients with HFrEF, 56,213 (19%) patients received IV diuretic therapy during the study period, accounting for 94,865 total IV diuretic episodes. Of patients receiving IV diuretics, 44% were female and 20% were Black. Among 85,827 (90%) IV diuretic episodes with available data on location of care, 14% were outpatient clinic visits, 60% were IP hospitalizations, and 21% were ED visits. Critical care, observation unit, and nursing facility locations each constituted ~1-2% of IV diuretic episodes. The proportion of outpatient IV diuretic visits and the overall distribution of IV diuretic episodes was similar over time, spanning the pre-pandemic and COVID-19 pandemic periods (Figure). Conclusion(s): In this cohort of US patients with HFrEF, approximately 1 in 7 care episodes involving IV diuretic therapy occurred in outpatient clinic. The relative proportion of outpatient IV diuretic visits did not meaningfully change during the first year of the COVID-19 pandemic. (Figure Presented).

The Design of the Dashboard Activated Services and Telehealth for Heart Failure (DASH-HF) Study: A Pragmatic Quality Improvement Randomized Implementation Trial for Patients with Heart Failure with Reduced Ejection Fraction

Heart failure is a leading diagnosis for hospitalization with a high risk of readmission. Despite robust data and recommendations by professional societies, there is a well-documented gap in delivering guideline-directed medical therapy (GDMT) known to reduce hospitalizations and improve mortality for patients with heart failure with reduced ejection fraction (HFrEF). The Dashboard Activated Services and Telehealth for HF (DASH-HF) is a quality improvement initiative to evaluate the effectiveness of proactive population management clinics to optimize use and dosing of GDMT for patients with HFrEF relative to usual care. The study utilizes the existing Veterans Affairs Academic Detailing HF Dashboard to target actionable patients (n=300) with a low optimization potential score (OPS) (Table 1). The intervention clinics utilize multidisciplinary providers (e.g., physicians, pharmacists) to perform chart review and telemedicine visits to address opportunities to optimize GDMT. The primary outcome of the study is the OPS 6 months after the end of the intervention, defined by active prescriptions and prescribed doses for each class of GDMT. Secondary outcomes include differences in hospitalizations and mortality and measures of health service efficiency such as patients contacted per clinic. The intervention duration was September to December 2021, and analysis is planned for June 2022. This is a unique study to systematically identify HFrEF patients with the largest gaps in GDMT and proactively engage with this group. We describe the study design for identifying target patients, logistics of the intervention, patient characteristics, and an overview of barriers faced during the intervention. The Coronavirus disease 2019 pandemic has led to a marked increase in telehealth services. If successful, this study may serve as a key pilot trial for more robust telehealth delivery, targeting patients at highest risk for HF-related hospitalizations and mortality.

PRE-PANDEMIC PREVALENCE AND CONTROL RATES OF HYPERTENSION IN THE USA: NHANES 2017-2020

Background The COVID pandemic has been a major disruptor of preventive health programs. We set out to establish the burden and control rates of hypertension(HTN) at the dawn of this pandemic, providing baseline reference measures for which the impact of the pandemic on HTN prevalence and control rates can be assessed in future. Methods HTN was classified as mean systolic blood pressure (mSBP) ≥130 mmHg or mean diastolic blood pressure (mDBP) ≥80 mmHg or self-reported current use of antihypertensive medications. Hypertensives on medications with mSBP <130 mmHg and mDBP <80 mmHg were considered as well-controlled. Chi-square test was used in subgroup comparisons of HTN prevalence and p-values <0.05 were considered statistically significant. Results The age-adjusted pre-pandemic prevalence of HTN in the US was 52.3% (50.2-54.3). The prevalence was significantly higher in men: 54.7% (51.6-57.8), Non Hispanic Blacks: 64.8%(62.8-66.9), obese: 62.8%(60.8-64.8) and persons aged ≥ 60years: 77.1%(74.3-79.8). The control rate of HTN was 44.2% (42.0-46.5). There was a statistically significant difference in the rate of control across socioeconomic and racial groups. Conclusion About 52% of individuals ≥20 years in the USA were hypertensives and less than half of them on medications were well-controlled. Significant discrepancies exist in the burden and control rates in different subpopulation categories. Our study calls for more screening for HTN during and especially post COVID pandemic. [Formula presented]

Quality of care and in-hospital outcomes of patients hospitalized for heart failure with reduced ejection fraction during the COVID-19 pandemic: Findings from the get with the guidelines-heart failure registry

Introduction: COVID-19's impact on in-hospital care quality and outcomes of patients hospitalized with acute heart failure (HF) has not been systematically evaluated nationally. Methods: Patients hospitalized with HF with ejection fraction (EF) <40% in the AHA GWTG-HF registry during the pandemic (3/1/2020 - 4/1/ 2021) and pre-pandemic (2/1/2019 - 2/29/2020) periods were included. Adherence to HF process of care measures, in-hospital mortality, and length of stay (LOS) were compared in the pre-pandemic vs pandemic period and among hospitalized HF patients with vs without COVID-19 across both periods. Results: 40,005 pre-pandemic and 35,561 pandemic period patients admitted across 346 centers (median age 68, 33% women, 58% White) were included. There were no differences in clinical characteristics, comorbidities, presentation vital signs, or EF during the pandemic vs pre-pandemic periods. Among process of care measures, utilization of guideline-directed medical therapy at discharge was comparable across both periods. In contrast, rates of ICD placement or prescription and blood pressure control at discharge were lower during the pandemic (vs pre-pandemic period) (Table). In-hospital death (2.5% vs. 3.0%, p<0.001) and LOS (mean 5.4 vs. 5.7 days, p=0.008) were higher during the pandemic vs pre-pandemic. Substantial geographic variation was seen in the inhospital death rates during the pandemic, with highest rates among patients hospitalized in the Northeast region (3.36%). Among HF patients hospitalized during the pandemic with COVID-19 (N = 527 [1.5%]), adherence to ICD placement or prescription at discharge and prescription of aldosterone antagonist or ACE/ARB/ARNi were lower, and risk of in-hospital death and length of stay were significantly higher than those without COVID-19. Conclusion: In-hospital mortality and adherence to certain quality measures worsened during COVID-19 pandemic among patients admitted for acute decompensated HFrEF.