Costs associated with unplanned readmissions among patients with heart failure with and without hyponatremia.

PURPOSE: Costs associated with unplanned readmissions among patients with heart failure with and without hyponatremia were studied. METHODS: This study estimated the costs of patients hospitalized for heart failure (HF) discharged with or without corrected sodium. A model was developed to monetize the 30-day readmission risk based on hyponatremia correction. Costs of discharging patient with corrected versus uncorrected hyponatremia were estimated using readmission rates from a previously published study and hospitalization costs from the Healthcare Costs and Utilization Cost Project and the Premier Healthcare Database. RESULTS: Discharging patients with HF and hyponatremia increased costs from $488-$569 per discharge compared to patients with corrected hyponatremia. This range reflected differences in readmission rates and sources of hospitalization costs. Sensitivity analyses showed hospitalization costs and readmission rates had the largest impact on model results. CONCLUSION: A retrospective study supports the value of upfront monitoring and correction of low serum sodium levels before discharge among patients with HF and hyponatremia by presenting an economic argument in addition to the clinical rational for reducing risk of readmission.

Economic impact of tolvaptan treatment vs. fluid restriction based on real-world data among hospitalized patients with heart failure and hyponatremia.

OBJECTIVES: To estimate the cost difference associated with tolvaptan treatment vs. fluid restriction (FR) among hospitalized patients with heart failure (HF) and hyponatremia (HN) based on a real-world registry of HN patients. METHODS: An Excel-based economic model was developed to evaluate the cost impact of tolvaptan treatment vs. FR. Model input for hospital length of stay (LOS) was based on published data from the Hyponatremia Registry (HNR). Based on HNR data, tolvaptan-treated patients had a 2-day (median) shorter LOS compared to FR. Real-world effectiveness of tolvaptan treatment from the HNR was applied to a national sample of inpatients visits from the Premier Hospital database to estimate the potential LOS-related cost difference between tolvaptan treatment and FR. A one-way sensitivity and multivariable Monte Carlo sensitivity analysis were conducted. RESULTS: Economic modeling results of the base-case analysis indicated that among hospitalized patients with HF, the hospital cost per admission, not including HN drug cost, was $3453 lower among patients treated with tolvaptan vs. FR, due to the shorter LOS associated with tolvaptan treatment. At wholesale acquisition cost of $362 per day and an average treatment duration of 3.2 days, the pharmacy cost of tolvaptan treatment per admission was estimated at $1157. Thus, after factoring the decrease in hospital medical costs and increase in pharmacy costs associated with tolvaptan treatment, results indicated a cost-offset opportunity of -$2296 per admission for patients treated with tolvaptan versus FR. Results of the sensitivity analyses were consistent with the base-case analysis. LIMITATIONS: The model derives inputs from real-world observational data. No causal relationship can be inferred from this analysis. CONCLUSIONS: Based on this economic analysis, tolvaptan treatment vs. FR among hospitalized patients with HF and HN may be associated with lower hospital-related costs, which offset the increase in pharmacy costs associated with tolvaptan treatment.

Utilization and budget impact of tolvaptan in the inpatient setting among patients with heart failure and hyponatremia.

OBJECTIVE: Assess characteristics of patients with heart failure (HF) and hyponatremia (HN) using tolvaptan, a selective vasopressin V2-receptor antagonist, for sodium correction, and estimate the budget impact of tolvaptan use in a hospital. METHODS: The Premier hospital database was analyzed to assess the utilization of tolvaptan, characteristics of users and non-users, and hospitalization costs among patients with HF and HN. Using these findings, a model was developed to estimate tolvaptan costs in proportion to total medical costs of managing patients with HF and HN, and the budget impact of tolvaptan use. Results were regenerated using data from the Healthcare Cost and Utilization Project (HCUP) database, and robustness was assessed in sensitivity analyses. RESULTS: Tolvaptan was used in 4.96% of inpatient visits among patients with HF and HN, more commonly among sicker patients as reflected in high utilization during intensive care stays (30.46%). Additionally, utilization increased by length of stay, which can serve as a proxy for disease severity. The model estimated that tolvaptan costs accounted for 0.3% of total hospitalization-related costs for patients with HF and HN, and the budget impact was $52.42 per visit. CONCLUSIONS: Results demonstrate that tolvaptan is used infrequently among patients with HF and HN, and is utilized among sicker patients. Tolvaptan accounted for 0.3% of total spending on management of inpatient visits with HF and HN, and had a marginal impact on hospital budget when compared with fluid restriction for HN correction. Availability of tolvaptan can provide an additional therapeutic option for sodium correction.

Current Management of Hyponatremia in Acute Heart Failure: A Report From the Hyponatremia Registry for Patients With Euvolemic and Hypervolemic Hyponatremia (HN Registry).

BACKGROUND: Hyponatremia (HN) occurs commonly in patients with acute heart failure and confers a worse prognosis. Current HN treatment varies widely, with no consensus. This study recorded treatment practices currently used for patients hospitalized with acute heart failure and HN. METHODS AND RESULTS: Data were collected prospectively from 146 US sites on patients hospitalized with acute heart failure and HN (serum sodium concentration [Na+] ≤130 mEq/L) present at admission or developing in the hospital. Baseline variables, HN treatment, and laboratory values were recorded. Of 762 patients, median [Na+] was 126 mEq/L (interquartile range, 7) at baseline and increased to 130 mEq/L at discharge. Fluid restriction was the most commonly prescribed therapy (44%), followed by no specific HN treatment beyond therapy for congestion (23%), isotonic saline (5%), tolvaptan (4%), and hypertonic saline (2%). Median rate of change in [Na+] varied by treatment (0.5 [interquartile range, 1.0] to 2.3 [8.0] mEq/L/d) and median treatment duration ranged from 1 (interquartile range, 1) to 6 (5) days. Fluid restriction and no specific HN treatment resulted in similar changes in [Na+], and were least effective in correcting HN. Few patients (19%) had [Na+] ≥135 mEq/L at discharge. CONCLUSIONS: The most commonly used treatment approaches for HN (fluid restriction and no specific treatment) in acute heart failure increased [Na+] minimally, and most patients remained hyponatremic at discharge.

Management of hyponatremia in heart failure: role of tolvaptan.

BACKGROUND: Asymptomatic or clinically mild hyponatremia commonly occurs in the setting of heart failure, especially among elderly and severely decompensated, fluid-overloaded patients, and is associated with increased morbidity and mortality. Successful detection and treatment of hyponatremia by cardiovascular and advanced practice nurses caring for patients with heart failure are part of multidisciplinary team care. Nurses should be able to detect signs and symptoms of hyponatremia and, even when patients are asymptomatic, initiate appropriate treatment promptly to prevent complications. PURPOSE: In this review, the epidemiology and pathophysiology of hyponatremia in heart failure, and signs and symptoms are described. In patients with heart failure, challenges involved in determining the type of hyponatremia (hypervolemic, hypovolemic, or euvolemic) and in correctly managing hyponatremia to prevent serious complications are presented. Conventional treatment options and their limitations are reviewed, and the vasopressin-receptor antagonist tolvaptan, an emerging oral therapy option, is introduced and discussed. CONCLUSIONS: Hyponatremia is a marker of morbidity and mortality in patients with heart failure. Nurses working collaboratively with other healthcare providers must be able to recognize the condition and understand treatment options, including potential adverse effects of current and emerging therapies. One emerging therapy--tolvaptan--can be used in hypervolemic and euvolemic hyponatremic patients with heart failure to correct serum sodium level without negatively affecting renal function. CLINICAL IMPLICATIONS: Improved nurse understanding of hyponatremia in patients with heart failure may promote nurse-initiated or nurse-facilitated detection and management, which could decrease mortality and morbidity.

Anticholinergic medications for managing noisy respirations in adult hospice patients.

PURPOSE: Anticholinergic medications for reducing noisy respirations in adult hospice patients are evaluated. SUMMARY: Anticholinergic medications used to reduce noisy respirations from retained secretions in terminal patients include atropine, glycopyrrolate, scopolamine, and scopolamine derivatives. Pharmaceutical anticholinergic treatment of retained secretions in hospice patients was evaluated in six studies, three of which compared the efficacy of glycopyrrolate to scopolamine in actively dying patients. Subcutaneous glycopyrrolate, scopolamine hydrobromide, and scopolamine butylbromide were similar in their ability to reduce noisy respirations overall and lower and the level of distress exhibited by family members and visitors. Two of the six studies compared the efficacy of medication therapy after institutional formulary changes from scopolamine to glycopyrrolate. The same dosages of subcutaneous glycopyrrolate and scopolamine, which delivered an initial bolus followed by continuous infusion, were reported in each study. Both studies concluded that there was equivalent efficacy between the two products. One study reported a more rapid response in patients treated with glycopyrrolate. In comparison, the last study reported more rapid responses in patients who received scopolamine compared with patients who received glycopyrrolate. Retrospective reports described symptom improvement with parenteral scopolamine in most patients. CONCLUSION: Parenteral and transdermal anticholinergic medications are useful for the reduction of noisy respirations in hospitalized hospice patients. Difficult administration makes oral and sublingual products less desirable for use in this population.

Increased risk of metabolic syndrome, diabetes mellitus, and cardiovascular disease in men receiving androgen deprivation therapy for prostate cancer.

Prostate cancer is the leading cancer diagnosis and second leading cause of cancer-related mortality for men in the United States. Due to the increased prevalence of prostate cancer in men older than 50 years, men at risk for prostate cancer represent the same population of men who are at greatest risk for metabolic syndrome, diabetes mellitus, and coronary artery disease (CAD). In addition to risk factors for CAD that are applicable to the general population, men with prostate cancer can be at increased risk for CAD due to long-term androgen deprivation therapy (ADT) administered as treatment for prostate cancer. Men undergo ADT by medical (drug therapy) or surgical (castration) means. Luteinizing hormone-releasing hormone (LHRH) agonists are the primary drug therapies used for ADT. Commercially available LHRH agonists are goserelin, histrelin, leuprolide, and triptorelin. Body composition changes, hyperlipidemia, insulin resistance, metabolic syndrome, and acute coronary syndrome are all reported adverse effects of ADT, which are consequences of reduced levels of circulating testosterone. Metabolic and body composition changes associated with ADT arise within months of beginning medical ADT and persist after discontinuation of therapy. To better understand the increased risk of metabolic syndrome, diabetes, and heart disease in patients undergoing ADT for prostate cancer, we performed a MEDLINE search (1986-2008) to identify pertinent studies and reports. Additional citations were obtained from the articles retrieved from the literature search. We found that the increased risk for serious cardiovascular disease becomes evident within months of beginning ADT. Pharmacists should provide counseling to these patients on primary disease prevention. Men receiving ADT should be monitored routinely for signs and symptoms of metabolic syndrome, diabetes, and CAD. Healthy lifestyle practices should be encouraged, and physical therapy should be considered for these patients.

Clinical and economic implications of new strategies for heart failure management in the managed care setting.

Clinical pharmacists in all settings see a large number of patients with heart failure, many of whom are Medicare recipients. Clinical studies have identified appropriate drug therapy for patients with heart failure, and several professional organizations have compiled excellent guidelines. Regardless, many patients are not benefiting from treatment with drugs proven to help reduce morbidity and mortality. Following the evidence-based or consensus guidelines can reduce morbidity, mortality, and costs associated with heart failure.