Building a Heart Failure Clinic: A Practical Guide from the Heart Failure Society of America.

Heart failure (HF) remains a leading cause of mortality and morbidity and a primary driver of health care resource use in the United States. As such, there continues to be much interest in the development and refinement of HF clinics that manage patients with HF in a guideline-directed, technology-enabled, and coordinated approach. Optimization of resource use and maintenance of collaboration with other providers are also important themes when considering implementation of HF clinics. Through this document, the Heart Failure Society of America aims to provide a contemporary, practical guide to creating and sustaining a HF clinic. The guide discusses (1) patient care considerations for delivering guideline-directed and patient-centered care, and (2) operational considerations including development of a HF clinic business plan, setting goals, leadership support, triggers for patient referral and patient follow-up, patient population served, optimal clinic staffing models, relationships with subspecialists, and continuous quality improvement. This document was developed to empower providers and clinicians who wish to build and sustain community-based, successful HF clinics.

Drug discount cards in an era of higher prescription drug prices: A retrospective population-based study.

OBJECTIVES: Drug discount programs have emerged as a potential option for patients seeking greater accessibility and affordability. However, there is limited knowledge regarding program utilization and cost savings. The objective of this study was to evaluate medication prescriptions with drug discount card usage and estimate cost savings. DESIGN: Retrospective study. SETTING AND PARTICIPANTS: Using population-based prescription data, the study included patients who filled prescriptions from January 2009 to December 2016 nationwide using NeedyMeds.org drug discount cards. OUTCOME MEASURES: We determined the frequency of drug discount card prescriptions (across pharmacy types, pharmacy location, and prescriber specialty), estimated cost savings using the drug discount card (average per drug discount card and total program dollars saved) and evaluated the top prescription drugs by frequency. RESULTS: A total of 4,638,581 prescriptions with discount cards were identified (79.8% at national, 6.3% at regional, and 12.9% at local pharmacies). Most were filled at urban locations (urban clusters, 88.6%; urbanized areas, 8.4%) and in ZIP codes with lower median household incomes (62.7%). Overall, 3.62 million prescriptions (78.0% of the total) were associated with discounts, resulting in a total savings of $199,183,112 (median cost savings, $17.80 [47.8%] per prescription). Opiates were the most common class of drugs for which discount cards were used. CONCLUSION: The use of a drug discount program over 8 years resulted in total savings of nearly $200 million (approximately $18 per prescription) compared with the original cost. However, although patients might accrue financial benefit, there is still a lack of price transparency. Additional research is needed to better understand the impact of these programs and to evaluate ways to improve medication access at a reasonable cost to patients.

Current treatment practice and outcomes. Report of the hyponatremia registry.

Current management practices for hyponatremia (HN) are incompletely understood. The HN Registry has recorded diagnostic measures, utilization, efficacy, and outcomes of therapy for eu- or hypervolemic HN. To better understand current practices, we analyzed data from 3087 adjudicated adult patients in the registry with serum sodium concentration of 130 mEq/l or less from 225 sites in the United States and European Union. Common initial monotherapy treatments were fluid restriction (35%), administration of isotonic (15%) or hypertonic saline (2%), and tolvaptan (5%); 17% received no active agent. Median (interquartile range) mEq/l serum sodium increases during the first day were as follows: no treatment, 1.0 (0.0-4.0); fluid restriction, 2.0 (0.0-4.0); isotonic saline, 3.0 (0.0-5.0); hypertonic saline, 5.0 (1.0-9.0); and tolvaptan, 4.0 (2.0-9.0). Adjusting for initial serum sodium concentration with logistic regression, the relative likelihoods for correction by 5 mEq/l or more (referent, fluid restriction) were 1.60 for hypertonic saline and 2.55 for tolvaptan. At discharge, serum sodium concentration was under 135 mEq/l in 78% of patients and 130 mEq/l or less in 49%. Overly rapid correction occurred in 7.9%. Thus, initial HN treatment often uses maneuvers of limited efficacy. Despite an association with poor outcomes and availability of effective therapy, most patients with HN are discharged from hospital still hyponatremic. Studies to assess short- and long-term benefits of correction of HN with effective therapies are needed.

Heart failure is a major contributor to hospital readmission penalties.

BACKGROUND: The Hospital Readmissions Reduction Program provides incentives to hospitals to reduce early readmissions for heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PNE). METHODS AND RESULTS: To examine the contribution of each diagnosis to readmissions penalty size, data were obtained from the Center for Medicare and Medicaid Services, American Hospital Association, and United States Census Bureau including number of cases; readmissions payment adjustment factor (values <1 indicate a penalty for excess readmissions), excess readmission ratio (ERR, or ratio of adjusted predicted readmission based on comorbidities, frailty, and individual patient demographics to expected probability of readmission at an average hospital) for each diagnosis, hospital teaching status, bed number, and zip code socioeconomic status. Of 2,228 hospitals with ≥25 cases per diagnosis, 1,636 received a penalty. Univariate correlation coefficients between penalty and ERR were -0.66, -0.61, and -0.43 for HF, PNE, and AMI, respectively (all P < .001). Correlation between ERRs was greatest for PNE and HF (0.30; P < .001) and weakest for PNE and AMI (0.12; P < .001). In regression analyses, the HF ERR explained the most variance in the penalty (R(2) range 0.21-0.44). CONCLUSION: HF ERR, not the number of cases, was related to penalty magnitude. These findings have implications for the design of hospital-based quality initiatives regarding readmissions.

Micronutrient Deficiencies in Patients With Heart Failure: Relationships With Body Mass Index and Age.

BACKGROUND: It is conceivable that lean patients (body mass index 18.5-24.9 kg/m(2)) with heart failure (HF) have low body weight due to low food consumption and that this may contribute to micronutrient deficiencies and to their poorer prognosis compared with overweight/obese patients. We hypothesized that lean patients have a greater number of inadequate micronutrient intakes (<50% of recommendations) than overweight/obese patients and that this also depends on age. METHODS AND RESULTS: Lean (n = 15) and overweight/obese (n = 49) patients underwent 24-hour diet and physical activity recall interviews. Inadequate essential micronutrient intakes were ubiquitous (intakes of 13 ± 1 of 27 micronutrients were inadequate) and did not depend on race, status, or access to supermarkets. Younger (40-64 y) lean patients had inadequate intakes of 20 ± 2 micronutrients, which was more than the other weight/age subgroups (all P < .01). Physical activity levels did not differ across weight and age groups. CONCLUSIONS: Patients with HF may be at risk of malnutrition due to numerous inadequate micronutrient intakes; younger lean patients may have an especially high risk. Future studies are needed to confirm these preliminary findings and to investigate the possibility that incorporating a micronutrient-dense meal plan will improve patient outcomes.

Autonomic Modulation in Heart Failure: Ready for Prime Time?

It has been known for many decades that multiple abnormalities of the autonomic nervous system (ANS) are present in heart failure (HF). Moreover, many of the effective therapies currently used to treat HF have either direct or indirect effects on the ANS. While therapies that block over-activity of the sympathetic nervous system are now standard of care, much less well studied are therapies aimed at augmenting the parasympathetic nervous system. This review will cover recent and ongoing investigations targeting modulation of the ANS, especially highlighting new and ongoing studies directed toward augmenting parasympathetic mechanisms.

Arrhythmias in a long-term adult survivor with uncorrected tetralogy of Fallot: Case report and review of the literature.

We present a case of a middle-aged adult with uncorrected Tetralogy of Fallot (TOF) with pulmonary atresia who developed symptomatic supraventricular and ventricular arrhythmias. The lack of data regarding management of electrical and other complications in adults with uncorrected TOF is highlighted and emphasizes the need for a registry to better understand the medical management of long-standing adult survivors.