Elsevier

American Heart Journal

Volume 158, Issue 4, October 2009, Pages 644-652
American Heart Journal

Clinical Investigation
Congestive Heart Failure
Characteristics and in-hospital outcomes for nonadherent patients with heart failure: Findings from Get With The Guidelines-Heart Failure (GWTG-HF)

https://doi.org/10.1016/j.ahj.2009.07.034Get rights and content

Background

Medication and dietary nonadherence are precipitating factors for heart failure (HF) hospitalization; however, the characteristics, outcomes, and quality of care of patients with nonadherence are unknown. Recognizing features of nonadherent patients may provide a means to reduce rehospitalization for this population.

Methods

GWTG-HF registry data were collected from 236 hospitals and 54,322 patients from January 1, 2005 to December 30, 2007. Demographics, clinical characteristics, in-hospital outcomes, and quality of care were stratified by precipitating factor for HF admission. Multivariate logistic regression analysis was used to determine the association of nonadherence with length of stay (LOS) and in-hospital mortality.

Results

Clinicians documented dietary and/or medication nonadherence as the reason for admission in 5576 (10.3%) of HF hospitalizations. Nonadherent patients were younger and more likely to be male, minority, uninsured, and have nonischemic HF. These patients had lower ejection fractions (34.9% vs 39.6%, P < .0001), more frequent previous HF hospitalizations, higher brain natriuretic peptide levels (1813 vs 1371 pg/mL, P < .0001), and presented with greater signs of congestion. Despite this, nonadherent patients had shorter LOS (odds ratio 0.94, 95% CI 0.92-0.97) and lower in-hospital mortality (odds ratio 0.65, 95% CI 0.51-0.83) in multivariate analysis. Although nonadherent patients received high rates of Joint Commission core measures, rates of other evidence-based treatments were less optimal.

Conclusions

Nonadherence is a common precipitant for HF admission. Despite a higher risk profile, nonadherent patients had lower in-hospital mortality and LOS, suggesting that it may be easier to stabilize nonadherent patients by reinstituting sodium and/or fluid restriction and resuming medical therapy.

Section snippets

Methods

The GWTG-HF program is overseen by the American Heart Association and is an ongoing, prospective observational data collection and quality improvement initiative.7 Hospitals participating in this registry include institutions from all regions of the United States and represent community hospitals as well as tertiary referral centers. Trained individuals at each site submitted clinical information regarding medical history, hospital care, and outcomes for consecutive patients hospitalized for HF

Results

A total of 95,127 patients were identified among 333 hospitals from January 1, 2005 to December 30, 2007. Ninety-seven hospitals either did not provide information with regard to the precipitating cause of HF or had a high missing rate (>25%) on reporting patient medical history; thus, 32,495 patients were excluded. In addition, 8,310 patients were admitted with a first time diagnosis of HF and were also excluded. The final analysis cohort included 54,322 patients from 236 hospitals. Clinicians

Discussion

We investigated a broad cohort of US patients admitted with acute decompensated HF to evaluate the influence of nonadherence on quality of care and outcomes. This study has 3 main findings. First, nonadherence is a common precipitant for HF admission, and such patients are sociodemographically disadvantaged relative to patients without nonadherence. In addition, medication nonadherence was more commonly noted among younger patients, ethnic minorities, and the uninsured, whereas dietary

Conclusions

Among GWTG-HF hospitals, patients with nonadherence as a factor for HF hospitalization tended to be younger and more sociodemographically disadvantaged. Despite evidence of greater volume overload and lower EF, this population had better in-hospital outcomes. This lower risk-adjusted mortality and LOS suggests that it may be easier to stabilize nonadherent patients by reinstituting sodium and/or fluid restriction and resuming appropriate medical therapy. Patients with nonadherence were equally

Disclosures

Dr Fonarow reports receiving research grants and honoraria from GlaxoSmithKline and Medtronic and serves as a consultant for GlaxoSmithKline, Medtronic, and Novartis. He serves as chair of the American Heart Association’s Get With the Guidelines Steering Committee. He is supported by the Ahmanson and Elliot Corday Foundations. Dr Hernandez reports receiving research grants from Scios, Medtronic, GlaxoSmithKline, and Roche Diagnostics and has served on the speaker’s bureau or has received

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Dr. Hernandez received American Heart Association Pharmaceutical Roundtable grant 0675060N.

Jack V. Tu, MD, PhD served as guest editor on this manuscript.

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