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Reasons for Guideline Nonadherence at Heart Failure Discharge
BACKGROUND: Cardiology has advanced guideline development and quality measurement. Recognizing the substantial benefits of guideline‐directed medical therapy, this study aims to measure and explain apparent deviations in heart failure (HF) guideline adherence by clinicians at hospital discharge and...
Autores principales: | , , , , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
John Wiley and Sons Inc.
2018
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6201460/ https://www.ncbi.nlm.nih.gov/pubmed/30371240 http://dx.doi.org/10.1161/JAHA.118.008789 |
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author | Gilstrap, Lauren G. Stevenson, Lynne W. Small, Roy Parambi, Ron Hamershock, Rose Greenberg, Jeffrey Carr, Christina Ghazinouri, Roya Rathman, Lisa Han, Elizabeth Mehra, Mandeep R. Desai, Akshay S. |
author_facet | Gilstrap, Lauren G. Stevenson, Lynne W. Small, Roy Parambi, Ron Hamershock, Rose Greenberg, Jeffrey Carr, Christina Ghazinouri, Roya Rathman, Lisa Han, Elizabeth Mehra, Mandeep R. Desai, Akshay S. |
author_sort | Gilstrap, Lauren G. |
collection | PubMed |
description | BACKGROUND: Cardiology has advanced guideline development and quality measurement. Recognizing the substantial benefits of guideline‐directed medical therapy, this study aims to measure and explain apparent deviations in heart failure (HF) guideline adherence by clinicians at hospital discharge and describe any impact on readmission rates. METHODS AND RESULTS: The extent of decongestion and prescription of neurohormonal therapy were recorded prospectively for 226 HF discharges, including 132 (58%) from an academic hospital and 94 (42%) from a community hospital. Among all discharges, 25% were discharged with residual congestion (30% academic versus 18% community, P=0.070). Among discharges of patients with HF with reduced ejection fraction, 37% (45% academic versus 18% community, P<0.001) were discharged without β‐blocker therapy or with lower doses than at admission. Moreover, 46% of patients with HF with reduced ejection fraction (48% academic versus 39% community, P=0.390) were discharged without an angiotensin‐converting enzyme inhibitor or angiotensin II receptor blocker or with lower doses than at admission. Renal dysfunction was the most common reason for discharge with congestion, and hypotension the most common reason for discharge with no or decreased neurohormonal therapy. There was a trend toward higher 90‐day readmission rates after discharge with residual congestion. CONCLUSIONS: Clinicians frequently deviate from guidelines in both academic and community hospitals; however, this deviation may not always indicate poor quality. Application of guidelines recommended for stable populations is increasingly limited for hospitalized patients by hypotension, renal dysfunction, and inotrope use. Patients with renal dysfunction, hypotension, and recent inotrope use merit further study to determine best practices and possibly to adjust quality metrics for HF severity. |
format | Online Article Text |
id | pubmed-6201460 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2018 |
publisher | John Wiley and Sons Inc. |
record_format | MEDLINE/PubMed |
spelling | pubmed-62014602018-10-31 Reasons for Guideline Nonadherence at Heart Failure Discharge Gilstrap, Lauren G. Stevenson, Lynne W. Small, Roy Parambi, Ron Hamershock, Rose Greenberg, Jeffrey Carr, Christina Ghazinouri, Roya Rathman, Lisa Han, Elizabeth Mehra, Mandeep R. Desai, Akshay S. J Am Heart Assoc Original Research BACKGROUND: Cardiology has advanced guideline development and quality measurement. Recognizing the substantial benefits of guideline‐directed medical therapy, this study aims to measure and explain apparent deviations in heart failure (HF) guideline adherence by clinicians at hospital discharge and describe any impact on readmission rates. METHODS AND RESULTS: The extent of decongestion and prescription of neurohormonal therapy were recorded prospectively for 226 HF discharges, including 132 (58%) from an academic hospital and 94 (42%) from a community hospital. Among all discharges, 25% were discharged with residual congestion (30% academic versus 18% community, P=0.070). Among discharges of patients with HF with reduced ejection fraction, 37% (45% academic versus 18% community, P<0.001) were discharged without β‐blocker therapy or with lower doses than at admission. Moreover, 46% of patients with HF with reduced ejection fraction (48% academic versus 39% community, P=0.390) were discharged without an angiotensin‐converting enzyme inhibitor or angiotensin II receptor blocker or with lower doses than at admission. Renal dysfunction was the most common reason for discharge with congestion, and hypotension the most common reason for discharge with no or decreased neurohormonal therapy. There was a trend toward higher 90‐day readmission rates after discharge with residual congestion. CONCLUSIONS: Clinicians frequently deviate from guidelines in both academic and community hospitals; however, this deviation may not always indicate poor quality. Application of guidelines recommended for stable populations is increasingly limited for hospitalized patients by hypotension, renal dysfunction, and inotrope use. Patients with renal dysfunction, hypotension, and recent inotrope use merit further study to determine best practices and possibly to adjust quality metrics for HF severity. John Wiley and Sons Inc. 2018-07-31 /pmc/articles/PMC6201460/ /pubmed/30371240 http://dx.doi.org/10.1161/JAHA.118.008789 Text en © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made. |
spellingShingle | Original Research Gilstrap, Lauren G. Stevenson, Lynne W. Small, Roy Parambi, Ron Hamershock, Rose Greenberg, Jeffrey Carr, Christina Ghazinouri, Roya Rathman, Lisa Han, Elizabeth Mehra, Mandeep R. Desai, Akshay S. Reasons for Guideline Nonadherence at Heart Failure Discharge |
title | Reasons for Guideline Nonadherence at Heart Failure Discharge |
title_full | Reasons for Guideline Nonadherence at Heart Failure Discharge |
title_fullStr | Reasons for Guideline Nonadherence at Heart Failure Discharge |
title_full_unstemmed | Reasons for Guideline Nonadherence at Heart Failure Discharge |
title_short | Reasons for Guideline Nonadherence at Heart Failure Discharge |
title_sort | reasons for guideline nonadherence at heart failure discharge |
topic | Original Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6201460/ https://www.ncbi.nlm.nih.gov/pubmed/30371240 http://dx.doi.org/10.1161/JAHA.118.008789 |
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