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Background: We aim to examine the association between primary care physicians' billing of Q050A, a pay-for-performance heart failure (HF) management incentive fee code, and the composite outcome of mortality, hospitalization, and emergency department visits., Methods and Results: This population-based cohort study linked administrative health databases in Ontario, Canada, for patients with HF aged >66 years between January 1, 2008, and March 31, 2020. Cases were patients with HF who had a Q050A fee code billed. Cases and controls were matched 1:1 on age, sex, patient status on being rostered to a primary care physician, cardiologist, or internist visit in the 6 months before study enrollment, Johns Hopkins Adjusted Clinical Group resource use bands, days between HF diagnosis and study enrollment (±2 years), and the logit of the propensity score. A Cox proportional hazards model assessed the association of Q050A with the outcome. A total of 59 664 cases had a Q050A billed, whereas 244 883 patients did not. Before matching, patients who had a Q050A billed were more likely to be men (52% versus 49%), were rostered to a primary care physician (100% versus 96%), had a higher Charlson Comorbidity Index, and had higher health care costs. The mean follow-up was 481 days for cases and 530 days for controls. The composite outcome (hazard ratio, 1.11 [95% CI, 1.09-1.12]) was significantly higher for cases than controls., Conclusions: The Q050A incentive improved financial compensation for primary care physicians managing patients with HF but was not associated with improvements in the outcome. Research on promoting evidence-based HF management is warranted.

Costs of end of life care for patients who have advanced heart failure (HF) are increasing. There is a perception that many of these patients receive aggressive treatments near the end of life. However, actual patterns of care are unclear. In this article we describe the use of life-sustaining treatments and the timing of goals of care discussions during patients' terminal admission for HF. We conducted a single-centre retrospective cohort study of patients aged 18 years or older with a most responsible discharge diagnosis of HF who died between April 2012 and December 2013. We identified 133 eligible decedents of whom 67 (50%) received some form of life-sustaining treatment, although only 14 (11%) received cardiopulmonary resuscitation (CPR). The first documented orders for scope of treatment were: CPR for 39 (29%), active medical treatment with no CPR for 81 (61%), and comfort care with no CPR for 11 (8%) patients. The last documented orders were for comfort care in 85 (64%) patients. There were 28 (21%) patients who received palliative care consultation. Median time between palliative care consultation and death was 6 days and between orders for comfort care and death was 24 hours. In contrast to the high mortality risk of our study cohort, palliative care consultation was often absent or in the final days of life, with orders for comfort-oriented care being written only 24 hours before death, suggesting there remain opportunities for earlier integration of palliative and goal-directed approaches to therapy for patients who have advanced HF., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Conversations about goals of care in hospital are important to patients who have advanced heart failure (HF)., Methods: We conducted a multicenter survey of cardiology nurses, fellows, and cardiologists at 8 Canadian teaching hospitals. The primary outcome was the importance of barriers to goals-of-care discussions in hospital (1 = extremely unimportant; 7 = extremely important). We also elicited perspectives on roles of different practitioners in having these conversations., Results: Questionnaires were returned by 770/1024 (75.2%) eligible clinicians. The most important perceived barriers were: family members' and patients' difficulty in accepting a poor prognosis (mean [SD] score 5.9 [1.1] and 5.7 [1.2], respectively), family members' and patients' lack of understanding about the limitations and harms of life-sustaining treatments (5.8 [1.1] and 5.7 [1.2], respectively), and lack of agreement among family members about goals of care (5.8 [1.2]). Interprofessional team members were viewed as having different but important roles in goals-of-care discussions., Conclusions: Cardiology clinicians perceive family and patient-related factors as the most important barriers to goals-of-care discussions in hospital. Many members of the interprofessional team were viewed as having important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication about goals of care in advanced HF., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Cardiac troponins (cTn) may be elevated among patients with acute heart failure syndromes (AHFS). However, the optimal approach to management of AHFS with elevated cTn is unknown., Methods and Results: We compared the care and outcomes of 13 656 patients with AHFS seeking care in the emergency department stratified by presence (cTn+, n=1845, 13.5%) or absence (cTn-) of elevated troponin. Clinically abstracted data on patients who were admitted or discharged from the emergency department in Ontario, Canada (April 1999 to March 2001 and April 2004 to March 2007) were examined. In an exploratory 2:1 propensity-matched analysis, we examined whether early coronary revascularization (within 14 days of emergency department visit) was associated with survival, stratified by cTn status. For cTn+ AHFS, rates of coronary angiography (21.8 vs 11.4 patients/100 person-years; P<0.001) and coronary revascularization (8.8 vs 3.2 patients/100 person-years; P<0.001) were higher than cTn-. Instantaneous 30-day adjusted hazard ratios for cTn+ versus cTn- patients were 9.17 (95% confidence interval [CI], 8.31-10.12; P<0.001) for death, 5.14 (95% CI, 4.66-5.67; P<0.001) for cardiovascular readmission, and 13.08 (95% CI, 10.95-15.62; P<0.001) for ischemic heart disease hospitalization. In propensity-matched analysis of 143 individuals with cTn+ AHFS, early coronary revascularization was associated with reduced mortality (adjusted hazard ratio, 0.29; 95% CI, 0.09-0.92; P=0.036) compared with those who were not revascularized. Mortality was not significantly reduced among 210 cTn- patients undergoing early coronary revascularization (adjusted hazard ratio, 0.61; 95% CI, 0.36-1.03; P=0.065)., Conclusions: Elevated cTn was associated with increased risk of death and cardiovascular hospitalizations. Highly selected cTn+ patients who underwent early coronary revascularization for obstructive coronary artery disease experienced improved survival.

Background: The type of outpatient physician care after an emergency department visit for heart failure may affect patients' outcomes., Methods and Results: Using the National Ambulatory Care Reporting System, we examined the care and outcomes of heart failure patients who visited and were discharged from the emergency department in Ontario, Canada (April 2004 to March 2007). Early collaborative care by a cardiologist and primary care (PC) physician within 30 days after discharge was compared with PC alone. Care for 10 599 patients (age, 74.9±11.9 years; 50.2% male) was provided by PC alone (n=6596), cardiologist alone (n=535), or concurrently by both cardiologist and PC (n=1478); 1990 did not visit a physician. Collaborative care patients were more likely to undergo assessment of left ventricular function (57.4% versus 28.7%), noninvasive stress testing (20.1% versus 7.8%), and cardiac catheterization (11.6% versus 2.7%) compared with PC. Drug prescriptions (patients ≥65 years of age) demonstrated higher use of angiotensin-converting enzyme inhibitors (58.8% versus 54.6%), angiotensin receptor blockers (22.7% versus 18.1%), β-adrenoceptor antagonists (63.4% versus 48.0%), loop diuretics (84.2% versus 79.6%), metolazone (4.8% versus 3.4%), and spironolactone (19.8% versus 12.7%) within 100 days after emergency department discharge for collaborative care compared with PC. In a propensity-matched model, mortality was lower with PC compared with no physician visit (hazard ratio, 0.75; 95% confidence interval, 0.64 to 0.87; P<0.001). Collaborative care reduced mortality compared with PC (hazard ratio, 0.79; 95% confidence interval, 0.63 to 1.00; P=0.045). Sole cardiology care conferred a trend to increased mortality (hazard ratio, 1.41 versus collaborative care; 95% confidence interval, 0.98 to 2.03; P=0.067)., Conclusions: Early collaborative heart failure care was associated with increased use of drug therapies and cardiovascular diagnostic tests and better outcomes compared with PC alone.

Background: An understanding of the life expectancy of patients with heart failure (HF) may assist in difficult treatment decisions such as placement of an implantable cardioverter-defibrillator or initiation of end-of-life care. However, previous studies have focused on predicting shorter-term mortality and limited data currently exist to predict expected survival among hospitalized patients with HF., Methods: We studied 9943 patients who were newly hospitalized with HF between 1999 and 2001 in Ontario, Canada. Median survival was calculated using survival analysis and stratified by baseline characteristics and the EFFECT HF risk score. These analyses were repeated for the 1467 patients who had left ventricular ejection fraction of < or = 30%., Results: The average age of our HF cohort was 75.8 years and 50.4% of the patients were female. After a median follow-up of 6 years, hospitalized patients with HF had a 5-year mortality rate of 68.7% and a median survival of 2.4 years. Mortality varied substantially across risk groups such that median survival was only 8 months for patients in the high-risk group and only 3 months in the very high risk group. Similarly, among patients with depressed left ventricular ejection fraction, median survival was only 6 and 3 months in the high- and very high risk groups, respectively., Conclusions: Prognostic estimations using median survival may improve the ability of physicians to identify subgroups of patients with HF who have limited life expectancy. This information may assist in communicating prognostic information and guiding difficult treatment decisions among hospitalized patients with HF.

Background: Troponin level elevations are common in patients with acute decompensated heart failure (ADHF), yet their prognostic value above and beyond traditional predictors of outcomes in heart failure is uncertain., Methods: In the EFFECT study, we determined the association between cardiac troponin I and all-cause mortality in 2025 patients hospitalized for heart failure in Ontario, Canada, between April 1, 1999, and March 31, 2001., Results: Cardiac troponin I levels >0.5 microg/L (median 1.7 microg/L, interquartile range 0.9-4.8 microg/L) occurred in 699 (34.5%) patients and was an independent predictor of mortality (adjusted hazard ratio 1.49, 95% CI 1.25-1.77, P < .001). Furthermore, we observed a dose-response relationship between cardiac troponin I and mortality that persisted after adjustment for potential confounding factors (adjusted hazard ratio 1.10 per 1 microg/L increase, 95% CI 1.05-1.15, P < .001). The association between cardiac troponin I and mortality was similar for patients with and without other features of acute ischemia on presentation (P > .05 for interaction)., Conclusions: In patients hospitalized for ADHF who had cardiac troponin levels measured during the course of clinical practice, cardiac troponin I was an independent predictor of all-cause mortality. Cardiac troponin testing is easily accessible, has predictive value above and beyond traditional clinical predictors of mortality, and may help guide medical decision making in patients with ADHF.

Background: The Randomized Aldactone Evaluation Study (RALES) established the safety and benefit of spironolactone for heart failure (HF) patients with systolic dysfunction. However, recent data have raised concerns regarding hyperkalemia secondary to spironolactone use and suggest it occurs more commonly in routine practice., Methods and Results: We explored factors potentially associated with hyperkalemia from spironolactone therapy in a population-based cohort of 9165 HF patients hospitalized in Ontario, Canada, between 1999 and 2001. Compared with patients enrolled in RALES, community-based patients were older (mean age 75 years versus 65 years, P < .001) and were more likely to be female (50% versus 27%, P < .001). Of the 1502 patients that were prescribed spironolactone at discharge, 18% had elevated serum potassium levels (>5 mmol/L) during hospitalization and 23% were discharged on concurrent potassium supplements. Although only 8% of patients had serum creatinine >2.5 mg/dL, many patients had stage III (53.1%), stage IV (12.8%), or stage V (3.9%) chronic renal insufficiency according to glomerular filtration rate., Conclusion: Spironolactone was often prescribed to inappropriate HF candidates because of the presence of relative or absolute contraindications. These findings highlight the need for more careful patient selection when prescribing spironolactone to minimize potential life-threatening hyperkalemia.

Background: Sudden cardiac death (SCD) is a devastating complication of hypertrophic cardiomyopathy (HCM). The optimal strategy for the primary prevention of SCD in HCM remains controversial. Methods: Using a Markov model, we compared the health benefits and cost-effectiveness of 3 strategies for the primary prevention of SCD: implantable cardioverter/defibrillator (ICD) insertion, amiodarone therapy, or no therapy. We modeled hypothetical cohorts of 45-year-old patients with HCM with no history of cardiac arrest but at significant risk of SCD (3%/y). Results: Over a lifetime, compared with no therapy, ICD therapy increased quality-adjusted survival by 4.7 quality-adjusted life years (QALYs) at an additional cost of $142800 ($30000 per QALY), whereas amiodarone increased quality-adjusted survival by 2.8 QALYs at an additional cost of $104900 ($37300 per QALY). Compared with no therapy, ICD therapy would cost <$50000 per QALY for patients (i) aged 25, with ≥1 risk factors for SCD, and (ii) aged 45 or 65, with ≥2 risk factors for SCD. Conclusions: An ICD strategy is projected to yield the greatest increase in quality-adjusted life expectancy of the 3 treatment strategies evaluated. Combined consideration of age and the number of risk factors for SCD may allow more precise tailoring of ICD therapy to its expected benefits. [Copyright &y& Elsevier]