Researchers find differences in outcomes, costs among diagnoses
Mortality differed by medication, comorbidity
Investigators have found that patients who are admitted to hospitals with heart failure as a secondary diagnosis often had a worse prognosis than those for whom heart failure was the primary diagnosis.1
Using a large database provided by the National Data Corp. (NDCHealth) of Atlanta, GA, and containing data from about 300 hospitals, researchers screened admissions in 2003 for either a primary or secondary discharge diagnosis of heart failure.1
"Since it's a large database we could look at certain trends," says Tien M.H. Ng, PharmD, BCPS, an assistant professor of clinical pharmacy at the University of Southern California School of Pharmacy in Los Angeles, CA.
"For the primary heart failure group, our findings were very similar to the findings of the acute heart failure registries out there," Ng says. "Therapies that target congestion, such as diuretics and vasodilatory agents, seemed associated with better outcomes for patients than when patients received second-line therapies."
Current research suggests a wiser first step is to go after the volume overload of patients who have acute heart failure than it is to try to make their heart pump harder, Ng adds.
The study tied in some of the costs of the care and compared the costs to outcomes.
"The cost of care mirrored what the outcomes would be in those patients," Ng says. "Those who did better had costs that were less."
Overall, pharmacy charges for patients in the database accounted for less than 2% of the total costs, Ng notes.
"So although pharmacy departments like to focus on the drug costs and the bottom line to that department, it's important to understand that some therapies may be a little more expensive," he adds. "But if they lead to improved outcomes they might be more cost effective."
When hospitals use a lot of IV medications in an acute heart failure case it can be quite expensive, Ng says.
"But what these data show is the actual drug costs is a very small component of the overall costs of managing heart failure patients," he explains. "So sometimes using a medication that may seem expensive from a pharmacy standpoint may lead to an overall lower cost if patient outcomes are improved."
Investigators also found that patients who were given a secondary diagnosis of heart failure did worse than patients who are admitted for a primary diagnosis of heart failure, Ng says.
"Their outcomes were worse; their costs were worse; their lengths of stay were worse," he adds. "Also, their in-hospital mortality was higher."
Patients with secondary diagnoses of heart failure most frequently had primary diagnoses of acute myocardial infarction, pneumonia, other forms of ischemic heart disease, cardiac dysrhythmias, and chronic bronchitis.
When heart failure was the primary diagnosis, the patients most commonly had secondary diagnoses of ischemic heart disease, essential hypertension, diabetes mellitus, cardiac dysrhythmias, cardiomyopathy, and disorders of fluid, electrolyte, and acid-base.
The study found that when compared to patients admitted for heart failure as a primary reason, these patients with a secondary diagnosis of heart failure were treated less frequently with vasodilatory agents and more often with vasopressor agents. The opposite trend was true of patients who had a primary diagnosis of heart failure.
Specifically, 12% of patients with a primary heart failure diagnosis received a vasodilator and 6.1% of the same group received a vasopressor. By contrast, 7.3% of patients who had a secondary diagnosis of heart failure received a vasodilator, and 10.4% received a vasopressor.
Most of all heart failure patients received diuretics, with 84.7% of patients with heart failure as a primary diagnosis receiving the treatment and 67.2% of patients with heart failure as a secondary diagnosis receiving diuretics. Also, 6.9% of the primary heart failure patients received inotropes and 4.3% of the secondary heart failure patients received inotropes.
"Patients receiving diuretics and vasodilatory agents tended to do better than patients who received vasopressors or inotropes," Ng says.
"One more interesting thing was that of all of the other drug classes, including diuretics and vasodilators and inotropes, the mortality was always higher with secondary heart failure patients than with primary heart failure patients," Ng says. "But with vasopressors, the actual mortality rates were lower in secondary heart failure patients than in primary heart failures."
The fact that patients with a secondary diagnosis of heart failure did better with vasopressors was a significant finding, he adds.
"Overall, the prognosis still was better in patients who didn't receive a vasopressor," Ng notes. "But in those who did get a vasopressor, if you looked at mortality rates for secondary versus primary heart failure patients, the secondary did better."
There isn't a clear-cut reason why this finding appeared, although it probably is related to what the vasopressors were used for, Ng says.
"In patients with sepsis, you have to use a vasopressor in order to maintain blood pressure and profusion, and so that might help their outcomes in that setting," he explains. "But in a heart-failure setting, that's a last-line therapy because if you're just trying to maintain blood pressure in a heart failure patient then that's indicative of a very serious problem."
Reference
- Ng TMH, et al. Characteristics, drug therapy, and outcomes from a database of 500,000 hospitalized patients with a discharge diagnosis of heart failure. Congest Heart Fail 2008;14:202-210.
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