The 17th Annual Scientific Meeting � HFSA S33

i.e., remote monitoring, transition care models, early clinic follow-up, etc. Hy-pothesis: An alert system from the ER (to a 24/7 HF team) during ER regis-tration of a patient within 30 days of hospital discharge will prompt early,aggressive and concerted intervention (in the ER itself) by a dedicated HFteam and prevent inpatient readmissions. Therefore, readmission rates wouldbe significantly different if compared between time periods before and afterthe above early alert intervention. Methods: The Indiana University Health-Methodist Hospital EMR has instituted a program that recognizes patientswith an index discharge diagnosis of HF and alerts the 24/7 on-call dedicatedHF team if that patient returns to the ER within 30 days of discharge. Thisalert is comprised of a page to a dedicated 24/7 pager and iPhones/Blackberryemail/text alert prompting the HF team (comprising of HF physician, NP’s, andRN heart coaches) to initiate protocol directed intervention (to prevent inpa-tient hospital readmission) as follows: a. Assist ER physician to expedite rele-vant investigation and initiate aggressive HF treatment in the ER itself. b.Admission to dedicated 24 hr Observation unit under HF team with an aggressivemulti-pronged approach including teaching/counselling, medication administra-tion and medication reconciliation. c. Coordination of disposition from ER or24 hr Observation with close clinic follow up at the dedicated HF clinic i.e.,within 1-5 business days. Results: Retrospective review of 30 day readmissionrates comparing a 12 month (from Jan 2012- Jan 2013) HF alert interventionperiod to a prior 12 month (from Jan 2011 -Jan 2012) non intervention period.Table 1. Shows inpatient 30 day readmission rates and utilization of 24 hrObservation between the two groups. Fisher’s Exact two tailed statistical analysiswith 95% confidence level revealed statistical significance (p50.003) for 30 dayreadmission. In addition, there was a statistically significant (p50.03) increase inadmission to 24 hr Observation unit by the post intervention group. Conclusions:An early 24/7 ER 30 day readmission alert system to a dedicated HF teamprimed to intervene via a protocol driven systematic strategy results in reductionof 30 day HF inpatient readmissions and increases utilization of 24 hr Observationunit.

Table 1. 12 month Comparison of Pre vs. Post HF Team Alert/Intervention

Pre-intervention Post-intervention

12mos 12 mos

Total HF Admits

833 825 30 d Readmissions (mean%) 204 (24.5%) 152 (18.4%) p50.003 Admit to Observation 19 34 p50.03

092Discharge Hospice Referral Is Associated with Lower 30-Day All-CauseHospital Readmission in Medicare Beneficiaries with Heart FailureChakradhari Inampudi1, Sridivya Parvataneni1, Kanan Patel1, Gregg C. Fonarow2,Inmaculada B. Aban1, Margaret Feller1, Thomas E. Love3, Rodney Tucker1,Robert C. Bourge1, Sumanth D. Prabhu1,4, Richard M. Allman1,4, Ali Ahmed1,4;1University of Alabama at Birmingham, Birmingham, AL; 2University ofCalifornia, Los Angeles, CA; 3Case Western Reserve University, Cleveland, OH;4Veterans Affairs Medical Center, Birmingham, AL

Background: Heart failure (HF) is the leading cause for hospital readmission forMedicare beneficiaries. HF patients are often referred to hospice for end-of-lifeand palliative care. However, if discharge referral to hospice is associated with lower30-day all-cause hospital readmission remains unknown. Methods: Of the 8032Medicare beneficiaries, discharged alive from 106 U.S. hospitals with a primarydischarge diagnosis of HF, 182 (2%) received hospice referral. Propensity scoresfor hospice referral, estimated for each of the 8032 patients, were used to assem-ble a matched cohort of 177 pairs of patients receiving and not receiving hospicecare who were balanced on 48 baseline characteristics. Results: Patients (n5354)had a mean age of 79 years, 57% were women, and 17% were African American.Association of hospice referral with 30-day all-cause hospital readmission, overall,and among those dead and alive are displayed in Table. HRs (95% CIs) for HF read-mission and all-cause mortality at 30 days post-discharge were 0.50 (0.16-1.60;p50.242) and 4.37 (2.69-7.09; p!0.001), respectively. During 6 months post-dis-charge, 73% and 43% of matched patients receiving and not receiving hospicedied (HR, 2.62; p!0.001) and 18% and 55% respectively were hospitalized for allcauses (HR, 0.42; p!0.001). Conclusions: Older adults hospitalized for HF who re-ceived hospice referral at the time of discharge had lower 30-day all-cause readmis-sion, a benefit that was also observed among those alive. Nearly half of the matchedpatients who did not receive hospice referral died within 6 months post-dischargesuggesting that these potential hospice-eligible patients could benefit from hospice-

associated lower readmission rates. Future studies need to develop and test tools toidentify these patients for potential hospice care.

Table 1. Association of hospice referral with 30-day all-cause readmissionamong propensity-matched Medicare beneficiaries hospitalized for heart

failure

% (events/at risk) Hospice referral

No

Yes Hazard ratio(95% CI); P value

Overall (N5354)

27% (48/177) 5% (9/177) 0.21 (0.10e0.43) !0.001 Dead (n595) 48% (10/21) 1% (1/74) 0.03 (0.00e0,22) 0.001 Alive (n5259) 24% (38/155) 8% (8/103) 0.29 (0.14e0.63) 0.002

093Consequences of Healthcare System Distrust in Patients Admitted with AcuteDecompensated Heart FailureCharu Gupta, Susan Bell, Kathryn Goggins, Courtney Cawthon, Sunil Kripalani;Vanderbilt University, Nashville, TN:

Heart failure is a chronic illness that affects more than 5.5 million people in the UnitedStates. Complicated medication regimens and extensive dietary limitations make day-to-daymanagement of heart failure challenging for patients. Hospitalized patients’ trustin their physicians and the healthcare systemmay be important factors in understandingshared decision-making, self-management, and healthcare utilization. We assessed therelationship between trust in the healthcare system, trust in one’s physician, and health-care utilization. Individuals with a diagnosis of acute decompensated heart failure(ADHF) were enrolled in a prospective cohort study. Participants completed a seriesof validated measurements including the Revised Healthcare System Distrust Scale,the Wake Forest Physician Trust Scale, and the Patient Health Questionnaire (PHQ-8) and welf-reported demographics. Unplanned healthcare utilization was assessed90 days after discharge based on follow up interviews.Unplanned healthcare utilizationwas defined as ER visits or hospital admissions. Patient scores on the Revised Health-care System Distrust Score were then broken into quartiles for further analysis. Among221 individuals studied, 39% were above the age of 65, 51% were female, 21% wereliving alone and 81% were unemployed or disabled. One- fourth of individuals (50 pa-tients) had total Revised Healthcare System Distrust scores of 30 or higher, indicatingthe highest level of distrust. There was no significant association between patient gen-der, race, education, or marital status and quartiles of health care system distrust. Therewas no significant association noted with health literacy or numeracy and healthcaresystem distrust. Among increasing levels of system distrust, the proportion of patientswith a regular physician was not significantly different (86%). A significant correlationwas noted between system distrust and all levels of depressive symptoms as measuredby scores on the PHQ-8 (p5 0.02). 44% of the total cohort reported either moderate orsevere depressive symptoms. Of the 50 individuals with the highest level of system dis-trust, 56% reported moderate or severe depressive symptoms. Health care system dis-trust was also inversely correlated with the physician trust scale (p ! 0.1). However,patients with increasing levels of healthcare system distrust were noted to have equalincidence of unplanned healthcare utilization (52-58%). Incidence of unplanned health-care utilization in our heart failure patients was high. Additionally, healthcare systemdistrust was prevalent among individuals hospitalized for ADHF. Though patientswith more healthcare system distrust were found to have higher levels of depressionand were less trusting of their physicians, there was no association noted betweenhealthcare system distrust and unplanned healthcare utilization in this study.

094Diuretic Resistance and Clinical Outcomes in Patients Hospitalized forWorsening Heart Failure: Insights from the EVEREST (Efficacy ofVasopressin Antagonism in Heart Failure: Outcome Study with Tolvaptan) TrialAlicia Mecklai1, Haris Subacius2, Stuart Katz1; 1New York University LangoneMedical Center, New York, NY; 2Northwestern University Feinberg School ofMedicine, Chicago, IL

Background: Diuretic resistance, defined as persistent congestion despite higher di-uretic dose, is common in hospitalized patients with heart failure (HF), but its as-sociation with clinical outcomes has not been characterized. We hypothesized thatthe association between in-hospital diuretic dose and clinical outcomes would differin patients with or without persistent congestion at the time of hospital discharge.Methods: We performed a post-hoc analysis of the EVEREST trial, a double-blindrandomized comparison of tolvaptan vs. placebo in hospitalized patients with wors-ening HF. Average daily loop diuretic dose (Loop Dose) during the first 72 hours ofhospitalization was calculated in furosemide equivalents and categorized in 3 groups