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Introduction: Hospital readmissions following an acute myocardial infarction (AMI) are associated with increased mortality and morbidity. The association of mental health disorders (MHD) and risk of readmission following AMI is not well studied. Hypothesis: We hypothesized that among patients with AMI, a co-morbid diagnosis of MHD is associated with increased risk of readmission. Methods: We analyzed the National Readmission Database for all adult AMI hospitalizations from 2016 to 2017. Co-morbid diagnoses of major depression, bipolar disorders, anxiety disorder and schizophrenia/other psychotic disorders were obtained using appropriate ICD-10 CM diagnostic codes. The primary outcome was 30-day all-cause unplanned readmission. A Cox-regression analysis was used to identify the association of MHD and risk of 30-day readmission adjusted for demographics, medical and cardiac comorbidities, and coronary revascularization. Results: We identified a total of 10,45,752 hospitalizations for AMI with a mean age of 66.6±12.9 years with 37.6% being females. The prevalence of any MHD was 15.0±0.9%. Readmission rates after AMI were higher for those with MHD compared to those without ( Figure ). After adjusting for potential confounders, comorbid diagnosis of major depression [rate 12.2%±0.5%, hazard ratio (HR) 1.11 (95% CI 1.07-1.15), p<0.001], bipolar disorders (rate 13.6±0.5%, HR 1.32 (1.19-1.45), p<0.001), anxiety disorders (rate 10.9±0.4%, HR 1.09 (1.05-1.13), p<0.001) and schizophrenia/other psychotic disorders (rate 17.5±0.6%, HR 1.56 (1.43-1.69), p<0.001) were independently associated with a higher risk of 30-day readmission compared to those with no comorbid MHD. Conclusions: Major depression, bipolar disorders, anxiety disorders and schizophrenia/other psychotic disorders are significantly associated with a higher independent risk of 30-day all-cause hospital readmissions among AMI hospitalizations in the United States.

Introduction: Optimal guideline-directed medical therapies (GDMT) improves clinical outcomes among patients with new-onset HFrEF. Limited data exist on achievement of optimal GDMT in the first 12 months among newly diagnosed patients with HFrEF. Methods: 2016-2020 OPTUM Claims Database, which includes privately insured and Medicare patients covered through the United Healthcare insurance, was used. Patients with new-onset HF were identified using validated ICD-10 codes and a 12-month look back to exclude prevalent HF. HFrEF patients were identified based on claims with ICD-10 codes of I50.2 and I50.4 within 6 months of HF diagnosis. Rates of optimal GDMT (≥50% target dose of ACEI or ARB or any dose of ARNI, ≥50% dose of beta-blocker, and any MRA) within 12 months of the incident HF diagnosis were compared overall and across race- and sex- groups. Adjusted Cox-proportional hazards models were used to evaluate the association of different patient-level factors with time to optimal GDMT during 12-month follow-up. Results: The study included 118963 patients with new-onset HFrEF (Age: 72 years, 15.8% Black, 57.4% Men). Only 8.3% achieved optimal GDMT during the 12 months after incident HF diagnosis. The optimal GDMT use within 12-months of HF diagnosis was low across the race-ethnic and gender groups ( Figure 1A/1B ). In adjusted Cox models, younger age, Black race, male sex, prevalent HF risk factors including hypertension, private (vs. Medicare insurance), and interval hospitalizations during the follow-up period were each associated with increased probability of achieving optimal GDMT ( Figure 1C ). In contrast, prevalent COPD, stroke/TIA, and polypharmacy were associated with a lower probability of achieving optimal GDMT. Conclusions: Utilization of optimal GDMT among patients with HFrEF is very low in the first 12 months after diagnosis. These findings highlight the need for aggressive implementation strategies to optimize GDMT utilization after new HF diagnosis.

Introduction: Intensive Care Units (ICUs) are among the most expensive components of hospital care. Experts believe that ICUs are overused; however, hospitals vary in their ICU admission rate. Our hypothesis is based on clinical observations that many patients with diabetic ketoacidosis (DKA), stroke, and gastrointestinal (GI) bleeding admitted to the ICU don’t really need it and could be managed safely in a non-ICU level of care. Reducing inappropriate admissions would reduce healthcare costs and improve outcomes. Our primary objective was to determine the frequency of inappropriate ICU admissions. Secondary objectives were to evaluate which diagnoses were more unnecessarily admitted to the ICU, evaluate different variables and comorbidities, and determine the mortality rates during ICU admissions. Methods: Patients admitted to the ICU, from the Emergency Department (ED) or transferred from the floor, during a one-year period were evaluated in this retrospective study. Patients 18-years old and above who had an admitting diagnosis of DKA, GI bleed, ischemic stroke, or hemorrhagic stroke were included. Patients in a comatose state, intubated, on vasopressors, hemodynamically unstable or had an unstable comorbid disease, subarachnoid hemorrhage, surgery during hospitalization prior to the ICU admission were excluded. Patients were categorized as having an appropriate or inappropriate ICU admission based on our institutional ICU admission criteria and data from available literature and guidelines. Results: A total of 95 patients were included in our cohort. Seventy-two out of 95 (76%) were considered as inappropriate ICU admissions. When comparing each of the four admitting diagnoses, a significantly higher proportion of DKA patients were considered inappropriate ICU admissions when compared to the other diagnoses ( P = 0.001). The overall mortality rate of ICU admissions was 16%, 15 patients out of 95 study population. When comparing each of the four admitting diagnoses, there was a significant difference in mortality rate with DKA having the lowest mortality (3%) and GI bleed having the highest mortality (43%). Out of the 15 patients who died, only 1 patient was categorized as an inappropriate ICU admission. Conclusions: More than three-quarters of our study population was admitted to the ICU inappropriately. Incorporating severity scores in ICU admission criteria could improve the appropriateness of ICU admission and financial feasibility. This article is based on a poster: Alsamman S, Alsamman MA, Castro M, Koselka H, Steinbrunner J: ICU admission patterns in patients with DKA, stroke and GI bleed: do they all need ICU? J Hosp Med. March 2015.

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Background: Patients in AUGUSTUS (n=4614) taking apixaban without aspirin had less bleeding and fewer hospitalizations with no significant increase in ischemic events than those taking VKA, aspirin, or both. It is safe and efficacious to reduce apixaban from 5 mg to 2.5 mg twice daily in patients with AF and ≥2 of the following: age ≥80 years, weight ≤60 kg, serum creatinine ≥1.5 mg/dL. Data on reduced versus standard dose apixaban in patients with AF and ACS and/or PCI are limited. Methods: We assessed how many patients receiving apixaban 2.5 mg met the dose reduction criteria. We compared major or CRNM bleeding, death or rehospitalization, and death or ischemic events in those who appropriately received 2.5 mg apixaban, inappropriately received 2.5 mg apixaban, and appropriately received 5 mg apixaban. We determined the association of apixaban versus warfarin on bleeding and ischemic events in patients appropriately assigned 2.5 mg apixaban and appropriately assigned 5 mg apixaban. Results: Of 2290 patients assigned apixaban, 229 received 2.5 mg and 98 (43%) of those met reduced dose criteria. Rates of major/CRNM bleeding, death or rehospitalization, and death or ischemic events were higher in patients appropriately receiving 2.5 mg apixaban (13.7%, 34.7%, 12.2%) compared with those inappropriately receiving 2.5 mg apixaban (10.5%, 32.5%, 12.3%) and appropriately receiving 5 mg apixaban (11.0%, 23.0%, 5.7%). Compared with VKA, 2.5 mg apixaban, when used appropriately, resulted in similar or greater benefits than 5 mg apixaban for major/CRNM bleeding, death or rehospitalization, and death or ischemic events (Table). Conclusion: Of those in AUGUSTUS who received 2.5 mg apixaban, fewer than half met the reduced dose criteria. In patients with AF and recent ACS or PCI, appropriate use of reduced dose apixaban was associated with a lower risk of bleeding and similar rates of rehospitalization and ischemic outcomes compared with VKA, similar to that for standard dose apixaban.

Introduction: The relationship between household income and trends in 30-day readmission among patients with heart failure (HF) is unknown. Further, whether the hospital readmission reduction program (HRRP) had differential associations with HF readmissions among patients with lower versus higher household income is unclear. Methods: The National Readmission Database (NRD) was examined to identify all admissions among adults with a primary diagnosis of HF who had at least one unplanned readmission within 30 days between 2010-2019. Median household income by patient zip code was assessed as quartiles: low income, middle income, upper-middle income, and high income. Yearly trends in adjusted all-cause 30-day readmission rates were assessed by household income quartile. Adjusted readmission rates were compared for the pre-HRRP period (2010-2012) vs. post-HRRP period (2013-2019). Results: Among 9,020,742 index hospitalizations between 2010-2019, adjusted all-cause 30-day readmission rates increased for patients in low-income (18.8% to 19.0%, P trend <0.001) and middle-income quartiles (17.6% to 17.9%, P trend <0.001), remained similar in the upper-middle income quartile (17.7% to 17.3%, P trend 0.24), and decreased in the high-income quartile (16.8% to 16.4%, P trend 0.039) (Figure, Panel A). Associations between HRRP and average adjusted all-cause readmission varied by income quartile, such that greater increases in readmissions were seen among patients in lower quartiles (p for interaction <0.001). ( Figure, Panel B) . Conclusions: Among patients hospitalized for HF in the US from 2010-2019, adjusted all-cause 30-day readmission rates significantly differed by neighborhood household income, and increased over time for patients in the lowest two quartiles of household income. Since adoption of the HRRP, greatest absolute increases in all-cause readmission have been observed among patients in the lowest quartile of neighborhood household income.