Figure.

The 18th Annual Scientific Meeting � HFSA S55

was 6.09 months (+/-0.8). Patient global assessment and HF event rates can be seen intable 1. NYHA class did drop from 2.55 (+/-0.83) to 1.85 (+/-0.73) reaching signifi-cance (P50.0004). Conclusions: Patients with CRT at sites with longer paced IVCDtimes showed significant improvement from baseline to 6 months. RV paced IVCDmay provide a useful tool to predict clinical outcomes in patients receiving CRT. Alonger prospective analysis should be considered to support these findings.

135Regional Hospital Collaboration Is Associated with Reduced 30-DayReadmission in Medicare Heart Failure PatientsJoy Pollard1, Sandra Oliver-McNeil2, Shilpa Patel3, Harolyn Baker4, Lisa Mason5,Annie Melia6, Scott L. Hummel6,7; 1St. Joseph Hospital, Pontiac, MI; 2WayneState University, Detroit, MI; 3American College of Cardiology, Washington, DC;4MPRO, Farmington Hills, MI; 5Greater Detroit Area Health Council, Detroit, MI;6University of Michigan, Ann Arbor, MI; 7Ann Arbor Veterans Affairs HealthSystem, Ann Arbor, MI

Background: 30-day heart failure (HF) readmissions can be reduced if multiple in-terventions are implemented, such as 7 day post-discharge follow up (7dFU), but thistask is challenging for health systems. Hypothesizing that 7dFU and 30-day readmis-sion rates would improve through collaboration, previously non-affiliated hospitals ina large metropolitan area shared best practices in a structured setting. Method:Twelve urban and suburban area southeast Michigan hospitals participated in a multi-system collaborative between May 1, 2012 and March 30, 2013 implementing “Seeyou in 7” Hospital-to-Home Initiative strategies. Collaborating hospitals (CH) devel-oped a process matrix to identify improvement goals. Hospital champions participatedin 4 in-person meetings and 8 webinars focused on up to 6 process metrics based onCH goals. CH shared best practices and received guidance from national experts. CHssubmitted a gap analysis, improvement plan, and quarterly progress reports. Aggre-gate claims data for Medicare Fee-for Service beneficiaries admitted for HF were ob-tained from May 1, 2011-April 30, 2012 (pre-collaborative) and May 1, 2012-March30, 2013 (during collaboration). The unadjusted 7dFU and 30-day all-cause readmis-sion rates for CH and statewide non-participating hospitals (NPH) were compared us-ing Chi-square testing. Results: The 7dFU rate significantly increased during theintervention period in both groups (CH: 31.3 to 35.0%; NPH: 29.7 to 32.6%, bothp!0.003). The overall 30-day readmission rate and the 30-day readmission rate inpatients with 7dFU was reduced more in CH than in NPH (overall: 30.2 to 27.3%vs. 27.3 to 26.2%, p50.008; 7dFU patients: CH: 32.7 to 28.2 vs. NPH: 29.0 to26.5%, p50.003). In both groups over both time periods, the 30-day readmissionrate was slightly higher in patients who attended 7dFU than those who did not.Conclusion: Regional collaboration between healthcare systems within a structuredquality improvement project was associated with reduced 30 day readmission ratesin Medicare HF patients beyond secular trends. Implementation strategies requireda team commitment from both staff and physicians. Further study is needed to under-stand the relationship between 7dFU and 30-day readmission rates.

Figure. 30-day readmission in collaborating vs. other Michigan hospitals. Abbrevi-ations: NPH, non-participating hospitals; CH, collaborating hospitals; 7dFU, read-mission rate in patients with 7-day follow-up; Q, 3-month quarter

136The Role of Nutritional Risk Index in Predicting Mortality in Advanced HeartFailure PatientsOluwayemisi Adejumo1, Todd M. Koelling1, Scott L. Hummel1,2; 1University ofMichigan, Ann Arbor, MI; 2Ann Arbor Veterans Affairs Health System, AnnArbor, MI

Introduction: Hospitalized advanced heart failure (HF) patients are at high risk formalnutrition and death. The Nutritional Risk Index (NRI) is a simple, well-validatedtool for identifying patients at risk for nutrition-related complications. We

hypothesized that in advanced HF patients from the ESCAPE (Evaluation Study ofCongestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) study,the NRI would improve discrimination of the ESCAPE discharge risk model for 6-month all-cause mortality. Methods: We analyzed the 169 ESCAPE index admissionsurvivors with complete NRI data, calculated as follows: NRI 5 (1.519 � dischargeserum albumin, g/dL) + {41.7 � discharge weight (kg)/ideal body weight (IBW;kg)}; as in previous studies, if discharge weight O IBW, this ratio was set 5 1.The integer ESCAPE mortality model includes age, 6-minute walk distance, CPR/mechanical ventilation, discharge beta-blocker prescription and diuretic dose, anddischarge serum sodium, blood urea nitrogen, and B-type natriuretic peptide levels.We used Cox proportional hazards modeling for the primary outcome of 6-monthmortality. Results: 31/169 patients died within 6 months of hospital discharge.The median NRI was 96 (IQR 91-102). The NRI independently predicted 6-monthmortality, with HR 0.59 (95% CI 0.38-0.93, p5.02) per 10 units, and increased Har-rell’s c index from 0.74 to 0.76 when NRI was added to the ESCAPE model. Of note,body mass index did not predict 6-month mortality in this cohort, nor did NRI ifcalculated from values available at hospital admission rather than discharge. TheNRI was most helpful in the 86/169 patients with high predicted mortality (O20%at 6 months) by the ESCAPE mortality model (Figure). Conclusions: The NRI isa simple tool that can improve mortality risk stratification in hospitalized patientswith advanced HF.

137Clinical Variables Affecting Outcomes of Cardiac Resynchronization Therapyin Chronic Heart FailureMilena Jani1, Kathleen Lane2, Changyu Shen3, Jim Zheng2, Edra Nordstrom1, MarcRosenman4, Azam Hadi5; 1Indiana University School of Medicine, Indianapolis, IN;2Regeinstrief Institute, Indianapolis, IN; 3Indiana University School of Medicine,Indianapolis, IN; 4Indiana University School of Medicine, Indianapolis, IN;5Indiana University School of Medicine, Indianapolis, IN

Introduction: Cardiac Resynchronization Therapy (CRT) devices are implanted toreverse ventricular remodeling and improve left ventricular systolic function. CRThas been proven (in several multicenter trials) to decrease heart failure admissionsand mortality in patients with chronic heart failure (CHF), reduced left ventricularejection fraction (LVEF) !35%, and ECG evidence of ventricular conduction delay(i.e., QRS duration O 120ms). However, there is a 20-40% non-responder rate in theliterature. Although certain parameters associated with poor response have alreadybeen established, including echocardiographic criteria, lead positioning, and extentof scarred myocardium, less is known about clinical variables. Objectives: To under-stand which clinical variables predict poor outcomes in patients with resynchroniza-tion devices; ultimately to guide improved selection of patients who will benefit fromthis therapy.Methods: Retrospective analysis of five major hospital systems was per-formed. CPT and ICD-9 codes for CRT implantation identified 1988 patients from2003-2013. Clinical and echocardiographic data was obtained in 414 patients withmean LVEF of 23 6 9% and QRS duration 152 6 33 ms. Primary endpoint wastime to any event, including cardiac hospitalizations, ventricular assist device place-ment, cardiac transplantation and all-cause mortality, whichever came first. Results:Sixty-one percent of the patients had ischemic cardiomyopathy and 27% were fe-males. During the mean follow-up period of 15 months (1 month - 10 years) afterCRT placement, 352 patients had events, 37% of the patients died and 72% had atleast one cardiac hospitalization. The significant predictors of better outcome fromunivariate survival analysis were male gender (HR 5 0.68; 95% CI 0.54-0.86;p50.0014), white race vs. non-white (HR 5 0.75; CI 0.57-0.98; p 5 0.0380), andGFR (HR50.81 per 1 SD unit; CI 5 0.71-0.93; p 5 0.0033). The only significantrisk factor was BNP (HR 1.2 per 1 SD unit; CI 1.1 - 1.3; p 5 0.0003). There wasno difference in outcomes between ischemic and nonischemic cardiomyopathy(p50.1602).

S56 Journal of Cardiac Failure Vol. 20 No. 8S August 2014

Placement of CRT improved LVEF to 31615% (p!0.0001). In addition, there wassignificant improvement in QRS duration, BNP, liver congestion, kidney function,and other markers of chronic disease (p!0.0001 for all). Conclusion: White malesand higher GFR univariately have better prognosis from CRT placement, irrespectiveof the etiology of cardiomyopathy. High BNP may be a marker of poor prognosis.

138Contemporary Cardiac Resynchronization Implantable CardioverterDefibrillator Battery Longevities in a Community Hospital Heart FailureCohortJeffrey Williams, Robert Stevenson; The Good Samaritan Hospital, Lebanon, PA

Introduction: Battery longevity for cardiac resynchronization (CRT) implantablecardioverter defibrillators (ICD) has important implications for patient outcomesand cost of care. Patients cared for in nonacademic community hospitals (NCH)may have substantial differences in age, gender, and comorbidities than those inacademic centers and national trials. This study examines battery longevities ina contemporary cohort of patients from a NCH. Methods: All CRT-ICD’s im-planted at our hospital from 1 July 2008 through 31 July 2010 were included inthis retrospective chart review. Baseline demographics, device, and lead datawere obtained from the electronic medical record. The final device longevitieswere evaluated through 31 October 2013. The primary endpoint was devicereplacement for the battery reaching the elective replacement indicator (ERI). Re-sults: A total of 90 patients were included in this analysis; mean age, creatinine,and ejection fraction were 72+/-9 years, 1 3+/-0 5 mg/dl, and 0 25+/-0 08, respec-tively. CRT-ICD manufacturers included Boston Scientific (BSC, n553), Med-tronic (MDT, n528), and St Jude Medical (SJM, n510). During 4+/-0 8 yearsfollow-up, 16 devices reached ERI (17 6%); CRT-ICD’s reaching primary eventoccurred in 1 of 53 BSC (1 9%), 14 of 28 MDT (50%), and 1 of 10 SJM (10%)(P!0 001). Kaplan-Meier survival curve is shown. Lead and device parametersshown in the table. BSC had the highest RA lead impedance while MDT had thehighest RV lead impedance (*p!0 05 for One-Way ANOVA comparison of devicemanufacturers). Covariates that can affect time to battery depletion were includedin a multivariate Cox proportional hazard model; Patients reaching ERI had higher

Figure.

Table. Device parameters and therapies by device manufacturer

BSC MDT SJM

RA Output (V) 2.260.4 2.161.1 2.360.4RA Pulse Width (ms) 0.5260.08 0.4560.19 0.5360.09RA Impedance (Ohms)* 5166109 476660 400647RA Pacing (%) 27637 27631 55628RV Output (V) 2.360.5 2.460.7 2.460.3RV Pulse Width (ms) 0.5060.10 0.5460.15 0.5060RV Impedance (Ohms)* 5096158 5496188 397673LV Output (V) 2.360.8 2.261.4 2.460.7LV Pulse Width (ms) 0.7660.32 0.7760.44 0.7560.35LV Impedance (Ohms) 6506198 6856488 5816273BiV Pacing (%) 9862 91627 9665Shocks per Patient 1.562 1.260.9 1.360.5

RV and LV output and RV pulse width. Conclusion: This is the first report todemonstrate significant differences in battery longevities of currently implantedCRT-ICD’s in a cohort of patients in a NCH. These findings have clinical signifi-cance as more frequent generator changes subject the patient to higher risk of com-plications and added costs of care.

139Chronic Kidney Disease and Higher Risk of 30-Day All-Cause Readmissions inHeart Failure: Findings from a Propensity-Matched StudyChakradhari Inampudi1, Sridivya Parvataneni2, Charity J. Morgan2, PrakashDeedwania3, Gregg C. Fonarow4, Sumanth D. Prabhu2,5, Javed Butler6, Wilbert S.Aronow7, Paul W. Sanders2,5, Richard M. Allman8, Ali Ahmed2,5; 1University ofIowa Hospitals and Clinics, Iowa city, IA; 2University of Alabama at Birmingham,Birmingham, AL; 3University of California San Francisco, Fresno, Fresno, CA;4University of California Los Angeles, Los Angeles, CA; 5Veterans AffairsMedical Center, Birmingham, AL; 6Emory University, Atlanta, GA; 7New YorkMedical College, Valhalla, NY; 8Department of Veterans Affairs, Geriatrics andExtended Care Services, Washington, DC

Background: The use of 30-day all-cause readmission as a hospital performancemeasure under the new health care reform has called for development of new strate-gies to reduce these events. Heart failure is the leading cause for 30 day all-cause re-admission and earlier studies have shown that chronic kidney disease (CKD) is anindependent risk factor for mortality but data is sparse on influence of CKD on30-day all-cause readmission. In the current study, we examined the influence ofCKD with 30-day all-cause readmission in HF patients. Methods: Of the 8049 Medi-care beneficiaries, discharged alive from 106 U.S. hospitals (1998-2001) with a pri-mary discharge diagnosis of HF, 7927 had data available on serum creatinine and5003 had CKD, defined as eGFR !60 ml/min/1.73m2. Propensity scores for CKDwere used to assemble a matched cohort of 2600 pairs of patients with and withoutCKD and were balanced on 39 baseline characteristics. Results: Matched patients(n55200) had a mean age of 75 (611) years, mean EF of 41, 55% were women,and 28% were African American. 30-day all-cause readmission occurred in 18%and 21% of matched patients without and with CKD, respectively (HR 1.20; 95%CI, 1.06e1.35). All-cause mortality rates at 30 days post-discharge follow-up are4% and 6% in patients without CKD and with CKD, respectively (HR 1.51; 95%CI, 1.18e1.93) Similar associations were found with all-cause readmission, HF read-mission and mortality at 6 months and longer follow-up. Conclusions: Findings fromour current study suggest that chronic kidney disease is an independent risk factor for30 day readmission in patients with heart failure. Future studies need to examine iftargeted management of CKD may help improve outcomes in HF patients.

140Angiotensin Converting Enzyme Inhibitors: Survival Benefit in Patients withSystolic Heart Failure and End Stage Renal Disease Undergoing DialysisChakradhari Inampudi, Vladimir Cotarlan; University of Iowa Hospitals and Clinics,Iowa City, IA

Background: Angiotensin converting enzyme inhibitors (ACEI) significantly reducemortality in patients with systolic heart failure (HF). However, ACEIs are frequentlydiscontinued in patients with advanced chronic kidney disease (CKD) especially thoseapproaching end stage renal disease (ESRD). The goal of the study was to assess theassociation betweenACEI use andmortality in patientswithESRDundergoing dialysis.

Figure 1.