Specialty Care Can Lower Need for Hospitalization With PH-HFpEF
Care at a specialty center is tied to a lower risk of hospitalization for people with heart failure with preserved ejection fraction (HFpEF) who have pulmonary hypertension, according to a new study.
In heart failure with preserved ejection fraction, the heart’s ability to pump blood out to the body is impaired. It is estimated that more than four in every five HFpEF patients develop pulmonary hypertension, or high blood pressure in the lung’s blood vessels, a condition referred to as PH-HFpEF.
Current guidelines recommend that people with PH-HFpEF be referred to a specialty center for care once their disease progresses to a certain point. However, the benefits of specialty care for this condition are not well-studied.
A team led by researchers at the University of Pittsburgh conducted an analysis of 2,863 PH-HFpEF who were cared for in the university’s hospital network from January 2008 through December 2018. Of these, 974 patients were managed at a specialty care center (SCC), while the remaining 1,889 were not.
The SCC patients tended to be younger (median age of 66 vs. 69), were more commonly female (60% vs. 51%), and had been receiving care for longer (5.3 vs. 4.1 years). On average, they also had significantly poorer measures on several tests of hemodynamics (assessing blood flow), and had higher rates of comorbidities or other health problems, including chronic obstructive pulmonary disease, pulmonary fibrosis, kidney disease, and coronary artery disease, than did non-SCC patients.
Differences in treatment were also evident between the two groups, with SCC patients more commonly prescribed a number of medications aiming to lower blood pressure, including loop diuretics, spironolactone, and vasodilators.
Statistical analyses indicated that SCC patients were significantly — by about 16% — less likely to be hospitalized. Additional analyses accounting for differences in treatment found a somewhat smaller, but still significant, effect.
“When adjusting for medications, improvement in [hospital] admissions was only partially blunted, indicating that medications play a part of improving admissions, but do not explain the total benefit of the SCC,” the researchers wrote.
The team suggested that part of the difference may be because SCCs are more likely to comply with guideline-directed disease monitoring. Indeed, patients at specialty centers were significantly more likely to undergo right heart catheterization, a procedure to measure blood pressure in the lung’s vessels, and to have hemodynamic follow-up. These centers usually also undertake more aggressive disease treatment, including for comorbidities.
“Medical management at SCC significantly improves outcomes,” and “this improvement in hospitalizations is partially driven by medication adjustment and partially related to greater adherence to disease management guidelines by the SCC,” the researchers wrote.
Other analyses showed no association between specialty center care and mortality rate.
“This study did not demonstrate a mortality benefit related to SCC care for PH-HFpEF patients,” the researchers wrote.
But this “may not be surprising, given the dearth of guideline-directed medications in PH-HFpEF and the challenges to manage many of the contributing comorbidities,” the team added, noting a need for more research into ways to better care for this patient population.
Overall, “specialty care centers improved hospitalizations but not mortality — in part due to more aggressive medication management and guideline-directed monitoring,” the researchers concluded, and this study’s findings offer quantitative proof of the need to bolster efforts to refer PH-HFpEF patients to SCCs.