Supporting Information for Acute Decompensated Heart Failure is
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1 Supporting Information for Acute Decompensated Heart Failure is Routinely Treated as a Cardiopulmonary Syndrome Kumar Dharmarajan, MD, MBA; Kelly M. Strait, MS; Tara Lagu, MD, MPH; Peter K. Lindenauer, MD, MSc; Mary E. Tinetti, MD; Joanne Lynn, MD; Shu-Xia Li, PhD; Harlan M. Krumholz, MD, SM 2 Table S1. Infections Other Than Pneumonia Potentially Requiring Antibiotic Treatment. ICD-9-CM Code Mycobacterial Disease 031.0 031.2 031.8 031.9 013.0 013.3 Meningitis/ Encephalitis 036.0 036.89 036.9 320.7 322.9 320 320.0 320.1 320.2 320.3 320.8 320.81 320.82 320.9 322 V12.42 Endocarditis 421.0 421.9 424.90 036.42 421.1 422.92 424.91 Sinusitis 461.0 461.1 461.2 461.3 461.8 461.9 473.0 Description Pulmonary Diseases Due to Other Mycobacteria Disseminated Mycobacterium Other Specified Mycobacterial Diseases Unspecified Diseases Due to Mycobacteria Tuberculous Meningitis Tuberculous Abscess of Brain Meningococcal Meningitis Other Specified Meningococcal Infections Unspecified Meningococcal Infections Meningitis in Other Bacterial Diseases Classified Elsewhere Unspecified Meningitis Bacterial Meningitis Haemophilus Meningitis Pneumococcal Meningitis Streptococcal Meningitis Staphylococcal Meningitis Meningitis Due to Other Specified Bacteria Anaerobic Meningitis Meningitis Due to Gram-Negative Bacteria, Not Elsewhere Classified Meningitis Due to Unspecified Bacterium Meningitis of Unspecified Cause Infections of the CNS-Encephalitis, Meningitis Acute and Subacute Bacterial Endocarditis Unspecified Acute Endocarditis Endocarditis Valve Unspecified Cause Meningococcal Endocarditis Acute and Subacute Infective Endocarditis in Diseases Classified Elsewhere Septic Myocarditis Endocarditis in Diseases Classified Elsewhere Acute Maxillary Sinusitis Acute Frontal Sinusitis Acute Ethmoidal Sinusitis Acute Sphenoidal Sinusitis Other Acute Sinusitis Acute Sinusitis, Unspecified Chronic Maxillary Sinusitis 3 473.1 473.2 473.3 473.8 473.9 Otitis 382.0 382.02 382.3 Oropharyngeal/ Laryngeal Infections 462 463 464.0 475 478.21 478.22 478.24 GI Infections 540 566 567.2 569.5 569.61 572.0 575.0 575.12 576.1 577.0 Urinary Tract Infection 599.0 Cellulitis and/or Abscess 681.00 681.10 682.0 682.1 682.2 682.3 682.4 682.5 682.6 682.7 682.8 682.9 Chronic Frontal Sinusitis Chronic Ethmoidal Sinusitis Chronic Sphenoidal Sinusitis Other Chronic Sinusitis Unspecified Sinusitis Acute Suppurative Otitis Media Acute Suppurative Otitis Media in Diseases Classified Elsewhere Unspecified Chronic Suppurative Otitis Media Acute Pharyngitis Acute Tonsillitis Acute Laryngitis Peritonsillar Abscess Cellulitis of Pharynx or Nasopharynx Parapharyngeal Abscess Retropharyngeal Abscess Acute Appendicitis Abscess of Anal and Rectal Regions Other Suppurative Peritonitis Abscess of Intestine Infection Colostomy or Enterostomy Abscess of Liver Acute Cholecystitis Acute and Chronic Cholecystitis Cholangitis Acute Pancreatitis Urinary Tract Infection Site Not Specified Unspecified Cellulitis and Abscess of Finger Unspecified Cellulitis and Abscess of Toe Cellulitis and Abscess of Face Cellulitis and Abscess of Neck Cellulitis and Abscess of Trunk Cellulitis and Abscess of Upper Arm and Forearm Cellulitis and Abscess of Hand Except Fingers and Thumb Cellulitis and Abscess of Buttock Cellulitis and Abscess Leg Except Foot Cellulitis and Abscess of Foot Except Toes Cellulitis and Abscess of Other Specified Sites Cellulitis and Abscess of Unspecified Sites 4 681.9 Cellulitis and Abscess of Unspecified Digit Osteomyelitis 730.00 Acute Osteomyelitis Site Unspecified 730.04 Acute Osteomyelitis Involving Hand 730.05 Acute Osteomyelitis Involving Pelvic Region and Thigh 730.07 Acute Osteomyelitis Involving Ankle and Foot 730.10 Chronic Osteomyelitis Site Unspecified 730.12 Chronic Osteomyelitis Involving Upper Arm 730.14 Chronic Osteomyelitis Involving Hand 730.15 Chronic Osteomyelitis Involving Pelvic Region and Thigh 730.16 Chronic Osteomyelitis Involving Lower Leg 730.17 Chronic Osteomyelitis Involving Ankle and Foot 730.20 Unspecified Osteomyelitis Site Unspecified 730.24 Unspecified Osteomyelitis Involving Hand 730.27 Unspecified Osteomyelitis Involving Ankle and Foot 730.28 Unspecified Osteomyelitis Involving Other Specified Sites ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification 5 Table S2. Conditions Other Than Exacerbated Chronic Obstructive Pulmonary Disease Potentially Requiring High-Dose Steroid Treatment. ICD-9-CM Code Skin Disease 693 693 693.1 693.8 693.9 694.4 694.5 694.8 695 695.1 695.11 695.12 695.13 695.14 695.15 695.19 695.2 695.4 686 686.01 136.1 Collagen Vascular Disease 710 710.1 710.3 710.4 710.8 710.9 714 714.1 714.2 725 135 Crystal Arthropathies 712 712.1 712.11 Description of Condition Dermatitis Due to Substances Taken Internally Dermatitis Due to Drugs and Medicines Taken Internally Dermatitis Due to Food Taken Internally Dermatitis Due to Other Specified Substances Taken Internally Dermatitis Due to Unspecified Substance Taken Internally Pemphigus Pemphigoid Other Specified Bullous Dermatoses Erythema Multiforme Erythema Multiforme, Unspecified Erythema Multiforme Minor Erythema Multiforme Major Stevens-Johnson Syndrome Stevens-Johnson Syndrome-Toxic Epidermal Necrolysis Overlap Syndrome Toxic Epidermal Necrolysis Other Erythema Multiforme Erythema Nodosum Lupus Erythematosus Pyoderma Unspecified Pyoderma Gangrenosum Behcet's Syndrome Systemic Lupus Erythematosus Systemic Sclerosis Dermatomyositis Polymyositis Other Specified Diffuse Diseases of Connective Tissue Unspecified Diffuse Connective Tissue Disease Rheumatoid Arthritis Felty's Syndrome Other Rheumatoid Arthritis With Visceral or Systemic Involvement Polymyalgia Rheumatica Sarcoidosis Crystal Arthropathies Chondrocalcinosis Due to Dicalcium Phosphate Crystals Chondrocalcinosis Due to Dicalcium Phosphate Crystals Involving Shoulder Region 6 712.12 712.13 712.14 712.15 712.16 712.17 712.18 712.19 712.2 712.2 712.21 712.22 712.23 712.24 712.25 712.26 712.27 712.28 712.29 712.3 712.3 712.31 712.32 712.33 712.34 712.35 712.36 712.37 712.38 712.39 712.8 712.8 712.81 712.82 Chondrocalcinosis Due to Dicalcium Phosphate Crystals Involving Upper Arm Chondrocalcinosis Due to Dicalcium Phosphate Crystals Involving Forearm Chondrocalcinosis Due to Dicalcium Phosphate Crystals Involving Hand Chondrocalcinosis Due to Dicalcium Phosphate Crystals Involving Pelvic Region And Thigh Chondrocalcinosis Due to Dicalcium Phosphate Crystals Involving Lower Leg Chondrocalcinosis Due to Dicalcium Phosphate Crystals Involving Ankle And Foot Chondrocalcinosis Due to Dicalcium Phosphate Crystals Involving Other Specified Sites Chondrocalcinosis Due to Dicalcium Phosphate Crystals Involving Multiple Sites Chondrocalcinosis Due to Pyrophosphate Crystals Chondrocalcinosis Due to Pyrophosphate Crystals Involving Unspecified Site Chondrocalcinosis Due to Pyrophosphate Crystals Involving Shoulder Region Chondrocalcinosis Due to Pyrophosphate Crystals Involving Upper Arm Chondrocalcinosis Due to Pyrophosphate Crystals Involving Forearm Chondrocalcinosis Due to Pyrophosphate Crystals Involving Hand Chondrocalcinosis Due to Pyrophosphate Crystals Involving Pelvic Region And Thigh Chondrocalcinosis Due to Pyrophosphate Crystals Involving Lower Leg Chondrocalcinosis Due to Pyrophosphate Crystals Involving Ankle And Foot Chondrocalcinosis Due to Pyrophosphate Crystals Involving Other Specified Sites Chondrocalcinosis Due to Pyrophosphate Crystals Involving Multiple Sites Chondrocalcinosis Cause Unspecified Chondrocalcinosis Cause Unspecified Involving Unspecified Site Chondrocalcinosis Cause Unspecified Involving Shoulder Region Chondrocalcinosis Cause Unspecified Involving Upper Arm Chondrocalcinosis Cause Unspecified Involving Forearm Chondrocalcinosis Cause Unspecified Involving Hand Chondrocalcinosis Cause Unspecified Involving Pelvic Region And Thigh Chondrocalcinosis Cause Unspecified Involving Lower Leg Chondrocalcinosis Cause Unspecified Involving Ankle And Foot Chondrocalcinosis Cause Unspecified Involving Other Specified Sites Chondrocalcinosis Cause Unspecified Involving Multiple Sites Other Specified Crystal Arthropathies Other Specified Crystal Arthropathies Site Unspecified Other Specified Crystal Arthropathies Involving Shoulder Region Other Specified Crystal Arthropathies Involving Upper Arm 7 712.83 712.84 712.85 712.86 712.87 712.88 712.89 712.9 712.9 712.91 712.92 712.93 712.94 712.95 712.96 712.97 712.98 712.99 Vasculitis 446 446.1 446.2 446.2 446.21 446.29 446.4 446.5 446.7 443.1 Gastrointestinal Disease 556 556 556.1 556.2 556.3 556.4 556.5 556.6 556.8 556.9 555 555 555.1 555.2 Other Specified Crystal Arthropathies Involving Forearm Other Specified Crystal Arthropathies Involving Hand Other Specified Crystal Arthropathies Involving Pelvic Region And Thigh Other Specified Crystal Arthropathies Involving Lower Leg Other Specified Crystal Arthropathies Involving Ankle And Foot Other Specified Crystal Arthropathies Involving Other Specified Sites Other Specified Crystal Arthropathies Involving Multiple Sites Unspecified Crystal Arthropathy Unspecified Crystal Arthropathy Site Unspecified Unspecified Crystal Arthropathy Involving Shoulder Region Unspecified Crystal Arthropathy Involving Upper Arm Unspecified Crystal Arthropathy Involving Forearm Unspecified Crystal Arthropathy Involving Hand Unspecified Crystal Arthropathy Involving Pelvic Region And Thigh Unspecified Crystal Arthropathy Involving Lower Leg Unspecified Crystal Arthropathy Involving Ankle And Foot Unspecified Crystal Arthropathy Involving Other Specified Sites Unspecified Crystal Arthropathy Involving Multiple Sites Polyarteritis Nodosa Acute Febrile Mucocutaneous Lymph Node Syndrome (MCLS) Hypersensitivity Angiitis Hypersensitivity Angiitis Unspecified Goodpasture's Syndrome Other Specified Hypersensitivity Angiitis Wegener's Granulomatosis Thrombotic Microangiopathy Takayasu's Disease Thromboangiitis Obliterans (Buerger's Disease) Ulcerative Enterocolitis Ulcerative (Chronic) Enterocolitis Ulcerative (Chronic) Ileocolitis Ulcerative (Chronic) Proctitis Ulcerative (Chronic) Proctosigmoiditis Pseudopolyposis of Colon Left-Sided Ulcerative (Chronic) Colitis Universal Ulcerative (Chronic) Colitis Other Ulcerative Colitis Ulcerative Colitis Unspecified Regional Enteritis Regional Enteritis of Small Intestine Regional Enteritis of Large Intestine Regional Enteritis of Small Intestine with Large Intestine 8 555.9 571.42 Hematologic Disease 203 203 203.01 203.02 287.31 283 284.89 284.9 Neurologic Disease 357.81 357 341.2 341.2 341.21 341.22 340 Endocrine Disease 255.4 255.41 Renal Disease 581.3 583.9 Cardiac Disease 420 420 420.9 420.91 420.99 422 422 422.9 422.9 422.91 Transplant-related Conditions 996.8 996.8 996.81 996.82 996.83 996.84 Regional Enteritis of Unspecified Site Autoimmune Hepatitis Multiple Myeloma Multiple Myeloma without Remission Multiple Myeloma in Remission Multiple Myeloma, in Relapse Immune Thrombocytopenic Purpura Autoimmune Hemolytic Anemias Red Cell Aplasia (Acquired) (Adult) (with Thymoma) Aplastic Anemia Unspecified Chronic Inflammatory Demyelinating Polyneuritis Acute Infective Polyneuritis Acute (Transverse) Myelitis Acute (Transverse) Myelitis Not Otherwise Specified Acute (Transverse) Myelitis in Conditions Classified Elsewhere Idiopathic Transverse Myelitis Multiple Sclerosis Corticoadrenal Insufficiency Glucocorticoid Deficiency Nephrotic Syndrome with Lesion of Minimal Change Glomerulonephritis Nephritis and Nephropathy Not Specified as Acute or Chronic With Unspecified Pathological Lesion in Kidney Acute Pericarditis Acute Pericarditis in Diseases Classified Elsewhere Other and Unspecified Acute Pericarditis Acute Idiopathic Pericarditis Other Acute Pericarditis Acute Myocarditis Acute Myocarditis in Diseases Classified Elsewhere Other and Unspecified Acute Myocarditis Acute Myocarditis Unspecified Idiopathic Myocarditis Complications f Transplanted Organ Complications of Unspecified Transplanted Organ Complications of Transplanted Kidney Complications of Transplanted Liver Complications of Transplanted Heart Complications of Transplanted Lung 9 996.85 996.86 996.87 996.89 Allergy-related Conditions 995 995.1 995.2 Complications of Transplanted Bone Marrow Complications of Transplanted Pancreas Complications of Transplanted Organ Intestine Complications of Other Specified Transplanted Organ Other Anaphylactic Reaction Not Elsewhere Classified Angioneurotic Edema Not Elsewhere Classified Unspecified Adverse Effect of Drug Medicinal and Biological Substance Not Elsewhere Classified 995.2 Unspecified Adverse Effect of Unspecified Drug, Medicinal and Biological Substance 995.27 Other Drug Allergy 995.3 Allergy Unspecified Not Elsewhere Classified ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification 10 Figure S1. Treatment During Days 1-2 Treatment During Days 3-5 Longitudinal Treatment Pathways. A sample pathway is shown for a patient who receives treatment for heart failure and bronchodilators during the first 2 hospital days and bronchodilators only during hospital days 3 through 5. Within each time period, treatment groups are mutually exclusive and inclusive of all patients. HF, heart failure. Table S3. Treatments Received During the First 2 Hospital Days and Hospital Days 3 through 5. Treatment Category Heart Failure Treatments Short-acting Inhaled Bronchodilators Antibiotics High-dose All Heart Failure Hospitalizations (N=164,494) Heart Failure Hospitalizations with Chronic Lung Disease (N=63,690) Percent of Patients Receiving Treatment During Days 1-2 (N=164,494) Percent of Patients Receiving Treatment During Days 1-2 (N=63,690) 29% Percent of Patients Receiving Treatment During Days 3-5 (N=61,948) 52% Oral Loop Diuretics Intravenous Loop Diuretics Intravenous Inotropes Intravenous Vasodilators Beta Agonists 28% Percent of Patients Receiving Treatment During Days 3-5 (N=157,830) 52% 90% 63% 90% 65% 5% 6% 5% 5% 7% 2% 7% 2% 35% 28% 56% 47% Anti-Cholinergics Other Any Bronchodilator Penicillins Cephalosporins Fluoroquinolones Macrolides Tetracyclines Vancomycin Aminoglycosides Carbapenems Other Any Antibiotic Intravenous 28% 1% 37% 21% 1% 30% 45% 2% 59% 36% 2% 50% 4% 13% 16% 9% 1% 4% 0% 0% 2% 33% 6% 4% 11% 15% 7% 1% 4% 0% 1% 3% 33% 1% 5% 15% 22% 12% 1% 5% 0% 3% 11% 42% 11% 5% 13% 20% 10% 2% 5% 0% 1% 3% 42% 2% Corticosteroids Corticosteroids Oral Corticosteroids Any Corticosteroid 3% 3% 6% 5% 10% 5% 17% 9% Table S4: Acute Respiratory Treatment During the First Two Days of Hospitalization by Patient Subgroup. Patient Subgroup Age in Years History of Acute Myocardial Infarction History of Chronic Lung Disease Daily Treatment with Loop Diuretics During Days 3-5 Natriuretic Peptide Testing During Days 1-2 Chest Radiograph During Days 1-2 HF, heart failure Number of Hospitalizations Initial Treatment (Hospital Days 1-2) HF Only HF + Bronchodilators HF + Antibiotics (± Bronchodilators) <50 5070 >70 Yes 11,522 50,893 53% 47% 16% 18% 24% 25% HF + Corticosteroids (± Bronchodilators) 3% 4% HF + Antibiotics + Corticosteroids (± Bronchodilators) 4% 6% 102,079 5,464 47% 40% 16% 16% 29% 34% 3% 3% 5% 6% No Yes 159,030 63,690 47% 27% 17% 25% 27% 31% 4% 6% 5% 11% No Yes 100,804 143,576 59% 47% 12% 17% 25% 27% 2% 4% 2% 5% No Yes 20,918 142,123 48% 46% 15% 17% 28% 27% 4% 4% 5% 6% No Yes 22,371 149,573 50% 46% 15% 17% 28% 28% 3% 4% 4% 5% No 14,921 57% 15% 22% 3% 3% Table S5. Longitudinal Treatment Pathways: Treatment During Hospital Days 3 through 5 for Patients within Each Initial Treatment Group. Continuing Treatment (Hospital Days 3-5); (% of patients) HF Only; (n=77,175) Initial Treatment (Hospital Days 1-2) (N=164,494) HF + HF + Antibiotics HF + Corticosteroids (± Bronchodilator (± Bronchodilators); s; (n=27,980) Bronchodilators); (n=44,846) (n=5,852) HF + Antibiotics + Corticosteroids (± Bronchodilators); (n=8,641) Discharged Before 6% 3% 2% 3% 1% Day 3 No Continuing 25% 13% 11% 15% 7% Treatment HF only 69% 35% 20% 29% 11% Bronchodilators Only 0% 12% 4% 9% 6% Antibiotics Only 0% 0% 15% 0% 12% (± Bronchodilators) Corticosteroids Only 0%* 0%* 0%* 6% 3% (± Bronchodilators) HF + Bronchodilators 0% 35% 7% 19% 10% HF + Antibiotics 0% 0% 37% 0% 25% (± Bronchodilators) HF + Corticosteroids 0%* 1% 1% 19% 7% (± Bronchodilators) Antibiotics + Corticosteroids 0% 0% 0%* 0% 5% (± Bronchodilators) HF + Antibiotics + Corticosteroids 0% 0% 1% 0% 14% (± Bronchodilators) *Patients in these categories comprised less than 1% of the total population. Cell percentages reflect the division of patients within each of the 5 initial treatment groups into 1 of 11 continuing treatment pathways. Pathways are mutually exclusive and exhaustive of all patients within the study sample. Darker cells have a larger percentage of patients. HF: heart failure
