Heart Failure (HF) is one of the leading causes of hospitalization in the United States accounting for ≈800,000 hospital discharges and $11 billion in annual costs. Delirium occurs in approximately 30% of elderly hospitalized patients and its incidence is significantly higher among those admitted to the critical care units. Despite this, there has been limited exploration of the clinical and economic impact of delirium in patients hospitalized with acute HF. We hypothesized that delirium in HF is associated with excess mortality and hospital costs.
Methods
We queried the 2001-2014 Nationwide Inpatient Sample to identify hospitalizations that included a primary discharge diagnosis of HF (ICD-9-CM: 428.xx) and stratified them by presence or absence of delirium (ICD-9-CM: 239.0, 290.41, 293.0, 293.1, 348.31). Differences in in-hospital mortality, length of stay (LOS), and hospital costs were assessed using propensity-score matched cohorts.
Results
Major predictors of delirium included advanced age, Caucasian race, underlying dementia or psychiatric diagnoses, higher Elixhauser Comorbidity Index, renal failure, cardiogenic shock, and coronary artery bypass surgery. In the propensity-score matched analysis of 76,411 hospitalization with delirium compared to 76,612 without delirium, in-hospital mortality (odds ratio: 1.67, 95% CI: 1.51–1.77), LOS (rate ratio [RR]: 1.47, 95% CI: 1.45–1.51), and hospital costs (RR: 1.44, 95% CI: 1.41–1.48) were all statistically higher in the presence of delirium (all p < 0.001).
Conclusion
In patients hospitalized with HF, delirium is an independent predictor of increased in-hospital mortality, longer LOS, and excess hospital costs despite adjustment for baseline characteristics.
SavareseGLundLH.Global public health burden of heart failure. Card Fail Rev2017; 3: 7–11.
2.
HeidenreichPAAlbertNMAllenLA, et al.Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail2013; 6: 606–619.
3.
DunlaySMRedfieldMMWestonSA, et al.Hospitalizations after heart failure diagnosis a community perspective. J Am Coll Cardiol2009; 54: 1695–1702.
4.
ViraniSSAlonsoABenjaminEJ, et al.Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation2020; 141: e139–e596.
5.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association, 2013.
6.
OhESFongTGHshiehTT, et al.Delirium in older persons: advances in diagnosis and treatment. J Am Med Assoc2017; 318: 1161–1174.
7.
MarcantonioER.Delirium in hospitalized older adults. N Engl J Med2017; 377: 1456–1466.
8.
O'KeeffeSLavanJ.The prognostic significance of delirium in older hospital patients. J Am Geriatr Soc1997; 45: 174–178.
9.
SalluhJIWangHSchneiderEB, et al.Outcome of delirium in critically ill patients: systematic review and meta-analysis. Br Med J2015; 350: h2538.
10.
LeslieDLMarcantonioERZhangY, et al.One-year health care costs associated with delirium in the elderly population. Arch Intern Med2008; 168: 27–32.
11.
AbdullahAEigbireGSalamaA, et al.Impact of delirium on patients hospitalized for myocardial infarction: a propensity score analysis of the National Inpatient Sample. Clin Cardiol2018; 41: 910–915.
12.
PauleyELishmanovASchumannS, et al.Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit. Am Heart J2015; 170: 79–.e1–86.e1.
13.
HCUP Databases. Healthcare Cost and Utilization Project (HCUP). April 2021. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/nisoverview.jsp (accessed 17 June 2021).
14.
PatilSShahMPatelB, et al.Readmissions among patients admitted with acute decompensated heart failure based on income quartiles. Mayo Clin Proc2019; 94: 1939–1950.
15.
ElixhauserASteinerCHarrisDR, et al.Comorbidity measures for use with administrative data, Med Care1998; 36: 8–27.
16.
MooreBJWhiteSWashingtonR, et al.Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: the AHRQ Elixhauser Comorbidity Index. Med Care2017; 55: 698–705.
GelmanA.Data analysis using regression and multilevel/hierarchical models. Cambridge: Cambridge University Press, 2006.
20.
HarrellFE. Regression modeling strategies: with applications to linear models. In: Logistic and ordinal regression, and survival analysis. New York: Springer International Publishing, 2015, pp. 23–28.
21.
ParsonsLS.Performing a 1:N case-control match on propensity score. In: SAS Conference Proceedings: SAS Users Group International 29, Montreal, Canada, 9--12 May 2004, pp. 165–29.
22.
HondaSNagaiTSuganoY, et al.Prevalence, determinants, and prognostic significance of delirium in patients with acute heart failure. Int J Cardiol2016; 222: 521–527.
23.
PakMHaraMMiuraS, et al.Delirium is associated with high mortality in older adult patients with acute decompensated heart failure. BMC Geriatr2020; 20: 524. https://doi.org/10.1186/s12877-020-01928-7
24.
UthamalingamSGurmGSDaleyM, et al.Usefulness of acute delirium as a predictor of adverse outcomes in patients >65 years of age with acute decompensated heart failure. Am J Cardiol2011; 108: 402–408.
25.
IwataEKondoTNishiyamaI, et al. P2815 The prognostic impact of delirium in patients with acute decompensated heart failure. Eur Heart J 2018; 39: ehy565. P2815, https://doi.org/10.1093/eurheartj/ehy565.
26.
NaksukNThongprayoonCParkJY, et al.Editor’s choice-clinical impact of delirium and antipsychotic therapy: 10-year experience from a referral coronary care unit. Eur Heart J Acute Cardiovasc Care2017; 6: 560–568.
27.
ElyEWSiegelMDInouyeSK.Delirium in the intensive care unit: an under-recognized syndrome of organ dysfunction. Semin Respir Crit Care Med2001; 22: 115–126.
28.
van ZylLTDavidsonPR.Delirium in hospital: an underreported event at discharge. Can J Psychiatry2003; 48: 555–560.
29.
GroverSSarkarSYaddanapudiLN, et al.Intensive care unit delirium: a wide gap between actual prevalence and psychiatric referral. J Anaesthesiol Clin Pharmacol2017; 33: 480–486.
30.
HayashiAKobayashiSMatsuiK, et al.The accuracy of delirium assessment by cardiologists treating heart failure inpatients: a single center retrospective survey. Biopsychosoc Med2020; 14: 15–. https://doi.org/10.1186/s13030-020-00188-6.
31.
InouyeSKForemanMDMionLC, et al.Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med2001; 161: 2467–2473.
32.
PisaniMARedlichCMcNicollL, et al.Underrecognition of preexisting cognitive impairment by physicians in older ICU patients. Chest2003; 124: 2267–2274.
33.
BarrJFraserGLPuntilloK, et al.Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med2013; 41: 263–306.
34.
HermesCAcevedo-NuevoMBerryA, et al.Gaps in pain, agitation and delirium management in intensive care: outputs from a nurse workshop. Intensive Crit Care Nurs2018; 48: 52–60.
35.
Faria RdaSMorenoRP.Delirium in intensive care: an under-diagnosed reality. Rev Bras Ter Intensiva2013; 25: 137–147.
36.
NydahlPDewesMDubbR, et al.Survey among critical care nurses and physicians about delirium management. Nurs Crit Care2018; 23: 23–29.
37.
MillerMAGovindanSWatsonSR, et al.ABCDE, but in that order? A cross-sectional survey of Michigan intensive care unit sedation, delirium, and early mobility practices. Ann Am Thorac Soc2015; 12: 1066–1071.
38.
PendleburySTLovettNGThomsonRJ, et al.Impact of a system-wide multicomponent intervention on administrative diagnostic coding for delirium and other cognitive frailty syndromes: observational prospective study. Clin Med (Lond)2020; 20: 454–464.
39.
McCoyTHSnapperLSternTA, et al.Underreporting of delirium in statewide claims data: implications for clinical care and predictive modeling. Psychosomatics2016; 57: 480–488.
40.
KatznelsonRDjaianiGTaitG, et al.Hospital administrative database underestimates delirium rate after cardiac surgery. Can J Anaesth2010; 57: 898–902.
41.
HopeCEstradaNWeirC, et al.Documentation of delirium in the VA electronic health record. BMC Res Notes2014; 7: 208. doi:10.1186/1756-0500-7-208.
42.
AmpaduJMorleyJE.Heart failure and cognitive dysfunction. Int J Cardiol2015; 178: 12–23.
43.
CannonJAMcMurrayJJQuinnTJ.‘Hearts and minds’: association, causation and implication of cognitive impairment in heart failure. Alzheimers Res Ther2015; 7: 22. doi: 10.1186/s13195-015-0106-5.
44.
McPhersonJAWagnerCEBoehmLM, et al.Delirium in the cardiovascular ICU: exploring modifiable risk factors. Crit Care Med2013; 41: 405–413.
45.
CorrealeMAltamuraMCarnevaleR, et al.Delirium in heart failure. Heart Fail Rev2020; 25: 713–723.
46.
KellerSFrishmanWH.Neuropsychiatric effects of cardiovascular drug therapy. Cardiol Rev2003; 11: 73–93.
47.
Klein KlouwenbergPMZaalIJSpitoniC, et al.The attributable mortality of delirium in critically ill patients: prospective cohort study. Br Med J2014; 349: g6652.
48.
ParkYBatemanBTKimDH, et al.Use of haloperidol versus atypical antipsychotics and risk of in-hospital death in patients with acute myocardial infarction: cohort study. Br Med J2018; 360: k1218.
49.
MaldonadoJR.Delirium pathophysiology: an updated hypothesis of the etiology of acute brain failure. Int J Geriatr Psychiatry2018; 33: 1428–1457.
LeslieDLZhangYHolfordTR, et al.Premature death associated with delirium at 1-year follow-up. Arch Intern Med2005; 165: 1657–1662.
52.
FalsiniGGrottiSPortoI, et al.Long-term prognostic value of delirium in elderly patients with acute cardiac diseases admitted to two cardiac intensive care units: a prospective study (DELIRIUM CORDIS). Eur Heart J Acute Cardiovasc Care2018; 7: 661–670.
53.
ElyEWShintaniATrumanB, et al.Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. J Am Med Assoc2004; 291: 1753–1762.
54.
ZywielMGHurleyRTPerruccioAV, et al.Health economic implications of perioperative delirium in older patients after surgery for a fragility hip fracture. J Bone Joint Surg Am2015; 97: 829–836.
55.
ZhangZPanLNiH.Impact of delirium on clinical outcome in critically ill patients: a meta-analysis. Gen Hosp Psychiatry2013; 35: 105–111.
56.
McCuskerJColeMGDendukuriN, et al.Does delirium increase hospital stay?J Am Geriatr Soc2003; 51: 1539–1546.
57.
ElieMColeMGPrimeauFJ, et al.Delirium risk factors in elderly hospitalized patients. J Gen Intern Med1998; 13: 204–212.
58.
EikelenboomPHoogendijkWJ.Do delirium and Alzheimer’s dementia share specific pathogenetic mechanisms?Dement Geriatr Cogn Disord1999; 10: 319–324.
59.
StelmokasJGabelNFlahertyJM, et al.Delirium detection and impact of comorbid health conditions in a post-acute rehabilitation hospital setting. PLoS One2016; 11: e0166754.
DudzinskiDMJanuzziJL.The evolving medical complexity of the modern cardiac intensive care unit. J Am Coll Cardiol2017; 69: 2008–2010.
62.
KheraRCramPLuX, et al.Trends in the use of percutaneous ventricular assist devices: analysis of national inpatient sample data, 2007 through 2012. JAMA Intern Med2015; 175: 941–950.
63.
GirardTDJacksonJCPandharipandePP, et al.Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med2010; 38: 1513–1520.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
