Research Objectives Heart failure (HF) is a common condition in persons older than 65 years. Existing literature indicated that hospital readmission rates after discharge for heart failure patients are immensely high. However, previous studies showed that almost half of the early hospital readmissions could be prevented. Moreover, Angiotensin-converting enzyme (ACE) inhibitor and Angiotensin receptor blocker (ARB) are the commonly used medications for heart failure patients to control blood pressure. Nevertheless, studies indicated that these two medications could also cause the risk of hospital readmission. Little studies examined the associations of medication use and hospital readmission of heart failure patients in Taiwan. This study aims to investigate the influence factors of hospital readmissions among heart failure patients in Taiwan. Study Design We collected the data from National Health Insurance (NHI) database during the period from year 2000 to 2006. Based on the rule of Bureau of National Health Insurance in Taiwan, the 14-day readmission is considered as a poor quality indicator. We categorized readmissions into 4 groups (14-day, 30-day, 180-day and over 180-day) and evaluated each group¡¦s demographic, hospital characteristics, medical resource utilization, Charlson Comorbidity Index and medication utilizations of ACE inhibitor and ARB. We conducted descriptive analyses by using chi-square and t tests and applied multivariate logistic regression analyses to estimate the probabilities of hospital readmissions of heart failure patients. Population Studied Patients aged 50 or older with heart failure were identified based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Principle Findings Among 1920 heart failure patients, 19.9% of them were readmitted within 14 days, 7.6% were readmitted within 30 days and 26% were readmitted within 180 days. The medical resource utilizations such as average inpatients cost per patient, average outpatients cost per patient, total medical cost, average of inpatients times per patient and average of outpatients times per patient were significantly higher in patients with readmissions than those without readmission. Age, Charlson Comorbidity Index, patients who had been treated with ACE inhibitors and patients who had been treated with ARB were significantly affected the probabilities of readmissions. Conclusion The heart failure patients with readmissions had significantly higher medical resource utilizations than those without readmission. The medication uses of ACE inhibitors or ARB were significantly affected the probabilities of hospital readmissions. By understanding more about the influence factors of readmissions among heart failure patients, we may provide continue improvements of quality of care and reduce unnecessary medical costs. This study results provide useful reference for policy-makers to establish effective disease management program and appropriate health care financing arrangement in the future.

Background: Insulin resistance may play a pathogenic role in cardiovascular disease (CVD). Resistance to insulin has been associated with obesity, hypertension, and abnormal glucose and lipid metabolism. The constellation of these features among insulin resistant subjects has been called the metabolic syndrome. Prevalence of the metabolic syndrome increases with age and is most common in the elderly. Different criteria have been proposed to define the metabolic syndrome (ATP, WHO, AACE, EGIR). Current management of metabolic syndrome focuses on the specific risk factors that the patient may have without targeting the underlying insulin resistance. Angiotensin Converting Enzyme Inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB) are widely used antihypertensive medications that may improve insulin sensitivity. We hypothesize that they can be used to reduce the long term cardiovascular complications in elderly hypertensive subjects with evidence of insulin resistance. In this study, we determined the effect of ACEI/ARB on the long term development of CVD in hypertensive non-diabetic elderly patients with the metabolic syndrome, as well as in patients with insulin resistance. Methods: Our research project utilizes the Cardiovascular Health Study (CHS) dataset. This dataset is a community based observational study where elderly participants were randomly selected and followed up for 11 years and the time to any cardiovascular event was recorded. In our project, we included hypertensive, non-diabetic individuals, with evidence of metabolic syndrome or insulin resistance, but had not experienced cardiovascular events at baseline. Cox regression model was used to evaluate the effect of ACEI/ARB on the time to the first cardiovascular event compared to the other antihypertensive medications adjusting for possible confounders such as age, race, gender, smoking status, triglycerides, LDL levels, systolic blood pressure, development of diabetes, congestive heart failure (CHF) and the number of anti-hypertensives. Results: In elderly hypertensive non-diabetic subjects with the metabolic syndrome according to the ATP and the WHO criteria, the hazard ratio for CVD associated with the use of ACEI/ARB was 0.65 or 0.68 (with 95 % C.I. of [0.45, 0.98], and [0.48, 0.96]) respectively when compared to the group exposed to the other anti-hypertensives. When the metabolic syndrome was defined according to the AACE and EGIR, the use of ACE/ARB was associated with hazard ratios for CVD equal to 0.74 and 0.899, respectively (with 95 % C.I. of [0.54, 1.09] and [0.61, 1.34]) compared to the use of the other anti-hypertensives. Hypertensive non-diabetic elderly subjects who were insulin resistant as evidenced by a HOMA-IR in the upper quartile, had a hazard ratio for CVD of 0.78 (95 % C.I. [0.56, 1.09]) associated with the use of ACEI/ARB compared to the use of other anti-hypertensives. Conclusions: The effect of ACEI/ARB on the development of cardiovascular events differs according to the definition of the metabolic syndrome. Elderly hypertensive patients with the metabolic syndrome, defined by ATP and WHO, seem to have lower risk of CVD with ACEI/ARB compared to the other antihypertensive medications. However, this association is not significant in elderly hypertensive patients in the upper quartile of HOMA and in patients with the metabolic syndrome as defined by AACE and EGIR criteria.

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