Abstract 325: Acute Decompensated Heart Failure, Pneumonia, and Exacerbated Chronic Obstructive Pulmonary Disease are all Routinely Treated as Cardiopulmonary Syndromes
Authors: Dharmarajan Kumar , Strait Kelly M , Lagu Tara , Lindenauer Peter K , Tinetti Mary E , Lynn Joanne , Li Shu-Xia , Krumholz Harlan M 
Published: March 2022

Background:
Patients hospitalized with a principal discharge diagnosis of heart failure (HF) are often treated for other common conditions causing shortness of breath such as pneumonia (PNA) and exacerbated COPD. We hypothesized that this pattern could be a more general phenomenon and that patients hospitalized with a principal diagnosis of any of these 3 conditions would often be treated concomitantly with medications indicated for the others. Such treatment would signal frequent diagnostic uncertainty or the concomitant presence of more than one acute condition in real-world practice.

Methods:
We included hospitalizations with principal discharge diagnoses of HF, PNA, or COPD from 2009-10 Premier, Inc., hospitals with age>65y, known admission source, and non-pediatric attending physician. To increase cohort specificity, length of stay had to be >2 days, the HF cohort required HF treatment (loop diuretics, inotropes, or IV vasodilators) during the first 2 hospital days, the PNA cohort required antibiotic treatment, and the COPD cohort required systemic corticosteroid treatment. To increase treatment specificity, we excluded hospitalizations with present-on-admission codes for ascites, infections besides PNA, and inflammatory, allergic, or autoimmune conditions besides COPD. For each cohort, we noted co-treatment for the other 2 conditions during the first 2 hospital days (for the COPD cohort, only co-treatment for HF was ascertainable as antibiotics are often used for acute COPD). To better understand patient complexity, we also calculated odds of in-hospital mortality among co-treated patients after adjusting for age, sex, and Elixhauser comorbidities.

Results:
Among 118,061 HF hospitalizations, 38% were co-treated during the first 2 hospital days (34% antibiotics, 9% corticosteroids). Among 91,709 PNA hospitalizations, 32% were co-treated (18% HF treatment, 18% corticosteroids). Among 41,052 COPD hospitalizations, 19% were co-treated (19% HF treatment). Death occurred during 3,483 (3.0%), 3,850 (4.2%), and 846 (2.1%) of hospitalizations for HF, PNA, and COPD, respectively. Adjusted odds of in-hospital mortality among co-treated compared with non co-treated patients were 1.61 (95% CI: 1.49, 1.73), 2.38 (2.22, 2.54), and 2.09 (1.81, 2.42) for HF, PNA, and COPD hospitalizations, respectively.

Conclusions:
Co-treatment for acute cardiac and pulmonary conditions is common across HF, PNA, and COPD hospitalizations and is a marker for adverse outcomes. These findings reveal the complexity of disease presentation and treatment in typical practice and the variable phenotypes among hospitalizations for common cardiopulmonary conditions. Further research can clarify motivations for co-treatment and its impact on outcomes. In the interim, there is a need for guidelines to reflect the reality of diagnostic uncertainty and co-existing active conditions.