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Shao Y, Zhang S, Raman VK, Patel SS, Cheng Y, Parulkar A, Lam PH, Moore H, Sheriff HM, Fonarow GC, Heidenreich PA, Wu WC, Ahmed A, Zeng-Treitler Q. Artificial intelligence approaches for phenotyping heart failure in U.S. Veterans Health Administration electronic health record. ESC Heart Fail 2024; 11:3155-3166. [PMID: 38873749 DOI: 10.1002/ehf2.14787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/23/2024] [Accepted: 03/15/2024] [Indexed: 06/15/2024] Open
Abstract
AIMS Heart failure (HF) is a clinical syndrome with no definitive diagnostic tests. HF registries are often based on manual reviews of medical records of hospitalized HF patients identified using International Classification of Diseases (ICD) codes. However, most HF patients are not hospitalized, and manual review of big electronic health record (EHR) data is not practical. The US Department of Veterans Affairs (VA) has the largest integrated healthcare system in the nation, and an estimated 1.5 million patients have ICD codes for HF (HF ICD-code universe) in their VA EHR. The objective of our study was to develop artificial intelligence (AI) models to phenotype HF in these patients. METHODS AND RESULTS The model development cohort (n = 20 000: training, 16 000; validation 2000; testing, 2000) included 10 000 patients with HF and 10 000 without HF who were matched by age, sex, race, inpatient/outpatient status, hospital, and encounter date (within 60 days). HF status was ascertained by manual chart reviews in VA's External Peer Review Program for HF (EPRP-HF) and non-HF status was ascertained by the absence of ICD codes for HF in VA EHR. Two clinicians annotated 1000 random snippets with HF-related keywords and labelled 436 as HF, which was then used to train and test a natural language processing (NLP) model to classify HF (positive predictive value or PPV, 0.81; sensitivity, 0.77). A machine learning (ML) model using linear support vector machine architecture was trained and tested to classify HF using EPRP-HF as cases (PPV, 0.86; sensitivity, 0.86). From the 'HF ICD-code universe', we randomly selected 200 patients (gold standard cohort) and two clinicians manually adjudicated HF (gold standard HF) in 145 of those patients by chart reviews. We calculated NLP, ML, and NLP + ML scores and used weighted F scores to derive their optimal threshold values for HF classification, which resulted in PPVs of 0.83, 0.77, and 0.85 and sensitivities of 0.86, 0.88, and 0.83, respectively. HF patients classified by the NLP + ML model were characteristically and prognostically similar to those with gold standard HF. All three models performed better than ICD code approaches: one principal hospital discharge diagnosis code for HF (PPV, 0.97; sensitivity, 0.21) or two primary outpatient encounter diagnosis codes for HF (PPV, 0.88; sensitivity, 0.54). CONCLUSIONS These findings suggest that NLP and ML models are efficient AI tools to phenotype HF in big EHR data to create contemporary HF registries for clinical studies of effectiveness, quality improvement, and hypothesis generation.
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Affiliation(s)
- Yijun Shao
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
| | - Sijian Zhang
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
| | - Venkatesh K Raman
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC, USA
- Georgetown University, Washington, DC, USA
| | - Samir S Patel
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
| | - Yan Cheng
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
| | - Anshul Parulkar
- Veterans Affairs Medical Center, Providence, RI, USA
- Brown University, Providence, RI, USA
| | - Phillip H Lam
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC, USA
- Georgetown University, Washington, DC, USA
- MedStar Washington Hospital Center, Washington, DC, USA
| | - Hans Moore
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
- Georgetown University, Washington, DC, USA
- Uniformed Services University, Bethesda, MD, USA
| | - Helen M Sheriff
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
| | | | - Paul A Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Wen-Chih Wu
- Veterans Affairs Medical Center, Providence, RI, USA
- Brown University, Providence, RI, USA
| | - Ali Ahmed
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
- Georgetown University, Washington, DC, USA
| | - Qing Zeng-Treitler
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
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Saha A, Li S, de Lemos JA, Pandey A, Bhatt DL, Fonarow GC, Nallamothu BK, Wang TY, Navar AM, Peterson E, Matsouaka RA, Bavry AA, Das SR, Grodin JL, Khera R, Drazner MH, Kumbhani DJ. Characteristics of High-Performing Hospitals in Cardiogenic Shock Following Acute Myocardial Infarction. Am J Cardiol 2024; 221:19-28. [PMID: 38583700 DOI: 10.1016/j.amjcard.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/06/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
Cardiogenic shock after acute myocardial infarction (AMI-CS) carries significant mortality despite advances in revascularization and mechanical circulatory support. We sought to identify the process-based and structural characteristics of centers with lower mortality in AMI-CS. We analyzed 16,337 AMI-CS cases across 440 centers enrolled in the National Cardiovascular Data Registry's Chest Pain-MI Registry, a retrospective cohort database, between January 1, 2015, and December 31, 2018. Centers were stratified across tertiles of risk-adjusted in-hospital mortality rate (RAMR) for comparison. Risk-adjusted multivariable logistic regression was also performed to identify hospital-level characteristics associated with decreased mortality. The median participant age was 66 (interquartile range 57 to 75) years, and 33.0% (n = 5,390) were women. The median RAMR was 33.4% (interquartile range 26.0% to 40.0%) and ranged from 26.9% to 50.2% across tertiles. Even after risk adjustment, lower-RAMR centers saw patients with fewer co-morbidities. Lower-RAMR centers performed more revascularization (92.8% vs 90.6% vs 85.9%, p <0.001) and demonstrated better adherence to associated process measures. Left ventricular assist device capability (odds ratio [OR] 0.78 [0.67 to 0.92], p = 0.002), more frequent revascularization (OR 0.93 [0.88 to 0.98], p = 0.006), and higher AMI-CS volume (OR 0.95 [0.91 to 0.99], p = 0.009) were associated with lower in-hospital mortality. However, several such characteristics were not more frequently observed at low-RAMR centers, despite potentially reflecting greater institutional experience or resources. This may reflect the heterogeneity of AMI-CS even after risk adjustment. In conclusion, low-RAMR centers do not necessarily exhibit factors associated with decreased mortality in AMI-CS, which may reflect the challenges in performing outcomes research in this complex population.
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Affiliation(s)
- Amit Saha
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shuang Li
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - James A de Lemos
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ambarish Pandey
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Gregg C Fonarow
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Michigan, Ann Arbor, Michigan
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Ann Marie Navar
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric Peterson
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Anthony A Bavry
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sandeep R Das
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Justin L Grodin
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rohan Khera
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Biostatistics, Section of Health Informatics, Yale School of Public Health, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Mark H Drazner
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Dharam J Kumbhani
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Reeves MJ, Fonarow GC, Smith EE, Sheth KN, Messe SR, Schwamm LH. Twenty Years of Get With The Guidelines-Stroke: Celebrating Past Successes, Lessons Learned, and Future Challenges. Stroke 2024; 55:1689-1698. [PMID: 38738376 PMCID: PMC11208062 DOI: 10.1161/strokeaha.124.046527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
The Get With The Guidelines-Stroke program which, began 20 years ago, is one of the largest and most important nationally representative disease registries in the United States. Its importance to the stroke community can be gauged by its sustained growth and widespread dissemination of findings that demonstrate sustained increases in both the quality of care and patient outcomes over time. The objectives of this narrative review are to provide a brief history of Get With The Guidelines-Stroke, summarize its major successes and impact, and highlight lessons learned. Looking to the next 20 years, we discuss potential challenges and opportunities for the program.
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Affiliation(s)
- Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Gregg C. Fonarow
- Division of Cardiology, Geffen School of Medicine, University of California Los Angeles (G.C.F.)
| | - Eric E. Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Kevin N. Sheth
- Center for Brain & Mind Health, Departments of Neurology & Neurosurgery (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Steven R. Messe
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (S.R.M.)
| | - Lee H. Schwamm
- Department of Neurology and Bioinformatics and Data Sciences (L.H.S.), Yale School of Medicine, New Haven, CT
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Elkind MSV, Arnett DK, Benjamin IJ, Eckel RH, Grant AO, Houser SR, Jacobs AK, Jones DW, Robertson RM, Sacco RL, Smith SC, Weisfeldt ML, Wu JC, Jessup M. The American Heart Association at 100: A Century of Scientific Progress and the Future of Cardiovascular Science: A Presidential Advisory From the American Heart Association. Circulation 2024; 149:e964-e985. [PMID: 38344851 DOI: 10.1161/cir.0000000000001213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
In 1924, the founders of the American Heart Association (AHA) envisioned an international society focused on the heart and aimed at facilitating research, disseminating information, increasing public awareness, and developing public health policy related to heart disease. This presidential advisory provides a comprehensive review of the past century of cardiovascular and stroke science, with a focus on the AHA's contributions, as well as informed speculation about the future of cardiovascular science into the next century of the organization's history. The AHA is a leader in fundamental, translational, clinical, and population science, and it promotes the concept of the "learning health system," in which a continuous cycle of evidence-based practice leads to practice-based evidence, permitting an iterative refinement in clinical evidence and care. This advisory presents the AHA's journey over the past century from instituting professional membership to establishing extraordinary research funding programs; translating evidence to practice through clinical practice guidelines; affecting systems of care through quality programs, certification, and implementation; leading important advocacy efforts at the federal, state and local levels; and building global coalitions around cardiovascular and stroke science and public health. Recognizing an exciting potential future for science and medicine, the advisory offers a vision for even greater impact for the AHA's second century in its continued mission to be a relentless force for longer, healthier lives.
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Badrish N, Sheifer S, Rosner CM. Systems of care for ambulatory management of decompensated heart failure. Front Cardiovasc Med 2024; 11:1350846. [PMID: 38455722 PMCID: PMC10918851 DOI: 10.3389/fcvm.2024.1350846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/25/2024] [Indexed: 03/09/2024] Open
Abstract
Heart failure (HF) represents a worldwide health burden and the annual per patient cost to treat HF in the US is estimated at $24,383, with most of this expense driven by HF related hospitalizations. Decompensated HF is a leading cause for hospital admissions and is associated with an increased risk of subsequent morbidity and mortality. Many hospital admissions for decompensated HF are considered preventable with timely recognition and effective intervention.Systems of care that include interventions to facilitate early recognition, timely and appropriate intervention, intensification of care, and optimization to prevent recurrence can help successfully manage decompensated HF in the ambulatory setting and avoid hospitalization.
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Affiliation(s)
- Narotham Badrish
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
| | - Stuart Sheifer
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
- Department of Cardiology, Virginia Heart, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
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Taniguchi FP, Bernardez-Pereira S, Ribeiro ALP, Morgan L, Curtis AB, Taubert K, Albuquerque DCD, Smith SC, Paola AAVD. A Nationwide Initiative to Improve Cardiology Quality: The Best Practice in Cardiology Program in Brazil. Arq Bras Cardiol 2023; 120:e20230375. [PMID: 38055374 DOI: 10.36660/abc.20230375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/16/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND A Nationwide Initiative to Improve Cardiology Quality: The Best Practice in Cardiology Program in Brazil ACEI/ARB: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker; LVEF: left ventricular ejection fraction; LVSD: left ventricular systolic dysfunction; AF: atrial fibrillation; PT/INR: prothrombin time/international normalized ratio. BACKGROUND Despite significant progress in improving the quality of cardiovascular care, persistent gaps remain in terms of inconsistent adherence to guideline recommendations. OBJECTIVE This study evaluates the effects of implementing a quality improvement program adapted from the American Heart Association's Get with the Guidelines™ initiative on adherence to guideline-directed medical therapy for acute coronary syndrome (ACS), atrial fibrillation (AF), and heart failure (HF). METHODS We examined demographics, quality measures, and short-term outcomes in patients hospitalized with ACS, AF, and HF enrolled in the Best Practice in Cardiology (BPC) Program from 2016 to 2022. RESULTS This study included 12,167 patients in 19 hospitals in Brazil. Mean age was 62.5 [53.8-71] y/o; 61.1% were male, 68.7% had hypertension, 32.0% diabetes mellitus, and 24.1% had dyslipidemia. Composite score had a sustainable performance in the period from baseline to the last quarter: 65.8±36.2% to 73± 31.2% for AF (p=0.024), 81.0± 23.6% to 89.9 ± 19.3% for HF (p<0.001), and from 88.0 ± 19.1 to 91.2 ±14.9 for ACS (p<0.001). CONCLUSIONS The BPC program is a quality improvement program in Brazil in which real-time data, obtained using cardiology guideline metrics, were implemented in a quality improvement program resulting in an overall sustained improvement in AF, HF, and ACS management.
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Affiliation(s)
| | | | | | | | - Anne B Curtis
- University at Buffalo - The State University of New York, Buffalo, New York - EUA
| | | | | | - Sidney C Smith
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina - EUA
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Nishi M, Shikuma A, Seki T, Horiguchi G, Matoba S. In-hospital mortality and cardiovascular treatment during hospitalization for heart failure among patients with schizophrenia: a nationwide cohort study. Epidemiol Psychiatr Sci 2023; 32:e62. [PMID: 37849318 PMCID: PMC10594642 DOI: 10.1017/s2045796023000744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/06/2023] [Accepted: 09/17/2023] [Indexed: 10/19/2023] Open
Abstract
AIMS Schizophrenia is associated with cardiovascular disease (CVD) risk, and patients with schizophrenia are more likely to receive suboptimal care for CVD. However, there is limited knowledge regarding in-hospital prognosis and quality of care for patients with schizophrenia hospitalized for heart failure (HF). This study sought to elucidate the association between schizophrenia and in-hospital mortality, as well as cardiovascular treatment in patients hospitalized with HF. METHODS Using the nationwide cardiovascular registry data in Japan, a total of 704,193 patients hospitalized with HF from 2012 to 2019 were included and stratified by age: young age, > 18 to 45 years (n = 20,289); middle age, >45 to 65 years (n = 114,947); and old age, >65 to 85 years (n = 568,957). All and 30-day in-hospital mortality as well as prescription of cardiovascular medications were assessed. After multiple imputation for missing values, mixed-effect multivariable logistic regression analysis was performed using patient and hospital characteristics with hospital identifier as a variable with random effects. RESULTS Patients with schizophrenia were more likely to experience prolonged hospital stays, and incur higher hospitalization costs. In-hospital mortality for non-elderly patients with schizophrenia was significantly worse than for those without schizophrenia: the mortality rate was 7.6% vs 3.5% and the adjusted odds ratio (OR) was 1.96 (95% confidence interval (CI): 1.24-3.10, P = 0.0037) in young adult patients; 6.2% vs 4.0% and 1.49 (95% CI: 1.17-1.88, P < 0.001) in middle-aged patients. Thirty-day in-hospital mortality was significantly worse in middle-aged patients: the mortality rate was 4.7% vs 3.0% and an adjusted OR was 1.40 (95% CI: 1.07-1.83, P = 0.012). In-hospital mortality in elderly patients did not differ between those with and without schizophrenia. Prescriptions of beta-blockers and angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were significantly lower in patients with schizophrenia across all age groups. CONCLUSION Schizophrenia was identified as a risk factor for in-hospital mortality and reduced prescription of cardioprotective medications in non-elderly patients hospitalized with HF. These findings highlight the necessity for differentiated care and management of HF in patients with severe mental illnesses.
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Affiliation(s)
- Masahiro Nishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akira Shikuma
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Go Horiguchi
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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8
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Nargesi AA, Adejumo P, Dhingra L, Rosand B, Hengartner A, Coppi A, Benigeri S, Sen S, Ahmad T, Nadkarni GN, Lin Z, Ahmad FS, Krumholz HM, Khera R. Automated Identification of Heart Failure with Reduced Ejection Fraction using Deep Learning-based Natural Language Processing. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.10.23295315. [PMID: 37745445 PMCID: PMC10516088 DOI: 10.1101/2023.09.10.23295315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Background The lack of automated tools for measuring care quality has limited the implementation of a national program to assess and improve guideline-directed care in heart failure with reduced ejection fraction (HFrEF). A key challenge for constructing such a tool has been an accurate, accessible approach for identifying patients with HFrEF at hospital discharge, an opportunity to evaluate and improve the quality of care. Methods We developed a novel deep learning-based language model for identifying patients with HFrEF from discharge summaries using a semi-supervised learning framework. For this purpose, hospitalizations with heart failure at Yale New Haven Hospital (YNHH) between 2015 to 2019 were labeled as HFrEF if the left ventricular ejection fraction was under 40% on antecedent echocardiography. The model was internally validated with model-based net reclassification improvement (NRI) assessed against chart-based diagnosis codes. We externally validated the model on discharge summaries from hospitalizations with heart failure at Northwestern Medicine, community hospitals of Yale New Haven Health in Connecticut and Rhode Island, and the publicly accessible MIMIC-III database, confirmed with chart abstraction. Results A total of 13,251 notes from 5,392 unique individuals (mean age 73 ± 14 years, 48% female), including 2,487 patients with HFrEF (46.1%), were used for model development (train/held-out test: 70/30%). The deep learning model achieved an area under receiving operating characteristic (AUROC) of 0.97 and an area under precision-recall curve (AUPRC) of 0.97 in detecting HFrEF on the held-out set. In external validation, the model had high performance in identifying HFrEF from discharge summaries with AUROC 0.94 and AUPRC 0.91 on 19,242 notes from Northwestern Medicine, AUROC 0.95 and AUPRC 0.96 on 139 manually abstracted notes from Yale community hospitals, and AUROC 0.91 and AUPRC 0.92 on 146 manually reviewed notes at MIMIC-III. Model-based prediction of HFrEF corresponded to an overall NRI of 60.2 ± 1.9% compared with the chart diagnosis codes (p-value < 0.001) and an increase in AUROC from 0.61 [95% CI: 060-0.63] to 0.91 [95% CI 0.90-0.92]. Conclusions We developed and externally validated a deep learning language model that automatically identifies HFrEF from clinical notes with high precision and accuracy, representing a key element in automating quality assessment and improvement for individuals with HFrEF.
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Affiliation(s)
- Arash A. Nargesi
- Heart and Vascular Center, Brigham and Women’s Hospital, Harvard School of Medicine, Boston, MA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Philip Adejumo
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Lovedeep Dhingra
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Benjamin Rosand
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Astrid Hengartner
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Andreas Coppi
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT
| | - Simon Benigeri
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sounok Sen
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Girish N Nadkarni
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT
| | - Faraz S. Ahmad
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT
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Nishi M, Seki T, Shikuma A, Kawamata H, Horiguchi G, Matoba S. Association between patient volume to cardiologist, process of care, and clinical outcomes in heart failure. ESC Heart Fail 2023. [PMID: 37075756 PMCID: PMC10375098 DOI: 10.1002/ehf2.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/07/2023] [Accepted: 04/04/2023] [Indexed: 04/21/2023] Open
Abstract
AIMS The impact of hospital volume on clinical performance has been investigated by many researchers to date and thought that it is associated with quality of care and outcome for patients with heart failure (HF). This study sought to determine whether annual admissions of HF per cardiologist are associated with process of care, mortality, and readmission. METHODS AND RESULTS Among the nationwide registry 'Japanese registry of all cardiac and vascular diseases - diagnostics procedure combination' data collected from 2012 to 2019, a total of 1 127 113 adult patients with HF and 1046 hospitals were included in the study. Primary outcome was in-hospital mortality, and secondary outcome was 30 day in-hospital mortality and readmission at 30 days and 6 months. Hospital and patient characteristics and process of care measures were also assessed. Mixed-effect logistic regression and Cox proportional-hazards model was used for multivariable analysis, and adjusted odds ratio and hazard ratio were evaluated. Process of care measures had inverse trends for annual admissions of HF per cardiologist (P < 0.01 for all measures: prescription rate of beta-blocker, angiotensin converting enzyme inhibitor or angiotensin II receptor blocker, mineralocorticoid receptor antagonist, and anticoagulant for atrial fibrillation). Adjusted odds ratio for in-hospital mortality was 1.04 (95% confidence interval (CI): 1.04-1.08, P = 0.04) and 30 day in-hospital mortality was 1.05 (95% CI: 1.01-1.09, P = 0.01) for interval of 50 annual admissions of HF per cardiologist. Adjusted hazard ratio for 30 day readmission was 1.05 (95% CI: 1.02-1.08, P < 0.01) and 6 month readmission was 1.07 (95% CI: 1.03-1.11, P < 0.01). Plots of the adjusted odds indicated 300 as the threshold of annual admissions of HF per cardiologist for substantial increase of in-hospital mortality risk. CONCLUSIONS Our findings demonstrated that annual admissions of HF per cardiologist are associated with worse process of care, mortality, and readmission with the threshold for mortality risk increased, emphasizing the optimal proportion of patients admitted with HF to cardiologist for better clinical performance.
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Affiliation(s)
- Masahiro Nishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akira Shikuma
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hirofumi Kawamata
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Go Horiguchi
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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10
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Bertoletti OA. Good Practices In Cardiology - A Lesson From Performance Indicators. Arq Bras Cardiol 2023; 120:e20230033. [PMID: 37042864 PMCID: PMC10473825 DOI: 10.36660/abc.20230033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Affiliation(s)
- Otávio Azevedo Bertoletti
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
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11
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Dai L, Dorje T, Gootjes J, Shah A, Dembo L, Rankin J, Hillis G, Robinson S, Atherton JJ, Jacques A, Reid CM, Maiorana A. Primary care Adherence To Heart Failure guidelines IN Diagnosis, Evaluation and Routine management (PATHFINDER): a randomised controlled trial protocol. BMJ Open 2023; 13:e063656. [PMID: 36972959 PMCID: PMC10069547 DOI: 10.1136/bmjopen-2022-063656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 02/06/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION General practitioners (GPs) routinely provide care for patients with heart failure (HF); however, adherence to management guidelines, including titrating medication to optimal dose, can be challenging in this setting. This study will evaluate the effectiveness of a multifaceted intervention to support adherence to HF management guidelines in primary care. METHODS AND ANALYSIS We will undertake a multicentre, parallel-group, randomised controlled trial of 200 participants with HF with reduced ejection fraction. Participants will be recruited during a hospital admission due to HF. Following hospital discharge, the intervention group will have follow-up with their GP scheduled at 1 week, 4 weeks and 3 months with the provision of a medication titration plan approved by a specialist HF cardiologist. The control group will receive usual care. The primary endpoint, assessed at 6 months, will be the difference between groups in the proportion of participants being prescribed five guideline-recommended treatments; (1) ACE inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor at least 50% of target dose, (2) beta-blocker at least 50% of target dose, (3) mineralocorticoid receptor antagonist at any dose, (4) anticoagulation for patients diagnosed with atrial fibrillation, (5) referral to cardiac rehabilitation. Secondary outcomes will include functional capacity (6-minute walk test); quality of life (Kansas City Cardiomyopathy Questionnaire); depressive symptoms (Patient Health Questionnaire-2); self-care behaviour (Self-Care of Heart Failure Index). Resource utilisation will also be assessed. ETHICS AND DISSEMINATION Ethical approval was granted by the South Metropolitan Health Service Ethics Committee (RGS3531), with reciprocal approval at Curtin University (HRE2020-0322). Results will be disseminated via peer-reviewed publications and conferences. TRIAL REGISTRATION NUMBER ACTRN12620001069943.
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Affiliation(s)
- Liying Dai
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Tashi Dorje
- Department of Cardiology, Mount Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Jan Gootjes
- WA Cardiology, Perth, Western Australia, Australia
| | - Amit Shah
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Lawrence Dembo
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Jamie Rankin
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Graham Hillis
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Suzanne Robinson
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- Deakin Health Economics, Deakin University, Melbourne, Western Australia, Australia
| | - John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Angela Jacques
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Institute for Health Research, The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Christopher M Reid
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Maiorana
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Department of Allied Health, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
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12
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Reeves MJ, Boden-Albala B, Cadilhac DA. Care Transition Interventions to Improve Stroke Outcomes: Evidence Gaps in Underserved and Minority Populations. Stroke 2023; 54:386-395. [PMID: 36689590 DOI: 10.1161/strokeaha.122.039565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/09/2022] [Indexed: 01/24/2023]
Abstract
In many countries hospital length of stay after an acute stroke admission is typically just a few days, therefore, most of a person's recovery from stroke occurs in the community. Care transitions, which occur when there is a change in, or handoff between 2 different care settings or providers, represent an especially vulnerable period for patients and caregivers. For some patients with stroke the return home is associated with substantial practical, psychosocial, and health-related challenges leading to substantial burden for the individual and caregiver. Underserved and minority populations, because of their exposure to poor environmental, social, and economic conditions, as well as structural racism and discrimination, are especially vulnerable to the problems of complicated care transitions which in turn, can negatively impact stroke recovery. Overall, there remain significant unanswered questions about how to promote optimal recovery in the post-acute care period, particularly for those from underserved communities. Evidence is limited on how best to support patients after they have returned home where they are required to navigate the chronic stages of stroke with little direct support from health professionals.
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Affiliation(s)
- Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Bernadette Boden-Albala
- Department of Health Society and Behavior, Department of Epidemiology and Biostatistics, Program in Public Health, Department of Neurology, School of Medicine, University of California (B.B.-A.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia (D.A.C.)
- Stroke theme, the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia (D.A.C.)
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13
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Cadilhac DA, Marion V, Andrew NE, Breen SJ, Grabsch B, Purvis T, Morrison JL, Lannin NA, Grimley RS, Middleton S, Kilkenny MF. A Stepped-Wedge Cluster-Randomized Trial to Improve Adherence to Evidence-Based Practices for Acute Stroke Management. Jt Comm J Qual Patient Saf 2022; 48:653-664. [PMID: 36307360 DOI: 10.1016/j.jcjq.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND There is limited evidence regarding the optimal design and composition of multifaceted quality improvement programs to improve acute stroke care. The researchers aimed to test the effectiveness of a co-designed multifaceted intervention (STELAR: Shared Team Efforts Leading to Adherence Results) directed at hospital clinicians for improving acute stroke care tailored to the local context using feedback of national registry indicator data. METHODS STELAR was a stepped-wedge cluster trial (partial randomization) using routinely collected Australian Stroke Clinical Registry data from Victorian hospitals segmented in two-month blocks. Each hospital (cluster) contributed control data from May 2017 and data for the intervention phase from July 2017 until September 2018. The intervention was multifaceted, delivered predominantly in two educational outreach workshops by experienced, external improvement facilitators, consisting of (1) feedback of registry data to identify practice gaps and (2) interprofessional education, barrier assessment, and documentation of an agreed action plan initiated by local clinical leaders appointed as change champions for prioritized clinical indicators. The researchers provided additional outreach support by e-mail/telephone for two months. Multilevel, multivariable regression models were used to assess change in a composite outcome of indicators selected for actions plans (primary outcome) and individual indicators (secondary outcome). Patient survival and disability 90-180 days after stroke were also compared. RESULTS Nine hospitals (clusters) participated, and 144 clinicians attended 18 intervention workshops. The control phase included 1,001 patients (median age 76.7 years; 47.4% female, 64.7% ischemic stroke), and the intervention phase 2,146 patients (median age 74.9 years; 44.2% female, 73.8% ischemic stroke). Compared to the control phase, the median score for the composite outcome for the intervention phase was 17% greater for the indicators included in the hospitals' action plans (range 3% to 30%, p = 0.016) and overall for the 10 indicators 6% greater (range 3% to 10%, p < 0.001). Compared to the control phase, patients in the intervention phase more often received stroke unit care (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.05-1.84), were discharged on antithrombotic medications (OR 1.87, 95% CI 1.50-2.33), and received a discharge care plan (OR 1.27, 95% CI 1.05-1.53). Patient outcomes were unchanged. CONCLUSION External quality improvement facilitation using workshops and remote support, aligned with routine monitoring via registries, can improve acute stroke care.
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14
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Zheng J, Tisdale RL, Heidenreich PA, Sandhu AT. Disparities in Hospital Length of Stay Across Race and Ethnicity Among Patients With Heart Failure. Circ Heart Fail 2022; 15:e009362. [PMID: 36378760 PMCID: PMC9673157 DOI: 10.1161/circheartfailure.121.009362] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 05/05/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reducing hospital length of stay (LOS) has been identified as an important lever for minimizing the burden of heart failure hospitalization, yet the impact of social and structural determinants of health on LOS has received little attention. We investigated disparities in LOS across race/ethnicity and their possible drivers. METHODS We analyzed patients hospitalized for heart failure from 2017 to 2020 using the Get With The Guidelines-Heart Failure registry. We characterized LOS differences across race/ethnicity by insurance and disposition, adjusting for demographics, comorbidities, and clinical severity. Effects of hospital-level clustering on LOS across race/ethnicity were assessed using hierarchical mixed-effects models. We evaluated the association between LOS and discharge rates of guideline-directed medical therapy. RESULTS Three thousand three seven hundred thirty patients hospitalized for heart failure were identified. After excluding inpatient deaths, the adjusted LOS for Black (5.72 days [95% CI, 5.62-5.82]), Hispanic (5.94 days [95% CI, 5.79-6.08]), and Indigenous American/Pacific Islander (6.06 days [95% CI, 5.85-6.27]) patients remained significantly longer compared with non-Hispanic White patients (5.32 days [95% CI, 5.25-5.39]). This pattern was driven by LOS differences among patients discharged to hospice or nursing facilities. After accounting for variability between hospitals, associations of race/ethnicity with LOS either were attenuated or reversed in direction. Guideline-directed medical therapy rates on discharge did not differ significantly across race/ethnicity despite longer LOS for Black, Hispanic, and Indigenous American/Pacific Islander patients. CONCLUSIONS Differences between hospitals drive LOS disparities across race/ethnicity. Longer LOS among Black, Hispanic, and Indigenous American/Pacific Islander patients was not associated with improved quality of care.
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Affiliation(s)
| | - Rebecca L Tisdale
- Department of Health Policy, Stanford University School of Medicine, Stanford, California
- Veteran’s Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - Paul A Heidenreich
- Veteran’s Affairs Palo Alto Healthcare System, Palo Alto, CA
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA
| | - Alexander T Sandhu
- Veteran’s Affairs Palo Alto Healthcare System, Palo Alto, CA
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA
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15
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DeVore AD, Bosworth HB, Granger BB. Improving implementation of evidence-based therapies for heart failure. Clin Cardiol 2022; 45 Suppl 1:S52-S59. [PMID: 35789019 PMCID: PMC9254671 DOI: 10.1002/clc.23845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 12/11/2022] Open
Abstract
Treatment options for patients with heart failure have improved rapidly over the last few decades. Data from large scale clinical trials demonstrate that medical and device therapies can improve quality of life, reduce hospitalizations for acute heart failure, and reduce mortality. However, the use of many of these therapies in routine practice is remarkably low. There are many reasons for suboptimal implementation of evidence-based therapies for heart failure, and we believe addressing the large gap between what can be accomplished in clinical trials versus routine practice is a critical and urgent public health issue. In this review, we outline reasons for this implementation gap and review recent studies attempting to address this issue. We also provide recommendations for future interventions and areas of clinical investigation to improve implementation for patients with heart failure.
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Affiliation(s)
- Adam D. DeVore
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
- Department of MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Hayden B. Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of MedicineDivision of General Internal Medicine, Duke University Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
- Duke University School of Nursing, Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Bradi B. Granger
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
- Duke University School of Nursing, Duke University School of MedicineDurhamNorth CarolinaUSA
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 710] [Impact Index Per Article: 355.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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17
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 891] [Impact Index Per Article: 445.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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18
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Breathett KK, Xu H, Sweitzer NK, Calhoun E, Matsouaka RA, Yancy CW, Fonarow GC, DeVore AD, Bhatt DL, Peterson PN. Is the affordable care act medicaid expansion associated with receipt of heart failure guideline-directed medical therapy by race and ethnicity? Am Heart J 2022; 244:135-148. [PMID: 34813771 PMCID: PMC8727506 DOI: 10.1016/j.ahj.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 09/17/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Uninsurance is a known contributor to racial/ethnic health inequities. Insurance is often needed for prescriptions and follow-up appointments. Therefore, we determined whether the Affordable Care Act(ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment(GDMT) at discharge among patients hospitalized with heart failure(HF) by race/ethnicity. METHODS Using Get With The Guidelines-HF registry, logistic regression was used to assess odds of receiving GDMT(HF medications; education; follow-up appointment) in early vs non-adopter states before(2012 - 2013) and after ACA Medicaid Expansion(2014 - 2019) within each race/ethnicity, accounting for patient-level covariates and within-hospital clustering. We tested for an interaction(p-int) between GDMT and pre/post Medicaid Expansion time periods. RESULTS Among 271,606 patients(57.5% early adopter, 42.5% non-adopter), 65.5% were White, 22.8% African American, 8.9% Hispanic, and 2.9% Asian race/ethnicity. Independent of ACA timing, Hispanic patients were more likely to receive all GDMT for residing in early adopter states compared to non-adopter states (P <.0001). In fully-adjusted analyses, ACA Medicaid Expansion was associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients [before ACA:OR 0.40(95%CI:0.13,1.23); after ACA:OR 2.46(1.10,5.51); P-int = .0002], but this occurred in the setting of an immediate decline in prescribing patterns, particularly among non-adopter states, followed by an increase that remained lowest in non-adopter states. The ACA was not associated with receipt of GDMT for other racial/ethnic groups. CONCLUSIONS Among GWTG-HF hospitals, Hispanic patients were more likely to receive all GDMT if they resided in early adopter states rather than non-adopter states, independent of ACA Medicaid Expansion timing. ACA implementation was only associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients. Additional steps are needed for improved GDMT delivery for all.
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Affiliation(s)
- Khadijah K. Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Haolin Xu
- Department of Biostatistics and Bioinformatics, Duke University,
Durham, NC
| | - Nancy K. Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Elizabeth Calhoun
- Center for Population Science and Discovery, University of Arizona,
Tucson, AZ
| | | | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of
Medicine, Chicago, IL
| | - Gregg C. Fonarow
- Division of Cardiology, University of California Los Angeles,
CA
| | | | - Deepak L. Bhatt
- Division of Cardiovascular Medicine, Brigham and Women’s
Hospital Heart & Vascular Center, Harvard Medical School, Boston,
MA
| | - Pamela N. Peterson
- Division of Cardiology, University of Colorado, Anschutz Medical
Campus, Aurora, CO and Division of Cardiology, Denver Health Medical Center,
Denver, CO
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Gandhi S, Garratt KN, Li S, Wang TY, Bhatt DL, Davis LL, Zeitouni M, Kontos MC. Ten-Year Trends in Patient Characteristics, Treatments, and Outcomes in Myocardial Infarction From National Cardiovascular Data Registry Chest Pain-MI Registry. Circ Cardiovasc Qual Outcomes 2022; 15:e008112. [PMID: 35041478 DOI: 10.1161/circoutcomes.121.008112] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The Chest Pain-MI registry affords a 10-year perspective of the acute myocardial infarction (MI) patient characteristics, management, and clinical outcomes in the United States. We report the changes in the treatment and cardiovascular outcomes of acute MI patients over 10 years. METHODS Annual trends in patient characteristics, in-hospital treatment, and outcomes of 604 936 ST-segment-elevation MI (STEMI) and 933 755 non-ST-segment-elevation MI (NSTEMI) patients at 1230 hospitals from 2009 to 2018 were analyzed. Using the validated Acute Coronary Intervention and Outcomes Network mortality risk model, trends in in-hospital risk-adjusted mortality rates were tested between 2011 and 2018. RESULTS Over 10 years, the prevalence of diabetes (22.8%-28.3% [STEMI] and 35.7%-41.3% [NSTEMI]) and atrial fibrillation (4.1%-6.1% and 9.4%-11.7%) increased, whereas the prevalence of smoking decreased (43.5%-37.9% and 30.2%-27.5%, P<0.001 for all) in patients with STEMI and NSTEMI, respectively. Among eligible patients with STEMI, primary percutaneous coronary intervention use increased (82.3%-96.0%) with shorter median first medical contact to device time (90 to 82 minutes, P<0.001). Among patients with NSTEMI, percutaneous coronary intervention use increased significantly (43.9%-54.5%, P<0.001). Adherence to guideline-directed medical therapies improved in both groups. From 2011 to 2018, risk-adjusted mortality rate (2.8%-2.7%, P=0.46) was stable in STEMI and declined significantly in patients with NSTEMI (1.9%-1.3%, P=0.0001). CONCLUSIONS Risk factors of patients presenting with acute MI have changed modestly while treatment improved over time. Risk-adjusted mortality rates remained stable for patients with STEMI and declined significantly for patients with NSTEMI.
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Affiliation(s)
- Sanjay Gandhi
- Case Western Reserve University- MetroHealth Hospital, Cleveland, OH (S.G.)
| | | | - Shuang Li
- DCRI, Durham, NC (S.L., T.Y.W., M.Z.)
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.L.B.)
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20
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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21
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Singh N, Ding L, Devera J, Magee GA, Garg PK. Prescribing of Statins After Lower Extremity Revascularization Procedures in the US. JAMA Netw Open 2021; 4:e2136014. [PMID: 34860245 PMCID: PMC8642785 DOI: 10.1001/jamanetworkopen.2021.36014] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
IMPORTANCE The use of statins in patients with symptomatic peripheral artery disease remains suboptimal despite strong clinical practice guideline recommendations; however, it is unknown whether rates are associated with substantial improvements after lower extremity revascularization. OBJECTIVE To report longitudinal trends of statin use in patients with peripheral artery disease undergoing lower extremity revascularization and to identify the clinical and procedural characteristics associated with prescriptions for new statin therapy at discharge. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective cross-sectional study using data from the Vascular Quality Initiative registry of patients who underwent lower extremity peripheral artery disease revascularization from January 1, 2014, through December 31, 2019. The Vascular Quality Initiative is a multicenter registry database including academic and community-based hospitals throughout the US. Patients aged 18 years or older undergoing lower extremity revascularization with available statin data (preprocedure and postprocedure) were included. Those not receiving statin therapy for medical reasons were excluded from final analyses. EXPOSURES Patients undergoing lower extremity revascularization for whom statin therapy is indicated. MAIN OUTCOMES AND MEASURES Multivariate logistic regression was used to determine the clinical and procedural characteristics associated with new statin prescription for patients not already taking a statin preprocedure. The overall rates of statin prescription as well as rates of new statin prescription at discharge were determined. In addition, the clinical, demographic, and procedural characteristics associated with new statin prescription were analyzed. RESULTS There were 172 025 procedures corresponding to 125 791 patients (mean [SD] age, 67.7 [11.0] years; 107 800 men [62.7%]; and 135 405 White [78.7%]) included in the analysis. Overall rates of statin prescription at discharge improved from 17 299 of 23 093 (75%) in 2014 to 29 804 of 34 231 (87%) in 2019. However, only 12 790 of 42 020 patients (30%) not already taking a statin at the time of revascularization during the study period were newly discharged with a statin medication. New statin prescription rates were substantially lower after endovascular intervention (7745 of 29 581 [26%]) than after lower extremity bypass (5045 of 12 439 [41%]). Body mass index of 30 or greater (odds ratio [OR], 1.13; 95% CI, 1.04-1.24; P < .001), diabetes (diet-controlled vs no diabetes, OR, 1.22; 95% CI, 1.05-1.41; P = .01), smoking (current vs never, OR, 1.32; 95% CI, 1.21-1.45; P < .001), hypertension (OR, 1.19; 95% CI, 1.09-1.29; P < .001), and coronary heart disease (OR, 1.26; 95% CI, 1.17-1.35; P < .001) were associated with an increased likelihood of new statin prescription after endovascular intervention, whereas female sex, older age, antiplatelet use, and prior peripheral revascularization were associated with a decreased likelihood. CONCLUSIONS AND RELEVANCE In this cross-sectional study, although statin use was associated with a substantial improvement after lower extremity revascularization, more than two-thirds of patients not already taking a statin preprocedure remained not taking a statin at discharge. Further investigations to understand the clinical implications of these findings and develop clinician- and system-based interventions are needed.
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Affiliation(s)
- Nikhil Singh
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Li Ding
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles
| | - Justin Devera
- Department of Internal Medicine, University of Southern California Keck School of Medicine, Los Angeles
| | - Gregory A. Magee
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles
| | - Parveen K. Garg
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 319] [Impact Index Per Article: 106.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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23
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 161] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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24
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Jaber D, Vargas F, Nguyen L, Ringel J, Zarzuela K, Musse M, Kwak MJ, Levitan EB, Maurer MS, Lachs MS, Safford MM, Goyal P. Prescriptions for Potentially Inappropriate Medications from the Beers Criteria Among Older Adults Hospitalized for Heart Failure. J Card Fail 2021; 28:906-915. [PMID: 34818566 DOI: 10.1016/j.cardfail.2021.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND We sought to better understand patterns of potentially inappropriate medications (PIMs) from the Beers criteria among older adults hospitalized with heart failure (HF). This observational study of hospitalizations was derived from the geographically diverse REasons for Geographic and Racial Differences in Stroke cohort. METHODS AND RESULTS We examined participants aged 65 years and older with an expert-adjudicated hospitalization for HF. The Beers criteria medications were abstracted from medical records. The prevalence of PIMs was 61.1% at admission and 64.0% at discharge. Participants were taking a median of 1 PIM (interquartile range [IQR] 0-1 PIM) at hospital admission and a median of 1 PIM (IQR 0-2 PIM) at hospital discharge. Between admission and discharge, 19.1% of patients experienced an increase in the number of PIMs, 15.1% experienced a decrease, and 37% remained on the same number between hospital admission and discharge. The medications with the greatest increase from admission to discharge were proton pump inhibitors (32.6% to 38.6%) and amiodarone (6.2% to 12.2%). The strongest determinant of potentially harmful prescribing patterns was polypharmacy (relative risk 1.34, 95% confidence interval 1.16-1.55, P < .001). CONCLUSIONS PIMs are common among older adults hospitalized for HF and may be an important target to improve outcomes in this vulnerable population.
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Affiliation(s)
- Diana Jaber
- School of Medicine & Health Sciences, George Washington University, Washington, DC
| | - Fabian Vargas
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Linh Nguyen
- School of Medicine, University of Colorado, Aurora, Colorado
| | - Joanna Ringel
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Kate Zarzuela
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Min Ji Kwak
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, Texas
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mathew S Maurer
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Mark S Lachs
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York.
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25
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Warren AF, Rosner C, Gattani R, Truesdell AG, Proudfoot AG. Cardiogenic Shock: Protocols, Teams, Centers, and Networks. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The mortality of cardiogenic shock (CS) remains unacceptably high. Delays in the recognition of CS and access to disease-modifying or hemodynamically stabilizing interventions likely contribute to poor outcomes. In parallel to successful initiatives in other disease states, such as acute ST-elevation MI and major trauma, institutions are increasingly advocating the use of a multidisciplinary ‘shock team’ approach to CS management. A volume–outcome relationship exists in CS, as with many other acute cardiovascular conditions, and the emergence of ‘shock hubs’ as experienced facilities with an interest in improving CS outcomes through a hub-and-spoke ‘shock network’ approach provides another opportunity to deliver improved CS care as widely and equitably as possible. This narrative review outlines improvements from a networked approach to care, discusses a team-based and protocolized approach to CS management, reviews the available evidence and discusses the potential benefits, challenges, and opportunities of such systems of care.
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Affiliation(s)
- Alex F Warren
- South-East Scotland School of Anaesthesia, Edinburgh, UK; Anaesthesia, Critical Care and Pain, University of Edinburgh, Edinburgh, UK
| | | | | | - Alex G Truesdell
- Inova Heart and Vascular Institute, Falls Church, VA; Virginia Heart, Falls Church, VA
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, London, UK; Clinic for Anaesthesiology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany; Department of Anaesthesiology and Intensive Care, German Heart Centre Berlin, Berlin, Germany; Queen Mary University of London, London, UK
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26
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Goyal P, Reshetnyak E, Khan S, Musse M, Navi BB, Kim J, Allen LA, Banerjee S, Elkind MSV, Shah SJ, Yancy C, Michos ED, Devereux RB, Okin PM, Weinsaft JW, Safford MM. Clinical Characteristics and Outcomes of Adults With a History of Heart Failure Hospitalized for COVID-19. Circ Heart Fail 2021; 14:e008354. [PMID: 34517720 DOI: 10.1161/circheartfailure.121.008354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is important to understand the risk for in-hospital mortality of adults hospitalized with acute coronavirus disease 2019 (COVID-19) infection with a history of heart failure (HF). METHODS We examined patients hospitalized with COVID-19 infection from January 1, 2020 to July 22, 2020, from 88 centers across the US participating in the American Heart Association's COVID-19 Cardiovascular Disease registry. The primary exposure was history of HF and the primary outcome was in-hospital mortality. To examine the association between history of HF and in-hospital mortality, we conducted multivariable modified Poisson regression models that included sociodemographics and comorbid conditions. We also examined HF subtypes based on left ventricular ejection fraction in the prior year, when available. RESULTS Among 8920 patients hospitalized with COVID-19, mean age was 61.4±17.5 years and 55.5% were men. History of HF was present in 979 (11%) patients. In-hospital mortality occurred in 31.6% of patients with history of HF, and 16.9% in patients without a history of HF. In a fully adjusted model, history of HF was associated with increased risk for in-hospital mortality (relative risk: 1.16 [95% CI, 1.03-1.30]). Among 335 patients with left ventricular ejection fraction, heart failure with reduced ejection fraction was significantly associated with in-hospital mortality in a fully adjusted model (heart failure with reduced ejection fraction relative risk: 1.40 [95% CI, 1.10-1.79]; heart failure with mid-range ejection fraction relative risk: 1.06 [95% CI, 0.65-1.73]; heart failure with preserved ejection fraction relative risk, 1.06 [95% CI, 0.84-1.33]). CONCLUSIONS Risk for in-hospital mortality was substantial among adults with history of HF, in large part due to age and comorbid conditions. History of heart failure with reduced ejection fraction may confer especially elevated risk. This population thus merits prioritization for the COVID-19 vaccine.
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Affiliation(s)
- Parag Goyal
- Department of Medicine (P.G., E.R., M.M., J.K., R.B.D., P.M.O., J.W.W., M.M.S.), Weill Cornell Medicine, New York, NY
| | - Evgeniya Reshetnyak
- Department of Medicine (P.G., E.R., M.M., J.K., R.B.D., P.M.O., J.W.W., M.M.S.), Weill Cornell Medicine, New York, NY
| | - Sadiya Khan
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL (S.K., S.J.S., C.Y.)
| | - Mahad Musse
- Department of Medicine (P.G., E.R., M.M., J.K., R.B.D., P.M.O., J.W.W., M.M.S.), Weill Cornell Medicine, New York, NY
| | - Babak B Navi
- Department of Neurology, Feil Family Brain and Mind Research Institute (B.B.N.), Weill Cornell Medicine, New York, NY
| | - Jiwon Kim
- Department of Medicine (P.G., E.R., M.M., J.K., R.B.D., P.M.O., J.W.W., M.M.S.), Weill Cornell Medicine, New York, NY
| | - Larry A Allen
- Division of Cardiology, University of Colorado, Denver (L.A.A.)
| | - Samprit Banerjee
- Department of Population Science (S.B.), Weill Cornell Medicine, New York, NY
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY (M.S.V.E.)
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL (S.K., S.J.S., C.Y.)
| | - Clyde Yancy
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL (S.K., S.J.S., C.Y.)
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (E.D.M.)
| | - Richard B Devereux
- Department of Medicine (P.G., E.R., M.M., J.K., R.B.D., P.M.O., J.W.W., M.M.S.), Weill Cornell Medicine, New York, NY
| | - Peter M Okin
- Department of Medicine (P.G., E.R., M.M., J.K., R.B.D., P.M.O., J.W.W., M.M.S.), Weill Cornell Medicine, New York, NY
| | - Jonathan W Weinsaft
- Department of Medicine (P.G., E.R., M.M., J.K., R.B.D., P.M.O., J.W.W., M.M.S.), Weill Cornell Medicine, New York, NY
| | - Monika M Safford
- Department of Medicine (P.G., E.R., M.M., J.K., R.B.D., P.M.O., J.W.W., M.M.S.), Weill Cornell Medicine, New York, NY
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27
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DeVore AD, Granger BB, Fonarow GC, Al-Khalidi HR, Albert NM, Lewis EF, Butler J, Piña IL, Allen LA, Yancy CW, Cooper LB, Felker GM, Kaltenbach LA, McRae AT, Lanfear DE, Harrison RW, Disch M, Ariely D, Miller JM, Granger CB, Hernandez AF. Effect of a Hospital and Postdischarge Quality Improvement Intervention on Clinical Outcomes and Quality of Care for Patients With Heart Failure With Reduced Ejection Fraction: The CONNECT-HF Randomized Clinical Trial. JAMA 2021; 326:314-323. [PMID: 34313687 PMCID: PMC8317015 DOI: 10.1001/jama.2021.8844] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
IMPORTANCE Adoption of guideline-directed medical therapy for patients with heart failure is variable. Interventions to improve guideline-directed medical therapy have failed to consistently achieve target metrics, and limited data exist to inform efforts to improve heart failure quality of care. OBJECTIVE To evaluate the effect of a hospital and postdischarge quality improvement intervention compared with usual care on heart failure outcomes and care. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized clinical trial was conducted at 161 US hospitals and included 5647 patients (2675 intervention vs 2972 usual care) followed up after a hospital discharge for acute heart failure with reduced ejection fraction (HFrEF). The trial was performed from 2017 to 2020, and the date of final follow-up was August 31, 2020. INTERVENTIONS Hospitals (n = 82) randomized to a hospital and postdischarge quality improvement intervention received regular education of clinicians by a trained group of heart failure and quality improvement experts and audit and feedback on heart failure process measures (eg, use of guideline-directed medical therapy for HFrEF) and outcomes. Hospitals (n = 79) randomized to usual care received access to a generalized heart failure education website. MAIN OUTCOMES AND MEASURES The coprimary outcomes were a composite of first heart failure rehospitalization or all-cause mortality and change in an opportunity-based composite score for heart failure quality (percentage of recommendations followed). RESULTS Among 5647 patients (mean age, 63 years; 33% women; 38% Black; 87% chronic heart failure; 49% recent heart failure hospitalization), vital status was known for 5636 (99.8%). Heart failure rehospitalization or all-cause mortality occurred in 38.6% in the intervention group vs 39.2% in usual care (adjusted hazard ratio, 0.92 [95% CI, 0.81 to 1.05). The baseline quality-of-care score was 42.1% vs 45.5%, respectively, and the change from baseline to follow-up was 2.3% vs -1.0% (difference, 3.3% [95% CI, -0.8% to 7.3%]), with no significant difference between the 2 groups in the odds of achieving a higher composite quality score at last follow-up (adjusted odds ratio, 1.06 [95% CI, 0.93 to 1.21]). CONCLUSIONS AND RELEVANCE Among patients with HFrEF in hospitals randomized to a hospital and postdischarge quality improvement intervention vs usual care, there was no significant difference in time to first heart failure rehospitalization or death, or in change in a composite heart failure quality-of-care score. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03035474.
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Affiliation(s)
- Adam D. DeVore
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
- Associate Section Editor, JAMA Cardiology
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Nancy M. Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Eldrin F. Lewis
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Ileana L. Piña
- Wayne State University and Detroit Medical Center, Detroit, Michigan
| | - Larry A. Allen
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
| | - Clyde W. Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Lauren B. Cooper
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - G. Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Lisa A. Kaltenbach
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - David E. Lanfear
- Henry Ford Heart and Vascular Institute, Department of Medicine, Cardiovascular Division, Henry Ford Hospital, Detroit, Michigan
| | - Robert W. Harrison
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Dan Ariely
- Center for Advanced Hindsight, Duke University, Durham, North Carolina
| | - Julie M. Miller
- Center for Advanced Hindsight, Duke University, Durham, North Carolina
| | - Christopher B. Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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28
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Brophy TJ, Warsavage TJ, Hebbe AL, Plomondon ME, Waldo SW, Rao SV, DeVore AD, Gutierrez JA, Swaminathan RV. Percutaneous coronary intervention in patients with stable coronary artery disease and left ventricular systolic dysfunction: insights from the VA CART program. Am Heart J 2021; 235:149-157. [PMID: 33567318 DOI: 10.1016/j.ahj.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/03/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Revascularization of ischemic cardiomyopathy by coronary artery bypass grafting has been shown to improve survival among patients with left ventricular ejection fraction (LVEF) ≤35%, but the role of percutaneous coronary intervention (PCI) in this context is incompletely described. This study sought to evaluate the effect of PCI on mortality and hospitalization among patients with stable coronary artery disease and reduced left ventricular ejection fraction. METHODS We performed a retrospective analysis comparing PCI with medical therapy among patients with ischemic cardiomyopathy in the Veterans Affairs Health Administration. Patients with angiographic evidence of 1 or more epicardial stenoses amenable to PCI and LVEF ≤35% were included in the analysis. Outcome data were determined by VA and non-VA data sources on mortality and hospital admission. RESULTS From 2008 through 2015, a study sample of 4,628 patients was identified, of which 1,322 patients underwent ad hoc PCI. Patients were followed to a maximum of 3 years. Propensity score weighted landmark analysis was used to evaluate the primary and secondary outcomes. The primary outcome of all-cause mortality was significantly lower in the PCI cohort compared with medical therapy (21.6% vs 30.0%, P <.001). The secondary outcome of all-cause rehospitalization or death was also lower in the PCI cohort (76.5% vs 83.8%, P <.001). CONCLUSIONS In this retrospective analysis of patients with ischemic cardiomyopathy with coronary artery disease amenable to PCI and LVEF ≤35%, revascularization by PCI was associated with decreased all-cause mortality and decreased all-cause death or rehospitalization.
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Tummalapalli SL, Warnock N, Mendu ML. The COVID-19 Pandemic Converges With Kidney Policy Transformation: Implications for CKD Population Health. Am J Kidney Dis 2021; 77:268-271. [PMID: 33171214 PMCID: PMC7648180 DOI: 10.1053/j.ajkd.2020.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/28/2020] [Indexed: 01/23/2023]
Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Healthcare Delivery Science & Innovation, Department of Population Health Sciences, Weill Cornell Medicine.
| | - Neil Warnock
- Medical Affairs - Market Access, Bayer AG, Whippany, NJ
| | - Mallika L Mendu
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Population Health, Partners Healthcare, Boston, MA
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30
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Meltzer SN, Weintraub WS. The Role of National Registries in Improving Quality of Care and Outcomes for Cardiovascular Disease. Methodist Debakey Cardiovasc J 2020; 16:205-211. [PMID: 33133356 DOI: 10.14797/mdcj-16-3-205] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Cardiovascular registries play an integral role in providing real-world data on a number of cardiovascular conditions and allowing measurement of quality metrics across a large cohort of patients. Over the past 35 years, the number of cardiovascular registries has skyrocketed, and their use will only continue to grow as data on novel procedures and devices will need to be collected and analyzed. The American College of Cardiology and Society of Thoracic Surgeons Transcatheter Valve Therapy Registry is just one example of a modern registry that plays a crucial role in collecting data on patients undergoing transcatheter valvular procedures. Through public reporting registries, data can be shared on a hospital and provider level for many quality performance measures. There remains much work to be done on allowing automated data extraction from the electronic medical record directly into registries. No matter how sophisticated and complete a registry is, it can never overcome the problem of treatment selection bias that is inherent in observational data. This review discusses the growth, benefits, and limitations of national registries and their role in developing evidence for best clinical practice, measuring outcomes, providing feedback to clinicians, and improving quality of care.
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Allen LA, Fonarow GC. Process Improvement in Heart Failure. Heart Fail Clin 2020; 16:xvii-xix. [PMID: 32888645 DOI: 10.1016/j.hfc.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Asnchutz Medical Campus, 12631 East 17th Avenue, Academic Office One, #7019, Mailstop B130, Aurora, CO 80045, USA.
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, University of California Los Angeles, 100 Medical Plaza Driveway, Suite 630, Los Angeles, CA 90095, USA.
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Naidech AM, Lawlor PN, Xu H, Fonarow GC, Xian Y, Smith EE, Schwamm L, Matsouaka R, Prabhakaran S, Marinescu I, Kording KP. Probing the Effective Treatment Thresholds for Alteplase in Acute Ischemic Stroke With Regression Discontinuity Designs. Front Neurol 2020; 11:961. [PMID: 32982952 PMCID: PMC7492202 DOI: 10.3389/fneur.2020.00961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 07/24/2020] [Indexed: 11/23/2022] Open
Abstract
Randomized Controlled Trials (RCTs) are considered the gold standard for measuring the efficacy of medical interventions. However, RCTs are expensive, and use a limited population. Techniques to estimate the effects of stroke interventions from observational data that minimize confounding would be useful. We used regression discontinuity design (RDD), a technique well-established in economics, on the Get With The Guidelines-Stroke (GWTG-Stroke) data set. RDD, based on regression, measures the occurrence of a discontinuity in an outcome (e.g., odds of home discharge) as a function of an intervention (e.g., alteplase) that becomes significantly more likely when crossing the threshold of a continuous variable that determines that intervention (e.g., time from symptom onset, since alteplase is only given if symptom onset is less than e.g., 3 h). The technique assumes that patients near either side of a threshold (e.g., 2.99 and 3.01 h from symptom onset) are indistinguishable other than the use of the treatment. We compared outcomes of patients whose estimated onset to treatment time fell on either side of the treatment threshold for three cohorts of patients in the GWTG-Stroke data set. This data set spanned three different treatment thresholds for alteplase (3 h, 2003-2007, N = 1,869; 3 h, 2009-2016, N = 13,086, and 4.5 h, 2009-2016, N = 6,550). Patient demographic characteristics were overall similar across the treatment thresholds. We did not find evidence of a discontinuity in clinical outcome at any treatment threshold attributable to alteplase. Potential reasons for failing to find an effect include violation of some RDD assumptions in clinical care, large sample sizes required, or already-well-chosen treatment threshold.
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Affiliation(s)
- Andrew M. Naidech
- Department of Neurology, Northwestern University, Chicago, IL, United States
| | - Patrick N. Lawlor
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
| | - Gregg C. Fonarow
- Division of Cardiology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ying Xian
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
- Department of Neurology, Duke University Medical Center, Durham, NC, United States
| | - Eric E. Smith
- Department of Neurology, University of Calgary, Calgary, AB, Canada
| | - Lee Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Roland Matsouaka
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States
- Program for Comparative Effectiveness Methodology, Duke Clinical Research Institute, Duke University, Durham, NC, United States
| | - Shyam Prabhakaran
- Department of Neurology, Northwestern University, Chicago, IL, United States
| | - Ioana Marinescu
- School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA, United States
| | - Konrad P. Kording
- Departments of Neuroscience and Bioengineering, University of Pennsylvania, Philadelphia, PA, United States
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Sterling MR, Kern LM, Safford MM, Jones CD, Feldman PH, Fonarow GC, Sheng S, Matsouaka RA, DeVore AD, Lytle B, Xu H, Allen LA, Deswal A, Yancy CW, Albert NM. Home Health Care Use and Post-Discharge Outcomes After Heart Failure Hospitalizations. JACC-HEART FAILURE 2020; 8:1038-1049. [PMID: 32800510 DOI: 10.1016/j.jchf.2020.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVES This study compared the characteristics of Medicare beneficiaries who were hospitalized for heart failure (HF) and then discharged home who received home health care (HHC) to the characteristics of those who did not, and examined associations among HHC and readmission and mortality rates. BACKGROUND After hospitalization for HF, some patients receive HHC. However, the use of HHC over time, the factors associated with its use, and the post-discharge outcomes after receiving it are not well studied. METHODS This study used Get With The Guidelines-HF data, merged with Medicare fee-for-service claims. Propensity score matching and Cox proportional hazards models were used to evaluate the associations between HHC and post-discharge outcomes. RESULTS From 2005 to 2015, 95,531 patients were admitted for HF, and 32,697 (34.2%) received HHC after discharge. The rate of HHC increased over time from 31.4% to 36.1% (p < 0.001). HHC recipients were older, more likely to be female, and had more comorbidities. HHC was associated with a higher risk of all-cause 30-day readmission (hazard ratio [HR]: 1.25; 95% confidence interval [CI]: 1.20 to 1.30), HF-specific 30-day readmission (HR: 1.20; 95% CI: 1.13 to 1.28), all-cause 90-day readmission (HR: 1.23; 95% CI: 1.19 to 1.26), HF-specific 90-day readmission (HR: 1.16; 95% CI: 1.11 to 1.22), and all-cause 30-and 90-day mortality, respectively (HR: 1.70; 95% CI: 1.56 to 1.86) and HR: 1.49; 95% CI: 1.41 to 1.57) compared to those who did not receive HHC. CONCLUSIONS Use of HHC after HF hospitalization increased among Medicare beneficiaries. HHC recipients were older and sicker than non-HHC recipients. Although HHC was associated with a higher risk of readmissions and mortality, this finding should be interpreted cautiously, given the presence of unmeasured variables that could affect receipt of HHC. Research is needed to determine whether the results reflect appropriate health care use.
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Affiliation(s)
| | - Lisa M Kern
- Weill Cornell Medicine, New York, New York, USA
| | | | | | | | - Gregg C Fonarow
- University of California Los Angeles, Los Angeles, California, USA
| | - Shubin Sheng
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | | | - Haolin Xu
- Duke University, Durham, North Carolina, USA
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anita Deswal
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Mutharasan RK. Transitioning Patients with Heart Failure to Outpatient Care. Heart Fail Clin 2020; 16:421-431. [PMID: 32888637 DOI: 10.1016/j.hfc.2020.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The transition from hospitalization to outpatient care is a vulnerable time for patients with heart failure. This requires specific focus on the transitional care period. Here the authors propose a framework to guide process improvement in the transitional care period. The authors extend this framework by (1) examining the role new technology might play in transitional care, and (2) offering practical advice for teams building transitional care programs.
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Affiliation(s)
- R Kannan Mutharasan
- Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Arkes Pavilion, Suite 6-071, Chicago, IL 60611, USA.
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35
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Bufalino VJ, Bleser WK, Singletary EA, Granger BB, O'Brien EC, Elkind MSV, Hamilton Lopez M, Saunders RS, McClellan MB, Brown N. Frontiers of Upstream Stroke Prevention and Reduced Stroke Inequity Through Predicting, Preventing, and Managing Hypertension and Atrial Fibrillation: A Call to Action From the Value in Healthcare Initiative's Predict & Prevent Learning Collaborative. Circ Cardiovasc Qual Outcomes 2020; 13:e006780. [PMID: 32683982 DOI: 10.1161/circoutcomes.120.006780] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.
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Affiliation(s)
| | - William K Bleser
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Elizabeth A Singletary
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Bradi B Granger
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Emily C O'Brien
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY (M.S.V.E.)
| | - Marianne Hamilton Lopez
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Robert S Saunders
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Mark B McClellan
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Nancy Brown
- American Heart Association, Dallas, TX (N.B.)
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Deng F, Zhang Y, Zhao Q, Deng Y, Gao S, Zhang L, Dong M, Yuan Z, Lei X. BMI differences among in-hospital management and outcomes in patients with atrial fibrillation: findings from the Care for Cardiovascular Disease project in China. BMC Cardiovasc Disord 2020; 20:270. [PMID: 32503432 PMCID: PMC7275422 DOI: 10.1186/s12872-020-01544-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 05/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Underweight or obese status influences the prognosis of atrial fibrillation (AF). However, the association between stratification of body mass index (BMI) and in-hospital outcomes in patients with AF, remains lacking in China. METHODS Using data from the Improving Care for Cardiovascular Disease in China-AF project, which was launched in February 2015 and recruited 150 hospitals in China, we compared characteristics, in-hospital treatments and clinical outcomes among the stratifications of BMI for Asians. RESULTS A total of 15,867 AF patients with AF were enrolled, including 830 (5.23%) underweight, 4965 (31.29%) with normal weight, 3716 (23.42%) overweight, 5263 (33.17%) obese class I and 1093 (6.89%) obese class II participants. Compared with normal weight patients, underweight, overweight, and obese patients showed increased percentages of CHADS2 scores (3-6) and CHA2DS2-VASc scores (5-9). During hospitalization, overweight or obese patients showed greater use of rhythm control medications, anticoagulant drugs, and intervention therapies than underweight-normal weight patients. In adjusted logistic models, BMI was a strong predictor of in-hospital mortality. Especially, underweight BMI was associated with higher incidence of in-hospital mortality, with an adjusted odds ratio of 2.08 (95% confidence interval, 1.56-4.46; p = 0.04) than overweight and obese BMI. CONCLUSIONS Asian patients with AF and high BMI received more medical treatments and presented less adverse in-hospital outcomes compared with those with underweight-normal weight. Although low BMI may be associated with other comorbidities and advanced age, underweight BMI retained a negative correlation with all-cause mortality in the patients with AF during hospitalization.
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Affiliation(s)
- Fuxue Deng
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China.,Department of Cardiovascular Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Yan Zhang
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Qiang Zhao
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Yangyang Deng
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Shanshan Gao
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Lisha Zhang
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Mengya Dong
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Zuyi Yuan
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China.,Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, People's Republic of China.,Key Laboratory of Molecular Cardiology, Shaanxi Province, Xi'an, Shaanxi, People's Republic of China
| | - Xinjun Lei
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China. .,Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, People's Republic of China. .,Key Laboratory of Molecular Cardiology, Shaanxi Province, Xi'an, Shaanxi, People's Republic of China.
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Treatment and Outcomes of Non-ST-Segment-Elevation Myocardial Infarction by Type of Center: A Tale of Patient Pathways, Access, and Clinician Aversion. Can J Cardiol 2020; 36:805-806. [PMID: 32387038 DOI: 10.1016/j.cjca.2020.02.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 11/21/2022] Open
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Mohammed M, Zainal H, Tangiisuran B, Harun SN, Ghadzi SM, Looi I, Sidek NN, Yee KL, Aziz ZA. Impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke. Pharm Pract (Granada) 2020; 18:1760. [PMID: 32256900 PMCID: PMC7092711 DOI: 10.18549/pharmpract.2020.1.1760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/09/2020] [Indexed: 01/01/2023] Open
Abstract
Background: Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are on the increase in the Asia Pacific, particularly in Malaysia. Various health organizations have recommended guidelines for managing ischemic stroke, but adherence to key performance indicators (KPI) from the guidelines and impact on patient outcomes, particularly mortality, are rarely explored. Objective: This study aims to evaluate the impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke. Methods: We included all first-ever ischemic stroke patients enrolled in the multiethnic Malaysian National Neurology Registry (NNeuR) - a prospective cohort study and followed-up for six months. Patients’ baseline clinical characteristics, risk factors, neurological findings, treatments, KPI and mortality outcome were evaluated. The KPI nonadherence (NAR) and relationship with mortality were evaluated. NAR>25% threshold was considered suboptimal. Results: A total of 579 first-ever ischemic stroke patients were included in the final analysis. The overall mortality was recorded as 23 (4.0%) in six months, with a median (interquartile) age of 65 (20) years. Majority of the patients (dead or alive) had partial anterior circulation infarct, PACI (43.5%; 34.0%) and total anterior circulation infarct, TACI (26.1%; 8.8%). In addition, DVT prophylaxis (82.8%), anticoagulant for atrial fibrillation (AF) patients (48.8%) and rehabilitation (26.2%) were considered suboptimal. NAR < 2 was significantly associated with a decrease in mortality (odds ratio 0.16; 0.02-0.12) compared to NAR>2. Survival analysis showed that death is more likely in patients with NAR>2 (p=0.05). Conclusions: KPI nonadherence was associated with mortality among ischemic stroke patients. The adherence to the KPI was sub-optimal, particularly in DVT prophylaxis, anticoagulant for AF patients and rehabilitation. These findings reflect the importance of continuous quality measurement and implementation of evidence recommendations in healthcare delivery to achieve optimal outcome among stroke patients.
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Affiliation(s)
- Mustapha Mohammed
- School of Pharmaceutical Sciences. University of Science Malaysia. Pulau Pinang (Malaysia).
| | - Hadzliana Zainal
- School of Pharmaceutical Sciences. University of Science Malaysia. Pulau Pinang (Malaysia).
| | | | - Sabariah N Harun
- School of Pharmaceutical Sciences. University of Science Malaysia. Pulau Pinang (Malaysia).
| | - Siti M Ghadzi
- School of Pharmaceutical Sciences. University of Science Malaysia. Pulau Pinang (Malaysia).
| | - Irene Looi
- Clinical Research Centre, Hospital Seberang Jaya, Pulau Pinang (Malaysia).
| | - Norsima N Sidek
- Clinical Research Centre, Hospital Sultanah Nur Zahirah. Terengganu (Malaysia).
| | - Keng L Yee
- National Institute of Health, Ministry of Health. Selangor (Malaysia).
| | - Zariah A Aziz
- Clinical Research Centre, Hospital Sultanah Nur Zahirah. Terengganu (Malaysia).
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O’Connor KD, Brophy T, Fonarow GC, Blankstein R, Swaminathan RV, Xu H, Matsouaka RA, Albert NM, Velazquez EJ, Yancy CW, Heidenreich PA, Hernandez AF, DeVore AD. Testing for Coronary Artery Disease in Older Patients With New-Onset Heart Failure: Findings From Get With The Guidelines-Heart Failure. Circ Heart Fail 2020; 13:e006963. [PMID: 32207996 PMCID: PMC10790075 DOI: 10.1161/circheartfailure.120.006963] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Current guidelines recommend evaluation for underlying heart disease and reversible conditions for patients with new-onset heart failure (HF). There are limited data on contemporary testing for coronary artery disease (CAD) in patients with new-onset HF. METHODS We performed an observational cohort study using the Get With The Guidelines-Heart Failure registry linked to Medicare claims. All patients were aged ≥65 and hospitalized for new-onset HF from 2009 to 2015. We collected left ventricular ejection fraction (LVEF), prior HF history, and in-hospital CAD testing from the registry, as well as testing for CAD using claims from 90 days before to 90 days after index HF hospitalization. RESULTS Among 17 185 patients with new-onset HF, 6672 (39%) received testing for CAD, including 3997 (23%) during the index hospitalization. Testing for CAD differed by LVEF: 53% in HF with reduced EF (LVEF ≤40%), 42% in HF with borderline EF (LVEF, 41%-49%), and 31% in HF with preserved EF (LVEF ≥50%). After multivariable adjustment, patients who received testing for CAD, compared with those who did not, were younger and more likely to be male, have a smoking history, have hyperlipidemia, and have HF with reduced ejection fraction or HF with borderline ejection fraction (all P<0.05). CONCLUSIONS The majority of patients hospitalized for new-onset HF did not receive testing for CAD either during the hospitalization or in the 90 days before and after. The rates of testing for CAD were higher in patients with LVEF ≤40% though remained low. These data highlight an opportunity to improve care by identifying appropriate candidates for optimal CAD medical therapy and revascularization.
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Affiliation(s)
- Kyle D. O’Connor
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC
| | - Todd Brophy
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Gregg C. Fonarow
- Division of Cardiology, University of California, Los Angeles, CA
| | - Ron Blankstein
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
| | | | - Haolin Xu
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC
| | - Roland A. Matsouaka
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Nancy M. Albert
- Office of Nursing Research and Innovation, Cleveland Clinic, Cleveland, OH
| | - Eric J. Velazquez
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT
| | - Clyde W. Yancy
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Paul A. Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Medicine, Division of Cardiology, Stanford University, Stanford, CA
| | - Adrian F. Hernandez
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC
| | - Adam D. DeVore
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC
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Taniguchi FP, Bernardez-Pereira S, Silva SA, Ribeiro ALP, Morgan L, Curtis AB, Taubert K, Albuquerque DCD, Weber B, Chrispim PPM, Toth CPP, Morosov EDM, Fonarow GC, Smith SC, Paola AAVD. Implementation of a Best Practice in Cardiology (BPC) Program Adapted from Get With The Guidelines®in Brazilian Public Hospitals: Study Design and Rationale. Arq Bras Cardiol 2020; 115:92-99. [PMID: 32187286 PMCID: PMC8384317 DOI: 10.36660/abc.20190393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/14/2019] [Indexed: 01/04/2023] Open
Abstract
Fundamento Existem grandes oportunidades de melhoria da qualidade do cuidado cardiovascular em países em desenvolvimento por meio da implementação de um programa de qualidade. Objetivo Avaliar o efeito de um programa de Boas Práticas em Cardiologia (BPC) nos indicadores de desempenho e desfechos clínicos dos pacientes relacionados à insuficiência cardíaca, fibrilação atrial e síndromes coronarianas agudas em um subconjunto de hospitais públicos brasileiros. Métodos O programa Boas Práticas em Cardiologia (BPC) foi adaptado do programa Get With The Guidelines (GWTG) da American Heart Association (AHA) para ser utilizado no Brasil. O programa está sendo iniciado em três domínios de cuidado simultaneamente (síndrome coronariana aguda, fibrilação atrial e insuficiência cardíaca), o que consiste em uma abordagem nunca testada no GWTG. Existem seis eixos de intervenções utilizadas pela literatura sobre tradução do conhecimento que abordará barreiras locais identificadas por meio de entrevistas estruturadas e reuniões regulares para auditoria e feedback. Planeja-se incluir no mínimo 10 hospitais e 1500 pacientes por doença cardíaca. O desfecho primário inclui as taxas de adesão às medidas de cuidado recomendadas pelas diretrizes. Desfechos secundários incluem o efeito do programa sobre o tempo de internação, mortalidade global e específica, taxas de readmissão, qualidade de vida, percepção do paciente sobre saúde e adesão dos pacientes às intervenções prescritas. Resultados Espera-se, nos hospitais participantes, uma melhoria e a manutenção das taxas de adesão as recomendações baseadas em evidência e dos desfechos dos pacientes. Este é o primeiro programa em melhoria da qualidade a ser realizado na América do Sul, que fornecerá informações importantes de como programas de sucesso originados em países desenvolvidos como os Estados Unidos podem ser adaptados às necessidades de países com economias em desenvolvimento como o Brasil. Um programa bem sucedido dará informações valiosas para o desenvolvimento de programas de melhoria da qualidade em outros países em desenvolvimento. Conclusões Este estudo de mundo real proverá informações para a avaliação e aumento da adesão às diretrizes de cardiologia no Brasil, bem como a melhora dos processos assistenciais. (Arq Bras Cardiol. 2020; 115(1):92-99)
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Gregg C Fonarow
- University of California Los Angeles, Los Angeles, Califórnia, EUA
| | - Sidney C Smith
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, EUA
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Zagrebelny AV, Lukina YV, Kutishenko NP, Lukyanov MM, Dmitrieva NA, Voronina VP, Okshina EY, Lerman OV, Blagodatskikh SV, Nekoshnova ES, Budaeva IV, Boytsov SA, Drapkina OM, Martsevich SY. Factors associated with in-hospital mortality in patients after acute cerebrovascular accident (according to the REGION-M register). КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2020. [DOI: 10.15829/1728-8800-2020-1-62-69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
| | - Yu. V. Lukina
- National Medical Research Center for Preventive Medicine
| | | | - M. M. Lukyanov
- National Medical Research Center for Preventive Medicine
| | | | - V. P. Voronina
- National Medical Research Center for Preventive Medicine
| | - E. Yu. Okshina
- National Medical Research Center for Preventive Medicine
| | - O. V. Lerman
- National Medical Research Center for Preventive Medicine
| | | | | | - I. V. Budaeva
- National Medical Research Center for Preventive Medicine
| | | | - O. M. Drapkina
- National Medical Research Center for Preventive Medicine
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Zagrebelny AV, Lukina YV, Kutishenko NP, Lukyanov MM, Dmitrieva NA, Voronina VP, Okshina EY, Lerman OV, Blagodatskikh SV, Nekoshnova ES, Budaeva IV, Boytsov SA, Drapkina OM, Martsevich SY. Factors associated with in-hospital mortality in patients after acute cerebrovascular accident (according to the REGION-M register). КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2020. [DOI: 10.15829/1728-8800-2020-1-2443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
| | - Yu. V. Lukina
- National Medical Research Center for Preventive Medicine
| | | | - M. M. Lukyanov
- National Medical Research Center for Preventive Medicine
| | | | - V. P. Voronina
- National Medical Research Center for Preventive Medicine
| | - E. Yu. Okshina
- National Medical Research Center for Preventive Medicine
| | - O. V. Lerman
- National Medical Research Center for Preventive Medicine
| | | | | | - I. V. Budaeva
- National Medical Research Center for Preventive Medicine
| | | | - O. M. Drapkina
- National Medical Research Center for Preventive Medicine
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Varma N, Jones P, Wold N, Cronin E, Stein K. How Well Do Results From Randomized Clinical Trials and/or Recommendations for Implantable Cardioverter-Defibrillator Programming Diffuse Into Clinical Practice? Translation Assessed in a National Cohort of Patients With Implantable Cardioverter-Defibrillators ( ALTITUDE ). J Am Heart Assoc 2020; 8:e007392. [PMID: 30712432 PMCID: PMC6405582 DOI: 10.1161/jaha.117.007392] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Inappropriate implantable cardioverter-defibrillator programming can be detrimental. Whether trials/recommendations informing best implantable cardioverter-defibrillator programming (high-rate cutoff and/or extended duration of detection) influence practice is unknown. Methods and Results We measured reaction to publication of MADIT-RIT (Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy; 2012) and the Consensus Statement (2015) providing generic programming parameters, in a national cohort of implantable cardioverter-defibrillator recipients, using the ALTITUDE database (Boston Scientific). Yearly changes in programmed parameters to either trial-specified or class 1 recommended parameters (≥185 beats per minute or delay ≥6 seconds) were assessed in parallel. From 2008 to 2017, 232 982 patients (aged 67±13 years; 28% women) were analyzed. Prevalence of MADIT- RIT -specific settings before publication was <1%, increasing to 13.6% in the year following. Thereafter, this increased by <6% over 5 years. Among preexisting implants (91 171), most patients (58 739 [64.4%]) underwent at least 1 in-person device reprogramming after trial publication, but <2% were reprogrammed to MADIT - RIT settings. Notably, prevalence of programming to ≥185 beats per minute or delay ≥6 seconds was increased by MADIT - RIT (57.4% in 2013 versus 40.2% at baseline), but the following publication of recommendations had minor incremental effect (73.2% in 2016 versus 70.8% in 2015). High-rate cutoff programming was favored almost 2-fold compared with extended duration throughout the test period. Practice changes demonstrated large interhospital and interstate variations. Conclusions Trial publication had an immediate effect during 1 year postpublication, but absolute penetration was low, and amplified little with time. Consensus recommendations had a negligible effect. However, generic programming was exercised more widely, and increased after trial publication, but not following recommendations.
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Meta-Analysis Comparing Cardiac Arrest Outcomes Before and After Resuscitation Guideline Updates. Am J Cardiol 2020; 125:618-629. [PMID: 31858970 DOI: 10.1016/j.amjcard.2019.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 11/22/2022]
Abstract
Updates of resuscitation guidelines have limited high-level supporting evidence. Moreover, the overall effect of such bundled practice changes depends not only on the impact of the individual interventions but also on their interplay and swift functioning of the entire chain of survival. Therefore, real-world data monitoring is essential. We performed a meta-analysis of comparative studies on outcomes before and after successive guideline updates. On January 16, 2019, we searched for comparative studies (PubMed, Web-of-Science, Embase, and the Cochrane Libraries) reporting outcomes before and after resuscitation guidelines 2005, 2010, and 2015. We followed PRISMA, Cochrane, and Moose-recommendations. Studies on outcomes during the 2005 versus 2000 guideline period (n = 23; 40,859 patients) reported significantly higher ROSC (odds ratio [OR] 1.21 [1.04 to 1.42], p = 0.014), survival to admission (OR 1.34 [1.09 to 1.65], p = 0.005), survival to discharge (OR 1.46 [1.25 to 1.70], p <0.001), and favorable neurologic outcome (OR 1.35 [1.01 to 1.81], p = 0.040). Studies on outcomes during the 2010 versus 2005 guideline period (n = 11; 1,048,112 patients) indicated no difference in ROSC (OR 1.25 [95% confidence interval 0.95 to 1.63], p = 0.11), whereas survival to discharge improved significantly (OR 1.30 [1.17 to 1.45], p <0.001). Only 2 studies reported on neurologic outcomes, both showing improved outcome after the 2010 guideline update. No data on the 2015 guidelines were available. This meta-analysis on real-world data of >1 million patients demonstrates improved outcomes after the 2005 and 2010 resuscitation guideline updates, and a lack of data on the 2015 guideline. In conclusion, although limited in terms of causality, this study suggests that the sum of all efforts to improve outcomes, including updated CPR guidelines, contributed to increased survival after cardiac arrest.
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DeVore AD, Granger BB, Fonarow GC, Al-Khalidi HR, Albert NM, Lewis EF, Butler J, Piña IL, Heidenreich PA, Allen LA, Yancy CW, Cooper LB, Felker GM, Kaltenbach LA, McRae AT, Lanfear DE, Harrison RW, Kociol RD, Disch M, Ariely D, Miller JM, Granger CB, Hernandez AF. Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure: Rationale and design of CONNECT-HF. Am Heart J 2020; 220:41-50. [PMID: 31770656 DOI: 10.1016/j.ahj.2019.09.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 09/18/2019] [Indexed: 11/29/2022]
Abstract
Many therapies have been shown to improve outcomes for patients with heart failure (HF) in controlled settings, but there are limited data available to inform best practices for hospital and post-discharge quality improvement initiatives. The CONNECT-HF study is a prospective, cluster-randomized trial of 161 hospitals in the United States with a 2×2 factorial design. The study is designed to assess the effect of a hospital and post-discharge quality improvement intervention compared with usual care (primary objective) on HF outcomes and quality-of-care, as well as to evaluate the effect of hospitals implementing a patient-level digital intervention compared with usual care (secondary objective). The hospital and post-discharge intervention includes audit and feedback on HF clinical process measures and outcomes for patients with HF with reduced ejection fraction (HFrEF) paired with education to sites and clinicians by a trained, nationally representative group of HF and quality improvement experts. The patient-level digital intervention is an optional ancillary study and includes a mobile application and behavioral tools that are intended to facilitate improved use of guideline-directed recommendations for self-monitoring and self-management of activity and medications for HFrEF. The effects of the interventions will be measured through an opportunity-based composite score on quality and time-to-first HF readmission or death among patients with HFrEF who present to study hospitals with acute HF and who consent to participate. The CONNECT-HF study is evaluating approaches for implementing HF guideline recommendations into practice and is one of the largest HF implementation science trials performed to date.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC.
| | | | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Ileana L Piña
- Wayne State University and Detroit Medical Center, Detroit, MI
| | - Paul A Heidenreich
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - Larry A Allen
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Cyde W Yancy
- Division of Cardiology, Northwestern University, Chicago, IL
| | - Lauren B Cooper
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA
| | - G Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - David E Lanfear
- Department of Medicine, Cardiovascular Division, and Henry Ford Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI
| | - Robert W Harrison
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | | | - Dan Ariely
- Center for Advanced Hindsight, Duke University, Durham, NC
| | - Julie M Miller
- Center for Advanced Hindsight, Duke University, Durham, NC
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
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Affiliation(s)
- Sidney C Smith
- Division of Cardiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Gregg C Fonarow
- University of California, Los Angeles (UCLA) Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Dong Zhao
- Beijing Institute of Heart, Lung & Blood Vessel Diseases, Capital Medical University Beijing Anzhen Hospital, Beijing, China
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Keshvani N, Gupta A, Pandey A. Towards global improvement in heart failure care. Eur J Heart Fail 2019; 22:661-663. [PMID: 31823517 DOI: 10.1002/ejhf.1687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 11/07/2022] Open
Affiliation(s)
- Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Aakriti Gupta
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, NY, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Prioritization, Development, and Validation of American Association of Cardiovascular and Pulmonary Rehabilitation Performance Measures. J Cardiopulm Rehabil Prev 2019; 38:208-214. [PMID: 29944573 DOI: 10.1097/hcr.0000000000000358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND In 2014, the American Association of Cardiovascular and Pulmonary Rehabilitation Quality of Care Committee was asked to develop performance measures (PMs) to assess program quality and aid in program improvement and certification. METHODS A 3-step process was used to prioritize, develop, and then validate new PMs for both cardiac and pulmonary rehabilitation programs. First, we surveyed national leadership, medical directors, and program directors to identify and rank various American Association of Cardiovascular and Pulmonary Rehabilitation potential PM topics. Then, the face validity of the drafted PMs was assessed in a second national survey. Finally, we assessed the inter- and intrarater reliability and feasibility of each PM by abstracting patient charts at programs throughout the United States. At each step, modifications were made to refine and improve the measures for clarity, reliability, and consistency. RESULTS Through survey answers received from 302 people (19% response rate), we identified 5 categories for PM development: optimal blood pressure control, tobacco use cessation, and improvement in functional capacity, depression, and sensation of dyspnea. After drafting the PMs, a second survey with 82 respondents (57% response rate), found that the proposed PMs had good face validity. Finally, we found excellent inter- and intrarater reliability for the blood pressure, functional capacity, depression, and dyspnea measures (κ generally >0.80.) However, validity concerns were raised about the tobacco intervention PM as written, and it continues to undergo further refinement and testing. CONCLUSIONS We developed and validated 5 new PMs for use in cardiac and pulmonary rehabilitation program quality assessment, improvement, and certification.
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Wang Y, Li Z, Zhao X, Liu L, Wang C, Wang C, Peterson ED, Schwamm LH, Fonarow GC, Smith SC, Bettger J, Wang D, Li H, Xian Y, Wang Y. Evidence-Based Performance Measures and Outcomes in Patients With Acute Ischemic Stroke. Circ Cardiovasc Qual Outcomes 2019; 11:e001968. [PMID: 30557048 DOI: 10.1161/circoutcomes.115.001968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke is the leading cause of death in China. Despite the wide dissemination of evidence-based guidelines, data about adherence to these in routine clinical practice are scarce. We conducted a study using a nationwide registry to evaluate the implementation of evidence-based stroke performance indicators and associated guidelines, for patients with an ischemic stroke in China. METHODS AND RESULTS The China National Stroke Registry is a prospective cohort study, including 12 416 patients diagnosed with acute ischemic stroke from 132 hospitals across China, for 1 year beginning September 2007. Twelve performance indicators were selected to evaluate the quality of stroke care. Multivariable Cox models were used to determine the association between optimal compliance and clinical outcomes. Conformity with performance measures ranged from a median of 6.5% for the use of intravenous tPA (tissue-type plasminogen activator) to 81.8% for early use of antithrombotics. The optimal compliance with all in-hospital measures was associated with 1-year death after admission (hazard ratio, 0.66; 95% CI, 0.55-0.79). The optimal compliance with all discharge measures was associated with the 1-year death after discharge (hazard ratio, 0.55; 95% CI, 0.44-0.69), 1-year stroke recurrence (hazard ratio, 0.81; 95% CI, 0.70-0.93), and favorable functional outcomes (defined as modified Rankin Scale score of ≤2) (hazard ratio, 1.10; 95% CI, 1.04-1.16). CONCLUSIONS Adherence to evidence-based ischemic stroke care measures in China revealed substantial gaps, and select measures were associated with improved outcomes. These findings support the need for ongoing quality measurement and improvement in stroke care in China.
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Affiliation(s)
- Yilong Wang
- TianTan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, China (Yilong Wang, Chunjuan Wang, H.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing (Yilong Wang, Z.L., X.Z., H.L., Yongjun Wang)
| | - Zixiao Li
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, China (Z.L., X.Z., Chunxue Wang, Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing (Yilong Wang, Z.L., X.Z., H.L., Yongjun Wang)
| | - Xingquan Zhao
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, China (Z.L., X.Z., Chunxue Wang, Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing (Yilong Wang, Z.L., X.Z., H.L., Yongjun Wang)
| | - Liping Liu
- Neuro Intensive Care Unit, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, China (L.L.).,Center of Stroke, Beijing Institute for Brain Disorders, China (L.L., Yongjun Wang)
| | - Chunxue Wang
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, China (Z.L., X.Z., Chunxue Wang, Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Chunxue Wang, Chunjuan Wang, Yongjun Wang)
| | - Chunjuan Wang
- TianTan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, China (Yilong Wang, Chunjuan Wang, H.L., Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Chunxue Wang, Chunjuan Wang, Yongjun Wang)
| | - Eric D Peterson
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Chunxue Wang, Chunjuan Wang, Yongjun Wang)
| | - Lee H Schwamm
- Duke Clinical Research Institute (DCRI), Durham, NC (E.D.P., J.B., Y.X.)
| | | | - Sidney C Smith
- Center for Cardiovascular Science and Medicine, University of North Carolina at Chapel Hill (S.C.S.)
| | - Janet Bettger
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Chunxue Wang, Chunjuan Wang, Yongjun Wang).,Duke University School of Nursing, Durham, NC (J.B.)
| | - David Wang
- INI Stroke Network, OSF Healthcare System, University of Illinois College of Medicine, Peoria (D.W.)
| | - Hao Li
- TianTan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, China (Yilong Wang, Chunjuan Wang, H.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing (Yilong Wang, Z.L., X.Z., H.L., Yongjun Wang)
| | - Ying Xian
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Chunxue Wang, Chunjuan Wang, Yongjun Wang)
| | - Yongjun Wang
- TianTan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, China (Yilong Wang, Chunjuan Wang, H.L., Yongjun Wang).,Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, China (Z.L., X.Z., Chunxue Wang, Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing (Yilong Wang, Z.L., X.Z., H.L., Yongjun Wang).,Center of Stroke, Beijing Institute for Brain Disorders, China (L.L., Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Chunxue Wang, Chunjuan Wang, Yongjun Wang)
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Newton PJ, Si S, Reid CM, Davidson PM, Hayward CS, Macdonald PS. Survival After an Acute Heart Failure Admission. Twelve-Month Outcomes From the NSW HF Snapshot Study. Heart Lung Circ 2019; 29:1032-1038. [PMID: 31708454 DOI: 10.1016/j.hlc.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 09/02/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The New South Wales (NSW) Heart Failure Snapshot sought to provide a contemporaneous profile of patients admitted with acute heart failure. We have previously reported the baseline results, and this paper reports the 30-day and 12-month outcomes. METHODS A prospective audit of consecutive patients admitted to 24 teaching hospitals across NSW and the Australian Capital Territory in July-August 2013 with acute heart failure. Follow-up data were obtained by integration of hospital administrative records and follow-up phone calls with the patients. RESULTS Eight hundred eleven (811) patients were recruited across the 24 sites. The NSW HF Snapshot was an elderly cohort (77 ± 14 yrs) with high comorbidity (mean Charlson Comorbidity Index 3.5 ± 2.6), and 71% were frail at baseline. Twenty-four per cent (24%) of patients were readmitted within 30-days post discharge. One hundred seventy-eight (178) patients died within 12 months post discharge. The independent predictors of death were frailty (Hazard Ratio 1.98 [95% Confidence interval 1.18-3.30]; p < 0.01) Charlson Comorbidity Index (HR 1.06 [95% CI 1.00-1.13]; p = 0.05); New York Heart Association (NYHA) class 4 (HR 2.62 [95% CI 1.32-5.22]; p < 0.01); eGFR<30 ml/min/1.73 m2 (HR 2.16 [95% CI 1.45-3.21]; p < 0.01); hypokalaemia at discharge (HR 2.55 [95% CI 1.44-4.51]; p < 0.01) and readmission within 30 days of baseline admission (HR 2.13 [95% CI 1.49-3.13]; p < 0.01). CONCLUSION In one of the largest prospective audits of acute heart failure outcomes in Australia, we found that short-term readmissions and mortality at 12 months remain high but were largely driven by patient-level factors.
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Affiliation(s)
- Phillip J Newton
- School of Nursing & Midwifery, Western Sydney University, Sydney, NSW, Australia.
| | - Si Si
- NHMRC Centre for Research Excellence in Cardiovascular Outcomes Improvement (CRECOI), School of Public Health, Curtin University, Perth, WA, Australia
| | - Christopher M Reid
- Monash Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health & Preventive Medicine, Monash University, Melbourne, Vic, Australia; School of Public Health, Curtin University, Perth, WA, Australia
| | - Patricia M Davidson
- School of Nursing, Johns Hopkins University, Baltimore, MD, USA; Faculty of Health, University of Technology, Sydney, NSW, Australia
| | - Christopher S Hayward
- St. Vincent's Hospital, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Peter S Macdonald
- St. Vincent's Hospital, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
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