Centers for cardiovascular outcomes research: defining a collaborative vision

How do hospitals that serve low socioeconomic status patients achieve low readmission rates? A qualitative study of safety-net hospitals

BACKGROUND

Hospital readmissions are an important quality of care indicator and are tied to hospitals' financial reimbursements. Safety-net hospitals, which serve a high proportion of patients of low socioeconomic status (SES), face unique challenges to reduce or maintain low readmission rates.

OBJECTIVE

We sought to understand strategies high-performing safety-net hospitals used to achieve low 30-day risk-standardised readmission rates (RSRRs) using qualitative methodology.

METHODS

Safety-net hospital status was defined by public ownership or a Medicaid population that is greater than 1 SD higher than the state proportion of Medicaid patients and the hospital payer source is composed of at least 15% Medicaid patients. Safety-net hospitals were selected based on their ranking among the lowest 20% of heart failure RSRRs, the best-performing quintile. We purposefully sampled hospitals to ensure variation in characteristics and conducted on-site interviews with key hospital staff. A multidisciplinary team analysed the data using thematic analysis.

RESULTS

We performed site visits at 9 safety-net hospitals (RSRR range: 18.1%-21.6%) in 9 states and conducted in-depth interviews with 108 hospital staff. Several thematic attributes and organisational strategies were evident in high-performing safety-net hospitals: (1) strong hospital support for quality improvement at all levels; (2) tailoring resources to meet patient needs; (3) facilitating collaboration and communication among and between providers and patients; (4) creating strong relationships with postacute care facilities and communities and (5) proactive approach to healthcare policy changes and other external factors.

CONCLUSIONS

The provision of high-quality and equitable care in hospitals serving a high proportion of low-SES populations is influenced by several modifiable factors. These findings may serve to inform lower-performing safety-net hospitals on how to optimise patient care and improve readmission outcomes.

Training cardiovascular outcomes researchers: A survey of mentees and mentors to identify critical training gaps and needs

BACKGROUND

Many young investigators are interested in cardiovascular (CV) outcomes research; however, the current training experience of early investigators across the United States is uncertain.

METHODS

From April to November 2014, we surveyed mentees and mentors of early-stage CV outcomes investigators across the United States. We contacted successful grantees of government agencies, members of professional organizations, and trainees in CV outcomes training programs.

RESULTS

A total of 185 (of 662) mentees and 76 (of 541) mentors completed the survey. Mentees were equally split by sex; most had completed training >3 years before completing the survey and were clinicians. Mentors were more likely women, mostly ≥20 years posttraining, and at an associate/full professor rank. Mentors reported devoting more time currently to clinical work than when they were early in their career and mentoring 2-4 people simultaneously. More than 80% of mentees started training to become academicians and completed training with the same goal. More than 70% of mentees desired at least 50% research time in future jobs. More than 80% of mentors believed that future investigators would need more than 50% time dedicated to research. Most mentees (80%) were satisfied with their relationship with their mentor and reported having had opportunities to develop independently. Mentors more frequently than mentees reported that funding cutbacks had negatively affected mentees' ability to succeed (84% vs 58%). Across funding mechanisms, mentees were more optimistic than mentors about securing funding. Both mentees and mentors reported greatest preparedness for job/career satisfaction (79% for both) and publications (84% vs 92%) and least preparedness for future financial stability (48% vs 46%) and work-life balance (47% vs 42%).

CONCLUSIONS

Survey findings may stimulate future discourse and research on how best to attract, train, and retain young investigators in CV outcomes research. Insights may help improve existing training programs and inform the design of new ones.

How well does early-career investigators' cardiovascular outcomes research training align with funded outcomes research?

BACKGROUND

Outcomes research training programs should prepare trainees to successfully compete for research funding. We examined how early-career investigators' prior and desired training aligns with recently funded cardiovascular (CV) outcomes research.

METHODS

We (1) reviewed literature to identify 13 core competency areas in CV outcomes research; (2) surveyed early-career investigators to understand their prior and desired training in each competency area; (3) examined recently funded grants commonly pursued by early-career outcomes researchers to ascertain available funding in competency areas; and (4) analyzed alignment between investigator training and funded research in each competency area. We evaluated 185 survey responses from early-career investigators (response rate 28%) and 521 funded grants from 2010 to 2014.

RESULTS

Respondents' prior training aligned with funded grants in the areas of clinical epidemiology, observational research, randomized controlled trials, and implementation/dissemination research. Funding in community-engaged research and health informatics was more common than prior training in these areas. Respondents' prior training in biostatistics and systematic review was more common than funded grants focusing on these specific areas. Respondents' desired training aligned similarly with funded grants, with some exceptions; for example, desired training in health economics/cost-effectiveness research was more common than funded grants in these areas. Restricting to CV grants (n=132) and National Heart, Lung, and Blood Institute-funded grants (n=170) produced similar results.

CONCLUSIONS

Identifying mismatch between funded grants in outcomes research and early-career investigators' prior/desired training may help efforts to harmonize investigator interests, training, and funding. Our findings suggest a need for further consideration of how to best prepare early-career investigators for funding success.

Priorities for Cardiovascular Outcomes Research: A Report of the National Heart, Lung, and Blood Institute's Centers for Cardiovascular Outcomes Research Working Group

The Centers for Cardiovascular Outcomes Research (CCORs) held a meeting to review how cardiovascular outcomes research had evolved in the decade since the National Heart, Lung, and Blood Institute 2004 working group report and to consider future directions. The conference involved representatives from governmental agencies, outcomes research thought leaders, and public and private healthcare partners. The main purposes of this meeting were to (1) advance collaborative high-yield, high-impact outcomes research; (2) identify priorities and barriers to important cardiovascular outcomes research; and (3) define future needs for the field. This report highlights the key topics covered during the meeting, including an examination of the recent history of outcomes research, an evaluation of the current academic climate, and a vision for the future of cardiovascular outcomes research.

Race and place differences in patients hospitalized with an acute coronary syndrome: Is there double jeopardy? Findings from TRACE-CORE

The objectives of this longitudinal study were to examine differences between whites and blacks, and across two geographical regions, in the socio-demographic, clinical, and psychosocial characteristics, hospital treatment practices, and post-discharge mortality for hospital survivors of an acute coronary syndrome (ACS). In this prospective cohort study, we performed in-person interviews and medical record abstractions for patients discharged from the hospital after an ACS at participating sites in Central Massachusetts and Central Georgia during 2011–2013. Among the 1143 whites in Central Massachusetts, 514 whites in Central Georgia, and 277 blacks in Central Georgia, we observed a gradient of socioeconomic position with whites in Central Massachusetts being the most privileged, followed by whites and then blacks from Central Georgia; similar gradients pertained to psychosocial vulnerability (e.g., 10.7%, 25.1%, and 49.1% had cognitive impairment, respectively) and to the hospital receipt of all 4 evidence-based cardiac medications (35.5%, 18.1%, and 14.4%, respectively) used in the acute management of patients hospitalized with an ACS. Multivariable adjusted odds ratios (95% confidence intervals) for the receipt of a percutaneous coronary intervention for whites and blacks in Georgia vs. whites in Massachusetts were 0.57 (0.46–0.71) and 0.40(0.30–0.52), respectively. Thirty-day and one-year mortality risks exhibited a similar gradient.

The results of this contemporary clinical/epidemiologic study in a diverse patient cohort suggest that racial and geographic disparities continue to exist for patients hospitalized with an ACS.

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We observed a gradient of socio-economic position, treatment practices, and dying.

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Interplay of race and place with treatment practices and post discharge outcomes.

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Racial and geographic disparities continue to exist for patients after an ACS.

Multiple Chronic Conditions and Psychosocial Limitations in Patients Hospitalized with an Acute Coronary Syndrome

BACKGROUND

As adults live longer, multiple chronic conditions have become more prevalent over the past several decades. We describe the prevalence of, and patient characteristics associated with, cardiac- and non-cardiac-related multimorbidities in patients discharged from the hospital after an acute coronary syndrome.

METHODS

We studied 2174 patients discharged from the hospital after an acute coronary syndrome at 6 medical centers in Massachusetts and Georgia between April 2011 and May 2013. Hospital medical records yielded clinical information including presence of eight cardiac-related and eight non-cardiac-related morbidities on admission. We assessed multiple psychosocial characteristics during the index hospitalization using standardized in-person instruments.

RESULTS

The mean age of the study sample was 61 years, 67% were men, and 81% were non-Hispanic whites. The most common cardiac-related morbidities were hypertension, hyperlipidemia, and diabetes (76%, 69%, and 31%, respectively). Arthritis, chronic pulmonary disease, and depression (20%, 18%, and 13%, respectively) were the most common noncardiac morbidities. Patients with ≥4 morbidities (37% of the population) were slightly older and more frequently female than those with 0-1 morbidity; they were also heavier and more likely to be cognitively impaired (26% vs 12%), have symptoms of moderate/severe depression (31% vs 15%), high perceived stress (48% vs 32%), a limited social network (22% vs 15%), low health literacy (42% vs 31%), and low health numeracy (54% vs 42%).

CONCLUSION

Multimorbidity, highly prevalent in patients hospitalized with an acute coronary syndrome, is strongly associated with indices of psychosocial deprivation. This emphasizes the challenge of caring for these patients, which extends well beyond acute coronary syndrome management.

Reliability of Predicting Early Hospital Readmission After Discharge for an Acute Coronary Syndrome Using Claims-Based Data

Early rehospitalization after discharge for an acute coronary syndrome, including acute myocardial infarction (AMI), is generally considered undesirable. The Centers for Medicare and Medicaid Services (CMS) base hospital financial incentives on risk-adjusted readmission rates after AMI, using claims data in its adjustment models. Little is known about the contribution to readmission risk of factors not captured by claims. For 804 consecutive patients >65 years discharged in 2011 to 2013 from 6 hospitals in Massachusetts and Georgia after an acute coronary syndrome, we compared a CMS-like readmission prediction model with an enhanced model incorporating additional clinical, psychosocial, and sociodemographic characteristics, after principal components analysis. Mean age was 73 years, 38% were women, 25% college educated, and 32% had a previous AMI; all-cause rehospitalization occurred within 30 days for 13%. In the enhanced model, previous coronary intervention (odds ratio [OR] = 2.05, 95% confidence interval [CI] 1.34 to 3.16; chronic kidney disease OR 1.89, 95% CI 1.15 to 3.10; low health literacy OR 1.75, 95% CI 1.14 to 2.69), lower serum sodium levels, and current nonsmoker status were positively associated with readmission. The discriminative ability of the enhanced versus the claims-based model was higher without evidence of overfitting. For example, for patients in the highest deciles of readmission likelihood, observed readmissions occurred in 24% for the claims-based model and 33% for the enhanced model. In conclusion, readmission may be influenced by measurable factors not in CMS' claims-based models and not controllable by hospitals. Incorporating additional factors into risk-adjusted readmission models may improve their accuracy and validity for use as indicators of hospital quality.

Characteristics of contemporary patients discharged from the hospital after an acute coronary syndrome

BACKGROUND

Limited contemporary data compare the clinical and psychosocial characteristics and acute management of patients hospitalized with an initial vs a recurrent episode of acute coronary disease. We describe these factors in a cohort of patients recruited from 6 hospitals in Massachusetts and Georgia after an acute coronary syndrome.

MATERIALS AND METHODS

We performed structured baseline in-person interviews and medical record abstractions for 2174 eligible and consenting patients surviving hospitalization for an acute coronary syndrome between April 2011 and May 2013.

RESULTS

The average patient age was 61 years, 64% were men, and 47% had a high school education or less; 29% had a low general quality of life, and 1 in 5 were cognitively impaired. Patients with a recurrent coronary episode had a greater burden of previously diagnosed comorbidities. Overall, psychosocial burden was high, and more so in those with a recurrent vs those with an initial episode. Patients with an initial coronary episode were as likely to have been treated with all 4 effective cardiac medications (51.6%) as patients with a recurrent episode (52.3%), but were significantly more likely to have undergone cardiac catheterization (97.9% vs 92.9%) and a percutaneous coronary intervention (73.7% vs 60.9%) (P < .001) during their index hospitalization.

CONCLUSIONS

Patients with a first episode of acute coronary artery disease have a more favorable psychosocial profile, less comorbidity, and receive more invasive procedures but similar medical management, than patients with previously diagnosed coronary disease. Implications of the high psychosocial burden on various patient-related outcomes require investigation.