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Sharma A, Mahaffey KW, Gibson CM, Hicks KA, Alexander KP, Ali M, Chaitman BR, Held C, Hlatky M, Jones WIS, Mehran R, Menon V, Rockhold FW, Seltzer J, Spitzer E, Wilson M, Lopes RD. Clinical events classification (CEC) in clinical trials: Report on the current landscape and future directions - proceedings from the CEC Summit 2018. Am Heart J 2022; 246:93-104. [PMID: 34973948 DOI: 10.1016/j.ahj.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 11/26/2022]
Abstract
IMPORTANCE Clinical events adjudication is pivotal for generating consistent and comparable evidence in clinical trials. The methodology of event adjudication is evolving, but research is needed to develop best practices and spur innovation. OBSERVATIONS A meeting of stakeholders from regulatory agencies, academic and contract research organizations, pharmaceutical and device companies, and clinical trialists convened in Chicago, IL, for Clinical Events Classification (CEC) Summit 2018 to discuss key topics and future directions. Formal studies are lacking on strategies to optimize CEC conduct, improve efficiency, minimize cost, and generally increase the speed and accuracy of the event adjudication process. Major challenges to CEC discussed included ensuring rigorous quality of the process, identifying safety events, standardizing event definitions, using uniform strategies for missing information, facilitating interactions between CEC members and other trial leadership, and determining the CEC's role in pragmatic trials or trials using real-world data. Consensus recommendations from the meeting include the following: (1) ensure an adequate adjudication infrastructure; (2) use negatively adjudicated events to identify important safety events reported only outside the scope of the primary endpoint; (3) conduct further research in the use of artificial intelligence and digital/mobile technologies to streamline adjudication processes; and (4) emphasize the importance of standardizing event definitions and quality metrics of CEC programs. CONCLUSIONS AND RELEVANCE As novel strategies for clinical trials emerge to generate evidence for regulatory approval and to guide clinical practice, a greater understanding of the role of the CEC process will be critical to optimize trial conduct and increase confidence in the data generated.
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Dreyer RP, Raparelli V, Tsang SW, D'Onofrio G, Lorenze N, Xie CF, Geda M, Pilote L, Murphy TE. Development and Validation of a Risk Prediction Model for 1-Year Readmission Among Young Adults Hospitalized for Acute Myocardial Infarction. J Am Heart Assoc 2021; 10:e021047. [PMID: 34514837 PMCID: PMC8649501 DOI: 10.1161/jaha.121.021047] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Readmission over the first year following hospitalization for acute myocardial infarction (AMI) is common among younger adults (≤55 years). Our aim was to develop/validate a risk prediction model that considered a broad range of factors for readmission within 1 year. Methods and Results We used data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study, which enrolled young adults aged 18 to 55 years hospitalized with AMI across 103 US hospitals (N=2979). The primary outcome was ≥1 all‐cause readmissions within 1 year of hospital discharge. Bayesian model averaging was used to select the risk model. The mean age of participants was 47.1 years, 67.4% were women, and 23.2% were Black. Within 1 year of discharge for AMI, 905 (30.4%) of participants were readmitted and were more likely to be female, Black, and nonmarried. The final risk model consisted of 10 predictors: depressive symptoms (odds ratio [OR], 1.03; 95% CI, 1.01–1.05), better physical health (OR, 0.98; 95% CI, 0.97–0.99), in‐hospital complication of heart failure (OR, 1.44; 95% CI, 0.99–2.08), chronic obstructive pulmomary disease (OR, 1.29; 95% CI, 0.96–1.74), diabetes mellitus (OR, 1.23; 95% CI, 1.00–1.52), female sex (OR, 1.31; 95% CI, 1.05–1.65), low income (OR, 1.13; 95% CI, 0.89–1.42), prior AMI (OR, 1.47; 95% CI, 1.15–1.87), in‐hospital length of stay (OR, 1.13; 95% CI, 1.04–1.23), and being employed (OR, 0.88; 95% CI, 0.69–1.12). The model had excellent calibration and modest discrimination (C statistic=0.67 in development/validation cohorts). Conclusions Women and those with a prior AMI, increased depressive symptoms, longer inpatient length of stay and diabetes may be more likely to be readmitted. Notably, several predictors of readmission were psychosocial characteristics rather than markers of AMI severity. This finding may inform the development of interventions to reduce readmissions in young patients with AMI.
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Affiliation(s)
- Rachel P Dreyer
- Center for Outcomes Research and Evaluation, Yale - New Haven Hospital New Haven CT.,Department of Emergency Medicine Yale School of Medicine New Haven CT
| | - Valeria Raparelli
- Department of Translational Medicine University of Ferrara Ferrara Italy.,Department of Nursing University of Alberta Edmonton Canada.,University Center for Studies on Gender Medicine University of Ferrara Ferrara Italy
| | - Sui W Tsang
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Gail D'Onofrio
- Department of Emergency Medicine Yale School of Medicine New Haven CT
| | - Nancy Lorenze
- Program on Aging Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Catherine F Xie
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Mary Geda
- Program on Aging Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Louise Pilote
- Centre for Outcomes Research and Evaluation McGill University Health Centre Research Institute Montreal Quebec Canada.,Divisions of Clinical Epidemiology and General Internal Medicine McGill University Health Centre Research Institute Montreal Quebec Canada
| | - Terrence E Murphy
- Program on Aging Department of Internal Medicine Yale School of Medicine New Haven CT
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Ascertaining Nonfatal Endpoints in Clinical Trials: Central Adjudication Versus Patient Insurance Claims. Ther Innov Regul Sci 2021; 55:1250-1257. [PMID: 34228318 DOI: 10.1007/s43441-021-00321-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The 21st Century Cures Act allows the US Food and Drug Administration (FDA) to utilize real-world data (RWD) to create real-world evidence (RWE) for new indications or post approval study requirements. We compared central adjudication with two insurance claims data sources to understand how endpoint accuracy differences impact RWE results. METHODS We developed a decision analytic model to compare differences in efficacy (all-cause death, stroke and myocardial infarction) and safety (bleeding requiring transfusion) results for a simulated acute coronary syndrome antiplatelet therapy clinical trial. Endpoint accuracy metrics were derived from previous studies that compared centrally-adjudicated and insurance claims-based clinical trial endpoints. RESULTS Efficacy endpoint results per 100 patients were similar for the central adjudication model (intervention event rate, 11.3; control, 13.7; difference, 2.4) and the prospective claims data collection model (intervention event rate, 11.2; control 13.6; difference, 2.3). However, the retrospective claims linking model's efficacy results were larger (intervention event rate, 14.6; control, 18.0; difference, 3.4). True positive event rate results (intervention, control and difference) for both insurance claims-based models were less than the central adjudication model due to false negative events. Differences in false positive event rates were responsible for differences in efficacy results for the two insurance claims-based models. CONCLUSION Efficacy endpoint results differed by data source. Investigators need guidance to determine which data sources produce regulatory-grade RWE.
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Schulz WL, Young HP, Coppi A, Mortazavi BJ, Lin Z, Jean RA, Krumholz HM. Temporal relationship of computed and structured diagnoses in electronic health record data. BMC Med Inform Decis Mak 2021; 21:61. [PMID: 33596898 PMCID: PMC7890604 DOI: 10.1186/s12911-021-01416-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/31/2021] [Indexed: 12/13/2022] Open
Abstract
Background The electronic health record (EHR) holds the prospect of providing more complete and timely access to clinical information for biomedical research, quality assessments, and quality improvement compared to other data sources, such as administrative claims. In this study, we sought to assess the completeness and timeliness of structured diagnoses in the EHR compared to computed diagnoses for hypertension (HTN), hyperlipidemia (HLD), and diabetes mellitus (DM). Methods We determined the amount of time for a structured diagnosis to be recorded in the EHR from when an equivalent diagnosis could be computed from other structured data elements, such as vital signs and laboratory results. We used EHR data for encounters from January 1, 2012 through February 10, 2019 from an academic health system. Diagnoses for HTN, HLD, and DM were computed for patients with at least two observations above threshold separated by at least 30 days, where the thresholds were outpatient blood pressure of ≥ 140/90 mmHg, any low-density lipoprotein ≥ 130 mg/dl, or any hemoglobin A1c ≥ 6.5%, respectively. The primary measure was the length of time between the computed diagnosis and the time at which a structured diagnosis could be identified within the EHR history or problem list. Results We found that 39.8% of those with HTN, 21.6% with HLD, and 5.2% with DM did not receive a corresponding structured diagnosis recorded in the EHR. For those who received a structured diagnosis, a mean of 389, 198, and 166 days elapsed before the patient had the corresponding diagnosis of HTN, HLD, or DM, respectively, recorded in the EHR. Conclusions We found a marked temporal delay between when a diagnosis can be computed or inferred and when an equivalent structured diagnosis is recorded within the EHR. These findings demonstrate the continued need for additional study of the EHR to avoid bias when using observational data and reinforce the need for computational approaches to identify clinical phenotypes.
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Affiliation(s)
- Wade L Schulz
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - H Patrick Young
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andreas Coppi
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Bobak J Mortazavi
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,Department of Computer Science and Engineering, Texas A&M University, College Station, TX, USA.,Center for Remote Health Technologies and Systems, Texas A&M University, College Station, TX, USA
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Raymond A Jean
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA.,Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA. .,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA. .,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.
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Caraballo C, Khera R, Jones PG, Decker C, Schulz W, Spertus JA, Krumholz HM. Rates and Predictors of Patient Underreporting of Hospitalizations During Follow-Up After Acute Myocardial Infarction: An Assessment From the TRIUMPH Study. Circ Cardiovasc Qual Outcomes 2020; 13:e006231. [PMID: 32552061 DOI: 10.1161/circoutcomes.119.006231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Many clinical investigations depend on participant self-report as a principal method of identifying health care events. If self-report is used as the trigger to collect and adjudicate medical records, any event that is not reported by the patient will be missed by the investigators, reducing the power of the study and misrepresenting the risk of its participants. We sought to determine the rates and predictors of underreporting hospitalization events during the follow-up period of a prospective study of patients hospitalized with an acute myocardial infarction. METHODS AND RESULTS The TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status) registry, a longitudinal multicenter cohort study of people with acute myocardial infarction in the United States, queried patients for hospitalization events during interviews at 1, 6, and 12 months. To validate these self-reports, medical records for all events at every hospital where the patient reported receiving care were acquired for adjudication, not just those for the reported events. Of the 4340 participants in TRIUMPH, 1209 (28%) reported at least one hospitalization. After medical records abstraction and adjudication, we identified 1086 hospitalizations from 639 participants (60.2±12 years of age, 38.2% women). Of these hospitalizations, 346 (31.9%) were underreported by the participants. Rates of underreporting ranged from 22.5% to 55.6% based on different patient characteristics. The odds of underreporting were highest for those not currently working (adjusted odds ratio, 1.66 [95% CI, 1.04-2.63]), lowest for those married (adjusted odds ratio, 0.50 [95% CI, 0.33-0.76]), and increased the longer the elapsed time between the admission and the patient's follow-up interview (adjusted odds ratio per month, 1.16 [95% CI, 1.08-1.24]). There was a substantial within-individual variation on the accuracy of reporting. CONCLUSIONS Hospitalizations after acute myocardial infarction are commonly underreported in interviews and should not be used alone to determine event rates in clinical studies.
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Affiliation(s)
- César Caraballo
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (C.C., W.S., H.M.K.)
| | - Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (R.K.)
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute, Kansas City, MO (P.G.J., C.D., J.A.S.)
| | - Carole Decker
- Saint Luke's Mid America Heart Institute, Kansas City, MO (P.G.J., C.D., J.A.S.)
| | - Wade Schulz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (C.C., W.S., H.M.K.).,Department of Laboratory Medicine (W.S.), Yale School of Medicine, New Haven, CT
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO (P.G.J., C.D., J.A.S.).,Division of Cardiology, Department of Internal Medicine, University of Missouri-Kansas City (J.A.S.)
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (C.C., W.S., H.M.K.).,Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT.,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
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Chavanon ML, Meyer T, Belnap BH, Huang Y, Abebe KZ, Rollman BL, Herrmann-Lingen C. Emotion regulation in patients with heart failure: Its relationship with depressive symptoms and rehospitalization. J Psychosom Res 2019; 125:109811. [PMID: 31450124 PMCID: PMC6752733 DOI: 10.1016/j.jpsychores.2019.109811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 08/12/2019] [Accepted: 08/12/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine the role of emotion regulation and its relationship to mental and physical health in patients with heart failure (HF). METHODS Patients hospitalized with HF were screened for depressive symptoms with the two-item Patient Health Questionnaire (PHQ-2) and classified as screen-positive if endorsing ≥1 item and otherwise as screen-negative. One month after hospital discharge, the Emotion Regulation Questionnaire (ERQ) was administered to assess suppression and reappraisal as emotion regulation strategies. In all participants who completed the ERQ (N = 394), all-cause rehospitalization and depressive symptoms using the PHQ-9 were assessed at 1-, 3-, and 6-months after hospital discharge. RESULTS Overall, PHQ-9 scores decreased by 6-months (-0.13 points/month, p = .003), and although suppression showed a small association with depression, neither strategy modulated the slope of the decline in depressive symptoms. Multivariable-adjusted Cox models showed that reappraisal and suppression were not related to all-cause rehospitalization in the entire cohort. However, increasing reappraisal reduced rehospitalization risk by 24% for screen-positive patients (N = 311, HR = 0.76, p = .02), but increased it by 94% in screen-negative patients (N = 83, HR = 1.94, p = .009). CONCLUSION Suppression and reappraisal showed specific and divergent associations in patients with HF: Suppression may relate to depressive symptoms. Reappraisal was associated with rehospitalization, but differently for patients with a positive vs. negative depression screen. Further studies are needed to examine whether emotion-regulation skill training can improve mental and physical health in depressed patients with HF or ameliorate depression in those at-risk.
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Affiliation(s)
- Mira-Lynn Chavanon
- Philipps-Universität Marburg, Department of Psychology, Marburg, Germany; Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany; German Center for Cardiovascular Research, Göttingen, Germany
| | - Thomas Meyer
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany; German Center for Cardiovascular Research, Göttingen, Germany
| | - Birgit Herbeck Belnap
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany; Center for Behavioral Health and Smart Technology, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yan Huang
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kaleab Z Abebe
- Center for Clinical Trials and Data Coordination, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bruce L Rollman
- Center for Behavioral Health and Smart Technology, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christoph Herrmann-Lingen
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany; German Center for Cardiovascular Research, Göttingen, Germany.
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Guimarães PO, Krishnamoorthy A, Kaltenbach LA, Anstrom KJ, Effron MB, Mark DB, McCollam PL, Davidson-Ray L, Peterson ED, Wang TY. Accuracy of Medical Claims for Identifying Cardiovascular and Bleeding Events After Myocardial Infarction : A Secondary Analysis of the TRANSLATE-ACS Study. JAMA Cardiol 2019; 2:750-757. [PMID: 28538984 DOI: 10.1001/jamacardio.2017.1460] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Pragmatic clinical trial designs have proposed the use of medical claims data to ascertain clinical events; however, the accuracy of billed diagnoses in identifying potential events is unclear. Objectives To compare the 1-year cumulative incidences of events when events were identified by medical claims vs by physician adjudication and to assess the accuracy of bill-identified events using physician adjudication as the criterion standard. Design, Setting, and Participants This post hoc analysis of a clinical trial assessed the medical claims forms and records for all rehospitalizations at 233 US hospitals within 1 year of the index acute myocardial infarction (MI) of 12 365 patients enrolled in the Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome (TRANSLATE-ACS) study between April 1, 2010, and October 31, 2012. Fourteen patients (0.1%) died during the index hospitalization and were excluded from analysis. Recurrent MI, stroke, and bleeding events were identified per the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedural codes in medical bills. These events were independently adjudicated by study physicians through medical record reviews using the prespecified criteria of recurrent MI and stroke and the bleeding definition by the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) scale. Medical claims were reported on a Uniform Bill-04 claims form; claims were collected from all hospitals visited by patients enrolled in TRANSLATE-ACS. Agreement between medical claims-identified events and physician-adjudicated events over the 12 months after discharge was assessed with the κ statistic. Data were analyzed from January 30, 2015, to March 2, 2017. Main Outcomes and Measures Event rates within 1 year after MI. Results Among 12 365 patients with acute MI, 8890 (71.9%) were men and mean (SD) age was 60 (11.6) years. The cumulative 1-year incidence of events identified by medical claims was 4.3% for MI, 0.9% for stroke, and 5.0% for bleeding. Incidence rates based on physician adjudication were 4.7% for MI, 0.9% for stroke, and 5.4% for bleeding. Agreement between medical claims-identified and physician-adjudicated events was modest, with a κ of 0.76 (95% CI, 0.73 to 0.79) for MI and 0.55 (95% CI, 0.41 to 0.68) for stroke events. In contrast, agreement between medical claims-identified and physician-adjudicated bleeding events was poor, with a κ of 0.24 (95% CI, 0.19 to 0.30) for any hospitalized bleeding event and 0.15 (95% CI, 0.11 to 0.20) for moderate or severe bleeding on the GUSTO scale. Conclusions and Relevance Event rates at 1 year after MI were lower for MI, stroke, and bleeding when medical claims were used to identify events than when adjudicated by physicians. Medical claims diagnoses were only modestly accurate in identifying MI and stroke admissions but had limited accuracy for bleeding events. An alternative approach may be needed to ensure good safety surveillance in cardiovascular studies. Trial Registration clinicaltrials.gov Identifier: NCT01088503.
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Affiliation(s)
- Patricia O Guimarães
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Arun Krishnamoorthy
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Mark B Effron
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Linda Davidson-Ray
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Ma Q, Chung H, Shambhu S, Roe M, Cziraky M, Jones WS, Haynes K. Administrative claims data to support pragmatic clinical trial outcome ascertainment on cardiovascular health. Clin Trials 2019; 16:419-430. [PMID: 31081367 DOI: 10.1177/1740774519846853] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND/AIMS Health plan administrative claims data present a cost-effective complement to traditional trial-specific ascertainment of clinical events typically conducted through patient report or a single health system electronic health record. We aim to demonstrate the value of health plan claims data in improving the capture of endpoints in longitudinal pragmatic clinical trials. METHODS This retrospective cohort study paralleled the design of the ADAPTABLE (Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness) trial designed to compare the effectiveness of two doses of aspirin. We applied the ADAPTABLE identification query in claims data from Anthem, an American health insurance company, and identified health plan members who met the ADAPTABLE trial criteria. Among the ADAPTABLE eligible members, we selected overlapping members with PCORnet Clinical Data Research Networks in the 2 years prior to the index date (1 April 2014). PCORnet Clinical Data Research Networks consist of network partners (or healthcare systems) that store their electronic health record data in the same format to support multi-institutional research. ADAPTABLE outcome events-cardiovascular hospitalizations including admissions for myocardial infarction, stroke, or cardiac procedures; hospitalizations for major bleeding; and in-hospital deaths-were evaluated for a 2-year follow-up period. Events were classified as within or outside PCORnet Clinical Data Research Networks using facility identifiers affiliated with each hospital stay. Patient characteristics were examined with descriptive statistics, and incidence rates were reported for available Clinical Data Research Networks and claims data. RESULTS Among 884,311 ADAPTABLE eligible health plan members, 11,101 patients overlapped with PCORnet Clinical Data Research Networks. Average age was 70 years, 71% were male, and average follow-up was 20.7 months. Patients had 1521 cardiovascular hospitalizations (571 (37.5%) occurred outside PCORnet Clinical Data Research Networks), 710 for major bleeding (296 (41.7%) outside PCORnet Clinical Data Research Networks), and 196 in-hospital deaths (67 (34.2%) outside PCORnet Clinical Data Research Networks). Incidence rates (events per1000 patient-months) differed between available network partners and claims data: cardiovascular hospitalizations, 4.1 (95% confidence interval: 3.9, 4.4) versus 6.6 (95% confidence interval: 6.3, 7.0), major bleeding, 1.8 (95% confidence interval: 1.6, 2.0) versus 3.1 (95% confidence interval: 2.9, 3.3), and in-hospital death, 0.56 (95% confidence interval: 0.47, 0.67) versus 0.85 (95% confidence interval: 0.74, 0.98), respectively. CONCLUSION This study demonstrated the value of supplementing longitudinal site-based clinical studies with administrative claims data. Our results suggest that claims data together with network partner electronic health record data constitute an effective vehicle to capture patient outcomes since >30% of patients have non-fatal and fatal events outside of enrolling sites.
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Affiliation(s)
- Qinli Ma
- 1 HealthCore, Inc., Wilmington, DE, USA
| | | | | | - Matthew Roe
- 2 Duke Heart Center, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | | | - W Schuyler Jones
- 2 Duke Heart Center, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
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9
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Fanaroff AC, Kaltenbach LA, Peterson ED, Hess CN, Cohen DJ, Fonarow GC, Wang TY. Management of Persistent Angina After Myocardial Infarction Treated With Percutaneous Coronary Intervention: Insights From the TRANSLATE-ACS Study. J Am Heart Assoc 2017; 6:JAHA.117.007007. [PMID: 29051217 PMCID: PMC5721884 DOI: 10.1161/jaha.117.007007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Angina has important implications for patients' quality of life and healthcare utilization. Angina management after acute myocardial infarction (MI) treated with percutaneous coronary intervention (PCI) is unknown. METHODS AND RESULTS TRANSLATE-ACS (Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) was a longitudinal study of MI patients treated with percutaneous coronary intervention at 233 US hospitals from 2010 to 2012. Among patients with self-reported angina at 6 weeks post-MI, we described patterns of angina and antianginal medication use through 1 year postdischarge. Of 10 870 percutaneous coronary intervention-treated MI patients, 3190 (29.3%) reported angina symptoms at 6 weeks post-MI; of these, 658 (20.6%) had daily/weekly angina while 2532 (79.4%) had monthly angina. Among patients with 6-week angina, 2936 (92.0%) received β-blockers during the 1 year post-MI, yet only 743 (23.3%) were treated with other antianginal medications. At 1 year, 1056 patients (33.1%) with 6-week angina reported persistent angina symptoms. Of these, only 31.2% had been prescribed non-β-blocker antianginal medications at any time in the past year. Among patients undergoing revascularization during follow-up, only 25.9% were on ≥1 non-β-blocker anti-anginal medication at the time of the procedure. CONCLUSIONS Angina is present in one third of percutaneous coronary intervention-treated MI patients as early as 6 weeks after discharge, and many of these patients have persistent angina at 1 year. Non-β-blocker antianginal medications are infrequently used in these patients, even among those with persistent angina and those undergoing revascularization.
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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology, Duke University, Durham, NC .,Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Eric D Peterson
- Division of Cardiology, Duke University, Durham, NC.,Duke Clinical Research Institute, Duke University, Durham, NC
| | - Connie N Hess
- Division of Cardiology, University of Colorado, and CPC Clinical Research, Aurora, CO
| | - David J Cohen
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, CA
| | - Tracy Y Wang
- Division of Cardiology, Duke University, Durham, NC.,Duke Clinical Research Institute, Duke University, Durham, NC
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10
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Dreyer RP, Dharmarajan K, Kennedy KF, Jones PG, Vaccarino V, Murugiah K, Nuti SV, Smolderen KG, Buchanan DM, Spertus JA, Krumholz HM. Sex Differences in 1-Year All-Cause Rehospitalization in Patients After Acute Myocardial Infarction: A Prospective Observational Study. Circulation 2017; 135:521-531. [PMID: 28153989 DOI: 10.1161/circulationaha.116.024993] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/13/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI. METHODS We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction. RESULTS One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12-1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08-1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96-1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women. CONCLUSIONS Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference.
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Affiliation(s)
- Rachel P Dreyer
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
| | - Kumar Dharmarajan
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Kevin F Kennedy
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Philip G Jones
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Viola Vaccarino
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Karthik Murugiah
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Sudhakar V Nuti
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Kim G Smolderen
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Donna M Buchanan
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - John A Spertus
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Harlan M Krumholz
- From Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, CT (R.P.D., K.D., K.M., S.V.N., H.M.K.); Department of Emergency Medicine (R.P.D.), Section of Cardiovascular Medicine (K.D., K.M., S.V.N., H.M.K.), Yale School of Medicine, New Haven, CT; Saint Luke's Mid America Heart Institute, Kansas City, MO (K.F.K., P.G.J., K.G.S., D.M.B., J.A.S.); School of Medicine, University of Missouri-Kansas City (P.G.J., K.G.S., D.M.B., J.A.S.); Department of Epidemiology (V.V.) and Department of Medicine, Division of Cardiology (V.V.), Emory University School of Public Health, Atlanta, GA; School of Medicine, Department of Biomedical & Health Informatics, University of Missouri-Kansas City (K.G.S); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
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