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Shwayder E, Dodson JA, Tellez K, Johanek C, Adhikari S, Meng Y, Schoenthaler A, Jennings LA. Goal setting among older adults starting mobile health cardiac rehabilitation in the RESILIENT trial. J Am Geriatr Soc 2024. [PMID: 38450759 DOI: 10.1111/jgs.18868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/12/2024] [Accepted: 02/14/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND There is growing recognition that healthcare should align with individuals' health priorities; however, these priorities remain undefined, especially among older adults. The Rehabilitation Using Mobile Health for Older Adults with Ischemic Heart Disease in the Home Setting (RESILIENT) trial, designed to test the efficacy of mobile health cardiac rehabilitation (mHealth-CR) in an older cohort, also measures the attainment of participant-defined health outcome goals as a prespecified secondary endpoint. This study aimed to characterize the health priorities of older adults with ischemic heart disease (IHD) using goal attainment scaling-a technique for measuring individualized goal achievement-in a sample of 100 RESILIENT participants. METHODS The ongoing RESILIENT trial randomizes patients aged ≥65 years with IHD (defined as hospitalization for acute coronary syndrome and/or coronary revascularization), to receive mHealth-CR or usual care. For the current study, we qualitatively coded baseline goal attainment scales from randomly selected batches of 20 participants to identify participants' cardiac rehabilitation outcome goals and their perceptions of barriers and action plans for goal attainment. We used a deductive framework (i.e., 4 value categories from Patient Priorities Care) and inductive approaches to code and analyze interviews until thematic saturation. RESULTS This sample of 100 older adults set diverse health outcome goals. Most (54.6%) prioritized physical activity, fewer (17.1%) identified symptom management, fewer still (13.7%) prioritized health metrics, mostly comprised of weight loss goals (10.3%), and the fewest (<4%) were related to clinical metrics such as reducing cholesterol or preventing hospital readmission. Participants anticipated extrinsic (access to places to exercise, time) and intrinsic (non-cardiac pain, motivation) barriers. Action plans detailed strategies for exercise, motivation, accountability, and overcoming time constraints. CONCLUSIONS Using goal attainment scaling, we elicited specific and measurable goals among older adults with IHD beginning cardiac rehabilitation. Priorities were predominantly functional, diverging from clinical metrics emphasized by clinicians and healthcare systems.
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Affiliation(s)
- Elianna Shwayder
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Division of Healthcare Delivery Science, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Kelly Tellez
- Division of Healthcare Delivery Science, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Camila Johanek
- Division of Healthcare Delivery Science, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Samrachana Adhikari
- Division of Biostatistics, New York University Grossman School of Medicine, New York, New York, USA
| | - Yuchen Meng
- Division of Biostatistics, New York University Grossman School of Medicine, New York, New York, USA
| | - Antoinette Schoenthaler
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York, New York, USA
| | - Lee A Jennings
- Reynolds Section of Geriatrics and Palliative Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Zhang H, Jethani N, Jones S, Genes N, Major VJ, Jaffe IS, Cardillo AB, Heilenbach N, Ali NF, Bonanni LJ, Clayburn AJ, Khera Z, Sadler EC, Prasad J, Schlacter J, Liu K, Silva B, Montgomery S, Kim EJ, Lester J, Hill TM, Avoricani A, Chervonski E, Davydov J, Small W, Chakravartty E, Grover H, Dodson JA, Brody AA, Aphinyanaphongs Y, Masurkar A, Razavian N. Evaluating Large Language Models in Extracting Cognitive Exam Dates and Scores. medRxiv 2024:2023.07.10.23292373. [PMID: 38405784 PMCID: PMC10888985 DOI: 10.1101/2023.07.10.23292373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Importance Large language models (LLMs) are crucial for medical tasks. Ensuring their reliability is vital to avoid false results. Our study assesses two state-of-the-art LLMs (ChatGPT and LlaMA-2) for extracting clinical information, focusing on cognitive tests like MMSE and CDR. Objective Evaluate ChatGPT and LlaMA-2 performance in extracting MMSE and CDR scores, including their associated dates. Methods Our data consisted of 135,307 clinical notes (Jan 12th, 2010 to May 24th, 2023) mentioning MMSE, CDR, or MoCA. After applying inclusion criteria 34,465 notes remained, of which 765 underwent ChatGPT (GPT-4) and LlaMA-2, and 22 experts reviewed the responses. ChatGPT successfully extracted MMSE and CDR instances with dates from 742 notes. We used 20 notes for fine-tuning and training the reviewers. The remaining 722 were assigned to reviewers, with 309 each assigned to two reviewers simultaneously. Inter-rater-agreement (Fleiss' Kappa), precision, recall, true/false negative rates, and accuracy were calculated. Our study follows TRIPOD reporting guidelines for model validation. Results For MMSE information extraction, ChatGPT (vs. LlaMA-2) achieved accuracy of 83% (vs. 66.4%), sensitivity of 89.7% (vs. 69.9%), true-negative rates of 96% (vs 60.0%), and precision of 82.7% (vs 62.2%). For CDR the results were lower overall, with accuracy of 87.1% (vs. 74.5%), sensitivity of 84.3% (vs. 39.7%), true-negative rates of 99.8% (98.4%), and precision of 48.3% (vs. 16.1%). We qualitatively evaluated the MMSE errors of ChatGPT and LlaMA-2 on double-reviewed notes. LlaMA-2 errors included 27 cases of total hallucination, 19 cases of reporting other scores instead of MMSE, 25 missed scores, and 23 cases of reporting only the wrong date. In comparison, ChatGPT's errors included only 3 cases of total hallucination, 17 cases of wrong test reported instead of MMSE, and 19 cases of reporting a wrong date. Conclusions In this diagnostic/prognostic study of ChatGPT and LlaMA-2 for extracting cognitive exam dates and scores from clinical notes, ChatGPT exhibited high accuracy, with better performance compared to LlaMA-2. The use of LLMs could benefit dementia research and clinical care, by identifying eligible patients for treatments initialization or clinical trial enrollments. Rigorous evaluation of LLMs is crucial to understanding their capabilities and limitations.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Abraham A Brody
- NYU Rory Meyers College of Nursing, NYU Grossman School of Medicine
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Gong Y, Song Y, Xu J, Dong H, Orkaby AR, Kramer DB, Dodson JA, Strom JB. Progression of Frailty and Cardiovascular Outcomes Among Medicare Beneficiaries. medRxiv 2024:2024.02.09.24302612. [PMID: 38405808 PMCID: PMC10889015 DOI: 10.1101/2024.02.09.24302612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background Frailty is associated with adverse cardiovascular outcomes independent of age and comorbidities, yet the independent influence of frailty progression remains uncertain. Methods Medicare Fee-for-service beneficiaries ≥ 65 years at cohort inception with continuous enrollment from 2003-2015 were included. Frailty trajectory was measured by annualized change in a validated claims-based frailty index (CFI) over a 5-year period. Linear mixed effects models, adjusting for baseline frailty, were used to estimate CFI change over a 5-year period. Survival analysis was used to evaluate associations of frailty progression and future health outcomes (major adverse cardiovascular and cerebrovascular events [MACCE], all-cause death, heart failure, myocardial infarction, ischemic stroke, and days alive at home [DAH] within the following calendar year). Results 26.4 million unique beneficiaries were included (mean age 75.4 ± 7.0 years, 57% female, 13% non-White). In total, 20% had frailty progression, 66% had no change in frailty, and 14% frailty regression over median follow-up of 2.4 years. Compared to those without a change in CFI, when adjusting for baseline frailty, those with frailty progression had significantly greater risk of incident MACCE (hazard ratio [HR] 2.30, 95% confidence interval [CI] 2.30-2.31), all-cause mortality (HR 1.59, 95% CI 1.58-1.59), acute myocardial infarction (HR 1.78, 95% CI 1.77-1.79), heart failure (HR 2.78, 95% CI 2.77-2.79), and stroke (HR 1.78, 95% CI 1.77-1.79). There was also a graded increase in risk of each outcome with more rapid progression and significantly fewer DAH with the most rapid vs. the slowest progression group (270.4 ± 112.3 vs. 308.6 ± 93.0 days, rate ratio 0.88, 95% CI 0.87-0.88, p < 0.001). Conclusions In this large, nationwide sample of Medicare beneficiaries, frailty progression, independent of baseline frailty, was associated with fewer DAH and a graded risk of MACCE, all-cause mortality, myocardial infarction, heart failure, and stroke compared to those without progression.
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Affiliation(s)
- Yusi Gong
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Huaying Dong
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ariela R. Orkaby
- Brigham and Women’s Hospital, Division on Aging, Boston, MA, USA
| | - Daniel B. Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Jordan B. Strom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Mukhopadhyay A, Blecker S, Li X, Kronish IM, Chunara R, Zheng Y, Lawrence S, Dodson JA, Kozloff S, Adhikari S. Neighborhood-Level Socioeconomic Status and Prescription Fill Patterns Among Patients With Heart Failure. JAMA Netw Open 2023; 6:e2347519. [PMID: 38095897 PMCID: PMC10722333 DOI: 10.1001/jamanetworkopen.2023.47519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/30/2023] [Indexed: 12/17/2023] Open
Abstract
Importance Medication nonadherence is common among patients with heart failure with reduced ejection fraction (HFrEF) and can lead to increased hospitalization and mortality. Patients living in socioeconomically disadvantaged areas may be at greater risk for medication nonadherence due to barriers such as lower access to transportation or pharmacies. Objective To examine the association between neighborhood-level socioeconomic status (nSES) and medication nonadherence among patients with HFrEF and to assess the mediating roles of access to transportation, walkability, and pharmacy density. Design, Setting, and Participants This retrospective cohort study was conducted between June 30, 2020, and December 31, 2021, at a large health system based primarily in New York City and surrounding areas. Adult patients with a diagnosis of HF, reduced EF on echocardiogram, and a prescription of at least 1 guideline-directed medical therapy (GDMT) for HFrEF were included. Exposure Patient addresses were geocoded, and nSES was calculated using the Agency for Healthcare Research and Quality SES index, which combines census-tract level measures of poverty, rent burden, unemployment, crowding, home value, and education, with higher values indicating higher nSES. Main Outcomes and Measures Medication nonadherence was obtained through linkage of health record prescription data with pharmacy fill data and was defined as proportion of days covered (PDC) of less than 80% over 6 months, averaged across GDMT medications. Results Among 6247 patients, the mean (SD) age was 73 (14) years, and majority were male (4340 [69.5%]). There were 1011 (16.2%) Black participants, 735 (11.8%) Hispanic/Latinx participants, and 3929 (62.9%) White participants. Patients in lower nSES areas had higher rates of nonadherence, ranging from 51.7% in the lowest quartile (731 of 1086 participants) to 40.0% in the highest quartile (563 of 1086 participants) (P < .001). In adjusted analysis, patients living in the lower 2 nSES quartiles had significantly higher odds of nonadherence when compared with patients living in the highest nSES quartile (quartile 1: odds ratio [OR], 1.57 [95% CI, 1.35-1.83]; quartile 2: OR, 1.35 [95% CI, 1.16-1.56]). No mediation by access to transportation and pharmacy density was found, but a small amount of mediation by neighborhood walkability was observed. Conclusions and Relevance In this retrospective cohort study of patients with HFrEF, living in a lower nSES area was associated with higher rates of GDMT nonadherence. These findings highlight the importance of considering neighborhood-level disparities when developing approaches to improve medication adherence.
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Affiliation(s)
- Amrita Mukhopadhyay
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Saul Blecker
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Xiyue Li
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Ian M. Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York
| | - Rumi Chunara
- Department of Biostatistics, NYU School of Global Public Health, New York, New York
- Department of Computer Science & Engineering, Tandon School of Engineering, New York, New York
| | - Yaguang Zheng
- NYU Rory Meyers College of Nursing, New York, New York
| | - Steven Lawrence
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - John A. Dodson
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Sam Kozloff
- Department of Medicine, University of Utah, Salt Lake City
| | - Samrachana Adhikari
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
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Masterson Creber R, Dodson JA, Bidwell J, Breathett K, Lyles C, Harmon Still C, Ooi SY, Yancy C, Kitsiou S. Telehealth and Health Equity in Older Adults With Heart Failure: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2023; 16:e000123. [PMID: 37909212 DOI: 10.1161/hcq.0000000000000123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Enhancing access to care using telehealth is a priority for improving outcomes among older adults with heart failure, increasing quality of care, and decreasing costs. Telehealth has the potential to increase access to care for patients who live in underresourced geographic regions, have physical disabilities or poor access to transportation, and may not otherwise have access to cardiologists with expertise in heart failure. During the COVID-19 pandemic, access to telehealth expanded, and yet barriers to access, including broadband inequality, low digital literacy, and structural barriers, prevented many of the disadvantaged patients from getting equitable access. Using a health equity lens, this scientific statement reviews the literature on telehealth for older adults with heart failure; provides an overview of structural, organizational, and personal barriers to telehealth; and presents novel interventions that pair telemedicine with in-person services to mitigate existing barriers and structural inequities.
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Viswanathan AV, Dodson JA, Blachman NL. GeriKit: A novel app for comprehensive geriatric assessment. Gerontol Geriatr Educ 2023; 44:641-648. [PMID: 35404774 PMCID: PMC9550877 DOI: 10.1080/02701960.2022.2048298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Given the growth of the older adult population in the United States, there is a greater need for tools to enable students, trainees, and clinicians to master the comprehensive geriatric assessment. Our goal was to develop a mobile phone application (app) to assist in performing this assessment. We performed a market survey of 45 apps that related to geriatrics and health screening. We evaluated for usability, target audience, and instruments used. Deficiencies included: (1) focusing on a single domain; (2) being time-intensive; and (3) having components behind a paywall. We then designed an app that incorporates instruments that are well-validated, available at no cost, and brief in length. GeriKit includes eight domains: cognition, depression, function, strength, medications, falls, and advance care planning. Each instrument requires fewer than 5 minutes, and once it is completed and scored, the user can access relevant educational materials. GeriKit was launched for Apple users in December 2020, and for Android in August 2021. There have been over 3,400 downloads to date. The GeriKit app makes the comprehensive geriatric assessment accessible to a wide audience, improving the ability to for learners to perform geriatric assessments.
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Affiliation(s)
- Ambika V Viswanathan
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - John A Dodson
- New York University Grossman School of Medicine, New York, New York, USA
| | - Nina L Blachman
- New York University Grossman School of Medicine, New York, New York, USA
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Stone KL, Zhong J, Lyu C, Chodosh J, Blachman NL, Dodson JA. Does Incident Cardiovascular Disease Lead to Greater Odds of Functional and Cognitive Impairment? Insights From the Health and Retirement Study. J Gerontol A Biol Sci Med Sci 2023; 78:1179-1188. [PMID: 36996314 PMCID: PMC10329231 DOI: 10.1093/gerona/glad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Although studies to date have broadly shown that cardiovascular disease (CVD) increases cognitive and physical impairment risk, there is still limited understanding of the magnitude of this risk among relevant CVD subtypes or age cohorts. METHODS We analyzed longitudinal data from 16 679 U.S. Health and Retirement Study participants who were aged ≥65 years at study entry. Primary endpoints were physical impairment (activities of daily living impairment) or cognitive impairment (Langa-Weir Classification of dementia). We compared these endpoints among participants who developed incident CVD versus those who were CVD free, both in the short term (<2-year postdiagnosis) and long term (>5 years), controlling for sociodemographic and health characteristics. We then analyzed the effects by CVD subtype (atrial fibrillation, congestive heart failure, ischemic heart disease, and stroke) and age-at-diagnosis (65-74, 75-84, and ≥85). RESULTS Over a median follow-up of 10 years, 8 750 participants (52%) developed incident CVD. Incident CVD was associated with significantly higher adjusted odds (aOR) of short-term and long-term physical and cognitive impairment. The oldest (≥85) age-at-diagnosis subgroup had the highest risk of short-term physical (aOR 3.01, 95% confidence interval [CI]: 2.40-3.77) and cognitive impairment (aOR 1.96, 95% CI: 1.55-2.48), as well as long-term impairment. All CVD subtypes were associated with higher odds of physical and cognitive impairment, with the highest risk for patients with incident stroke. CONCLUSIONS Incident CVD was associated with an increased risk of physical and cognitive impairment across CVD subtypes. Impairment risk after CVD was highest among the oldest patients (≥85 years) who should therefore remain a target for prevention efforts.
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Affiliation(s)
- Katherine L Stone
- Division of Geriatric Medicine and Palliative Care, Department of Medicine, New York University Langone Medical Center, New York, New York, USA
| | - Judy Zhong
- Division of Biostatistics, Department of Population Health, New York University Langone Medical Center, New York, New York, USA
| | - Chen Lyu
- Division of Biostatistics, Department of Population Health, New York University Langone Medical Center, New York, New York, USA
| | - Joshua Chodosh
- Division of Geriatric Medicine and Palliative Care, Department of Medicine, New York University Langone Medical Center, New York, New York, USA
| | - Nina L Blachman
- Division of Geriatric Medicine and Palliative Care, Department of Medicine, New York University Langone Medical Center, New York, New York, USA
| | - John A Dodson
- Division of Biostatistics, Department of Population Health, New York University Langone Medical Center, New York, New York, USA
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Medical Center, New York, New York, USA
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Nguyen DD, Spertus JA, Alexander KP, Newman JD, Dodson JA, Jones PG, Stevens SR, O'Brien SM, Gamma R, Perna GP, Garg P, Vitola JV, Chow BJW, Vertes A, White HD, Smanio PEP, Senior R, Held C, Li J, Boden WE, Mark DB, Reynolds HR, Bangalore S, Chan PS, Stone GW, Arnold SV, Maron DJ, Hochman JS. Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease: The ISCHEMIA Trial. J Am Coll Cardiol 2023; 81:1697-1709. [PMID: 37100486 PMCID: PMC10902923 DOI: 10.1016/j.jacc.2023.02.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/08/2023] [Accepted: 02/21/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown. OBJECTIVES The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. METHODS One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure. RESULTS Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29). CONCLUSIONS Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- Dan D Nguyen
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA.
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | - Jonathan D Newman
- New York University Grossman School of Medicine, New York, New York, USA
| | - John A Dodson
- New York University Grossman School of Medicine, New York, New York, USA
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | - Sean M O'Brien
- Duke Clnical Research Institute, Durham, North Carolina, USA
| | - Reto Gamma
- Department of Cardiology, Swiss Cardiovascular Centre, University Hospital Inselspital, Bern, Switzerland
| | - Gian P Perna
- Department of Cardiology, Ospedali Riuniti Ancona, Ancona, Italy
| | - Pallav Garg
- London Health Sciences Centre, London, Ontario, Canada
| | | | | | - Andras Vertes
- Dél-pesti Centrumkóház Hospital, National Institute of Hematology and Infectious Disease, Cardiovascular Department, Budapest, Hungary
| | - Harvey D White
- Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand; University of Auckland, Auckland, New Zealand
| | - Paola E P Smanio
- Instituto Dante Pazzanese de Cardiologia e Fleury Medicina e Saúde, São Paulo, Brazil
| | - Roxy Senior
- Department of Medicine, Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala, Sweden
| | - Jianghao Li
- Duke Clnical Research Institute, Durham, North Carolina, USA
| | - William E Boden
- Veteran Affairs, New England Healthcare System, Boston, Massachusetts, USA
| | - Daniel B Mark
- Duke Clnical Research Institute, Durham, North Carolina, USA
| | - Harmony R Reynolds
- New York University Grossman School of Medicine, New York, New York, USA
| | - Sripal Bangalore
- New York University Grossman School of Medicine, New York, New York, USA
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - David J Maron
- Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Judith S Hochman
- New York University Grossman School of Medicine, New York, New York, USA
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Hajduk AM, Dodson JA, Murphy TE, Chaudhry SI. A risk model for decline in health status after acute myocardial infarction among older adults. J Am Geriatr Soc 2023; 71:1228-1235. [PMID: 36519774 PMCID: PMC10089939 DOI: 10.1111/jgs.18162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Health status is increasingly recognized as an important patient-centered outcome after acute myocardial infarction (AMI). Yet drivers of decline in health status after AMI remain largely unknown in older adults. We sought to develop and validate a predictive risk model for health status decline among older adult survivors of AMI. METHODS Using data from a prospective cohort study conducted from 2013 to 2017 of 3041 patients age ≥75 years hospitalized with acute myocardial infarction at 94 U.S. hospitals, we examined a broad array of demographic, clinical, functional, and psychosocial variables for their association with health status decline, defined as a decrease of ≥5 points in the Short Form-12 (SF-12) physical component score from hospitalization to 6 months post-discharge. Model selection was performed in logistic regression models of 20 imputed datasets to yield a parsimonious risk prediction model. Model discrimination and calibration were evaluated using c-statistics and calibration plots, respectively. RESULTS Of the 2571 participants included in the main analyses, 30% of patients experienced health status decline from hospitalization to 6 months post-discharge. The risk model contained 14 factors, 10 associated with higher risk of health status decline (age, pre-existing AMI, pre-existing cancer, pre-existing COPD, pre-existing diabetes, history of falls, presenting Killip class, acute kidney injury, baseline health status, and mobility impairment) and four associated with lower risk of health status decline (male sex, higher hemoglobin, receipt of revascularization, and arrhythmia during hospitalization). The model displayed good discrimination (c-statistic = 0.74 in validation cohort) and calibration (p > 0.05) in both development and validation cohorts. CONCLUSIONS We used split sampling to develop and validate a risk model for health status decline in older adults after hospitalization for AMI and identified several risk factors that may be modifiable to mitigate the threat of this important patient-centered outcome. External validation of this risk model is warranted.
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Affiliation(s)
- Alexandra M Hajduk
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA
- Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Terrence E Murphy
- Department of Public Health Sciences, Penn State College of Medicine, State College, Pennsylvania, USA
| | - Sarwat I Chaudhry
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Sidhu S, Sheng S, Sweeney G, Pierre A, Whiteson J, Reyentovich A, Dodson JA. EXAMINING RISK FACTORS RELATED TO CARDIAC REHABILITATION CESSATION AMONG HEART TRANSPLANT RECIPIENTS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02186-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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11
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Kovell L, McCabe P, Juraschek SP, Sanchez MV, Bothwick V, Yang W, Tellez K, Pena S, Schoenthaler A, Adhikari S, Dodson JA. PATTERNS OF ADHERENCE TO HOME BLOOD PRESSURE MONITORING IN THE RESILIENT TRIAL OF MOBILE CARDIAC REHABILITATION IN OLDER ADULTS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02326-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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12
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Stone KL, Zhong J, Lyu C, Chodosh J, Blachman N, Dodson JA. DOES INCIDENT CARDIOVASCULAR DISEASE LEAD TO GREATER ODDS OF DISABILITY? INSIGHTS FROM THE HEALTH AND RETIREMENT STUDY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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13
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Demkowicz PC, Hajduk AM, Dodson JA, Oladele CR, Chaudhry SI. Racial disparities among older adults with acute myocardial infarction: The SILVER-AMI study. J Am Geriatr Soc 2023; 71:474-483. [PMID: 36415964 PMCID: PMC9957871 DOI: 10.1111/jgs.18084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 08/23/2022] [Accepted: 09/17/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Despite an aging population, little is known about racial disparities in aging-specific functional impairments and mortality among older adults hospitalized for acute myocardial infarction (AMI). METHODS We analyzed data from patients aged 75 years or older who were hospitalized for AMI at 94 US hospitals from 2013 to 2016. Functional impairments and geriatric conditions were assessed in-person during the AMI hospitalization. The association between race and risk of mortality (primary outcome) was evaluated with logistic regression adjusted sequentially for age, clinical characteristics, and measures of functional impairment and other conditions associated with aging. RESULTS Among 2918 participants, 2668 (91.4%) self-identified as White and 250 (8.6%) as Black. Black participants were younger (80.8 vs 81.7 years; p = 0.010) and more likely to be female (64.8% vs 42.5%; p < 0.001). Black participants were more likely to present with impairments in cognition (37.6% vs 14.5%; p < 0.001), mobility (66.0% vs 54.6%; p < 0.001) and vision (50.1% vs 35.7%; p < 0.001). Black participants were also more likely to report a disability in one or more activities of daily living (22.4% vs 13.0%; p < 0.001) and an unintentional loss of more than 10 lbs in the year prior to hospitalization (37.2% vs 13.0%; p < 0.001). The unadjusted odds of 6-month mortality among Black participants (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.4-2.8) attenuated to non-significance after adjustment for age, clinical characteristics (OR 1.70, 95% CI 1.7, 1.2-2.5), and functional/geriatric conditions (OR 1.5, 95% CI 1.0-2.2). CONCLUSIONS Black participants had a more geriatric phenotype despite a younger average age, with more functional impairments. Controlling for functional impairments and geriatric conditions attenuated disparities in 6-month mortality somewhat. These findings highlight the importance of systematically assessing functional impairment during hospitalization and also ensuring equitable access to community programs to support post-AMI recovery among Black older adults.
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Affiliation(s)
- Patrick C. Demkowicz
- Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Alexandra M. Hajduk
- Department of Internal Medicine, Section of Geriatrics, Yale University School of Medicine, New Haven, Connecticut
| | - John A. Dodson
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Carol R. Oladele
- Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Equity Research and Innovation Center, Yale University School of Medicine, New Haven, Connecticut
| | - Sarwat I. Chaudhry
- Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Mukhopadhyay A, Adhikari S, Li X, Dodson JA, Kronish IM, Shah B, Ramatowski M, Chunara R, Kozloff S, Blecker S. Association Between Copayment Amount and Filling of Medications for Angiotensin Receptor Neprilysin Inhibitors in Patients With Heart Failure. J Am Heart Assoc 2022; 11:e027662. [PMID: 36453634 PMCID: PMC9798787 DOI: 10.1161/jaha.122.027662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/19/2022] [Indexed: 12/03/2022]
Abstract
Background Angiotensin receptor neprilysin inhibitors (ARNI) reduce mortality and hospitalization for patients with heart failure. However, relatively high copayments for ARNI may contribute to suboptimal adherence, thus potentially limiting their benefits. Methods and Results We conducted a retrospective cohort study within a large, multi-site health system. We included patients with: ARNI prescription between November 20, 2020 and June 30, 2021; diagnosis of heart failure or left ventricular ejection fraction ≤40%; and available pharmacy or pharmacy benefit manager copayment data. The primary exposure was copayment, categorized as $0, $0.01 to $10, $10.01 to $100, and >$100. The primary outcome was prescription fill nonadherence, defined as the proportion of days covered <80% over 6 months. We assessed the association between copayment and nonadherence using multivariable logistic regression, and nonbinarized proportion of days covered using multivariable Poisson regression, adjusting for demographic, clinical, and neighborhood-level covariates. A total of 921 patients met inclusion criteria, with 192 (20.8%) having $0 copayment, 228 (24.8%) with $0.01 to $10 copayment, 206 (22.4%) with $10.01 to $100, and 295 (32.0%) with >$100. Patients with higher copayments had higher rates of nonadherence, ranging from 17.2% for $0 copayment to 34.2% for copayment >$100 (P<0.001). After multivariable adjustment, odds of nonadherence were significantly higher for copayment of $10.01 to $100 (odds ratio [OR], 1.93 [95% CI, 1.15-3.27], P=0.01) or >$100 (OR, 2.58 [95% CI, 1.63-4.18], P<0.001), as compared with $0 copayment. Similar associations were seen when assessing proportion of days covered as a proportion. Conclusions We found higher rates of not filling ARNI prescriptions among patients with higher copayments, which persisted after multivariable adjustment. Our findings support future studies to assess whether reducing copayments can increase adherence to ARNI and improve outcomes for heart failure.
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Affiliation(s)
- Amrita Mukhopadhyay
- Department of Medicine (Cardiology)New York University School of MedicineNew YorkNY
| | - Samrachana Adhikari
- Department of Population HealthNew York University School of MedicineNew YorkNY
| | - Xiyue Li
- Department of Population HealthNew York University School of MedicineNew YorkNY
| | - John A. Dodson
- Department of Medicine (Cardiology)New York University School of MedicineNew YorkNY
| | - Ian M. Kronish
- Center for Behavioral Cardiovascular HealthColumbia University Irving Medical CenterNew YorkNY
| | - Binita Shah
- Department of Medicine (Cardiology)VA New York Harbor Healthcare SystemNew YorkNY
| | - Maggie Ramatowski
- Department of Population HealthNew York University School of MedicineNew YorkNY
| | - Rumi Chunara
- New York University School of Computer Science & Engineering and School of Global Public HealthNew YorkNY
| | - Sam Kozloff
- Department of MedicineUniversity of UtahSalt Lake CityNY
| | - Saul Blecker
- Department of Population HealthNew York University School of MedicineNew YorkNY
- Department of MedicineNew York University School of MedicineNew YorkNY
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15
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Affiliation(s)
- Adam S Faye
- *Department of Medicine, New York University School of Medicine, New York, U.S
| | - John A Dodson
- *Department of Medicine, New York University School of Medicine, New York, U.S
| | - Aasma Shaukat
- *Department of Medicine, New York University School of Medicine, New York, U.S
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16
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Dodson JA, Schoenthaler A, Fonceva A, Gutierrez Y, Shimbo D, Banco D, Maidman S, Olkhina E, Hanley K, Lee C, Levy NK, Adhikari S. Study design of BETTER-BP: Behavioral economics trial to enhance regulation of blood pressure. Int J Cardiol Cardiovasc Risk Prev 2022; 15:200156. [PMID: 36573193 PMCID: PMC9789360 DOI: 10.1016/j.ijcrp.2022.200156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/19/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
Background Nonadherence to antihypertensive medications remains a persistent problem that leads to preventable morbidity and mortality. Behavioral economic strategies represent a novel way to improve antihypertensive medication adherence, but remain largely untested especially in vulnerable populations which stand to benefit the most. The Behavioral Economics Trial To Enhance Regulation of Blood Pressure (BETTER-BP) was designed in this context, to test whether a digitally-enabled incentive lottery improves antihypertensive adherence and reduces systolic blood pressure (SBP). Design BETTER-BP is a pragmatic randomized trial conducted within 3 safety-net clinics in New York City: Bellevue Hospital Center, Gouveneur Hospital Center, and NYU Family Health Centers - Park Slope. The trial will randomize 435 patients with poorly controlled hypertension and poor adherence (<80% days adherent) in a 2:1 ratio (intervention:control) to receive either an incentive lottery versus passive monitoring. The incentive lottery is delivered via short messaging service (SMS) text messages that are delivered based on (1) antihypertensive adherence tracked via a wireless electronic monitoring device, paired with (2) a probability of lottery winning with variable incentives and a regret component for nonadherence. The study intervention lasts for 6 months, and ambulatory systolic blood pressure (SBP) will be measured at both 6 and 12 months to evaluate immediate and durable lottery effects. Conclusions BETTER-BP will generate knowledge about whether an incentive lottery is effective in vulnerable populations to improve antihypertensive medication adherence. If successful, this could lead to the implementation of this novel strategy on a larger scale to improve outcomes.
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Affiliation(s)
- John A. Dodson
- NYU Langone Medical Center, New York, NY, USA
- Corresponding author. New York University Grossman School of Medicine, 227 East 30th Street, TRB 851, New York, NY, 10016, USA.
| | | | - Ana Fonceva
- NYU Langone Medical Center, New York, NY, USA
| | | | - Daichi Shimbo
- Columbia University Irving Medical Center, New York, NY, USA
| | - Darcy Banco
- NYU Langone Medical Center, New York, NY, USA
| | | | | | | | - Carson Lee
- NYU Langone Medical Center, New York, NY, USA
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17
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Maidman SD, Adhikari S, Levy N, Lee C, Hanley K, Shimbo D, Gutierrez Y, de Brito S, Qian K, Fonceva A, Dodson JA. Abstract P012: Agreement In Same Day Research-Quality And Casual Systolic Blood Pressure Measurements: Insights From BETTER-BP. Hypertension 2022. [DOI: 10.1161/hyp.79.suppl_1.p012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Prior studies suggest that BPs measured casually during routine clinic workflow are higher than research-grade measurements. However, BPs in these studies were typically collected on different days. We sought to compare the influence of day of assessment on this difference, within the context of an ongoing randomized trial.
Methods:
This is a cross-sectional interim analysis of the BETTER-BP trial, which examines the effect of behavioral economic incentives for medication adherence on BP. Our study focused on concordance between baseline BP measurements and did not analyze trial outcome data. We included the first 171 participants (1/1/20-3/31/22). Research BP was measured in a seated position after a 5 minute rest period using a standard cuff (Omron HEM 907-XL). Casual BP measurements (most recent recording prior to the research measurement) as well as baseline characteristics were abstracted from the EHR. Participants were divided into two groups based on whether their casual BP was measured on the same day (vs different day) as their research BP. The mean systolic BP (SBP) obtained for research versus casual measurements were compared, for the two separate groups, using paired T-tests.
Results:
Mean age was 55 years, 49.1% were female, 93.2% were nonwhite, and 48.5% were Spanish-speaking. Common comorbidities were diabetes (48.5%) and obesity (49.1%). Among the 132 patients with same day measurements, mean research SBP was 139.2 ± 20.4 mmHg and casual SBP was 137.9 ± 16.4 mmHg (mean within person difference=1.3 mmHg; P=0.259). Among the 39 patients with different days of measurement (median 14 [IQR 6-47] days), mean research SBP was 136.5 ± 23.3 mmHg and casual SBP was 144.2 ± 18.9 mmHg (mean within person difference= -7.7 mmHg; P=0.007). Casual SBP was higher among patients with measurements on different days compared to patients with same day measurements (P=0.043).
Conclusion:
SBP measured casually during clinical practice were concordant with research-quality measurements when obtained on the same day. SBP measurements differed significantly when obtained on different days. These findings suggest that prior reports showing casual BPs to be consistently higher than research BPs may have been influenced by temporal variability.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Kun Qian
- NYU Langone Health, New York, NY
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18
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Sheng SP, Feinberg JL, Bostrom JA, Tang Y, Sweeney G, Pierre A, Katz ES, Whiteson JH, Haas F, Dodson JA, Halpern DG. Adherence and Exercise Capacity Improvements of Patients With Adult Congenital Heart Disease Participating in Cardiac Rehabilitation. J Am Heart Assoc 2022; 11:e023896. [PMID: 35929458 PMCID: PMC9496295 DOI: 10.1161/jaha.121.023896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background As the number of adults with congenital heart disease increases because of therapeutic advances, cardiac rehabilitation (CR) is increasingly being used in this population after cardiac procedures or for reduced exercise tolerance. We aim to describe the adherence and exercise capacity improvements of patients with adult congenital heart disease (ACHD) in CR. Methods and Results This retrospective study included patients with ACHD in CR at New York University Langone Rusk Rehabilitation from 2013 to 2020. We collected data on patient characteristics, number of sessions attended, and functional testing results. Pre‐CR and post‐CR metabolic equivalent task, exercise time, and maximal oxygen uptake were assessed. In total, 89 patients with ACHD (mean age, 39.0 years; 54.0% women) participated in CR. Referral indications were reduced exercise tolerance for 42.7% and post–cardiac procedure (transcatheter or surgical) for the remainder. Mean number of sessions attended was 24.2, and 42 participants (47.2%) completed all 36 CR sessions. Among participants who completed the program as well as pre‐CR and post‐CR functional testing, metabolic equivalent task increased by 1.3 (95% CI, 0.7–1.9; baseline mean, 8.1), exercise time increased by 66.4 seconds (95% CI, 21.4–111.4 seconds; baseline mean, 536.1 seconds), and maximal oxygen uptake increased by 2.5 mL/kg per minute (95% CI, 0.7–4.2 mL/kg per minute; baseline mean, 20.2 mL/kg per minute). Conclusions On average, patients with ACHD who completed CR experienced improvements in exercise capacity. Efforts to increase adherence would allow more patients with ACHD to benefit.
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Affiliation(s)
- S Peter Sheng
- Department of Medicine New York University Grossman School of Medicine New York NY 10016
| | - Jodi L Feinberg
- Leon H. Charney Division of Cardiology New York University Grossman School of Medicine New York NY 10016
| | - John A Bostrom
- Leon H. Charney Division of Cardiology New York University Grossman School of Medicine New York NY 10016
| | - Ying Tang
- Department of Physical Medicine and Rehabilitation New York University Grossman School of Medicine New York NY 10016
| | - Greg Sweeney
- Department of Physical Medicine and Rehabilitation New York University Grossman School of Medicine New York NY 10016
| | - Alicia Pierre
- Department of Physical Medicine and Rehabilitation New York University Grossman School of Medicine New York NY 10016
| | - Edward S Katz
- Leon H. Charney Division of Cardiology New York University Grossman School of Medicine New York NY 10016
| | - Jonathan H Whiteson
- Department of Physical Medicine and Rehabilitation New York University Grossman School of Medicine New York NY 10016
| | - François Haas
- Department of Physical Medicine and Rehabilitation New York University Grossman School of Medicine New York NY 10016
| | - John A Dodson
- Leon H. Charney Division of Cardiology New York University Grossman School of Medicine New York NY 10016
| | - Dan G Halpern
- Leon H. Charney Division of Cardiology New York University Grossman School of Medicine New York NY 10016
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19
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Udell JA, Lu D, Bagai A, Dodson JA, Desai NR, Fonarow GC, Goyal A, Garratt KN, Lucas J, Weintraub WS, Forman DE, Roe MT, Alexander KP. Preexisting frailty and outcomes in older patients with acute myocardial infarction. Am Heart J 2022; 249:34-44. [PMID: 35339451 DOI: 10.1016/j.ahj.2022.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 02/23/2022] [Accepted: 03/17/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little is known about the prevalence and prognostic impact of preexisting frailty on acute care and in-hospital outcomes in older adults in the setting of acute myocardial infarction (AMI). METHODS Preexisting frailty was assessed at baseline in consecutive AMI patients ≥65 years of age treated at 778 hospitals participating in the NCDR ACTION Registry between January 1, 2015 to December 31, 2016. Three domains of preexisting frailty (cognition, ambulation, and functional independence) were abstracted from chart review and summed in 2 ways: an ACTION Frailty Scale based on responses to 6 groups adapted from the Canadian Study of Health and Aging Clinical Frailty Scale and an ACTION Frailty Score derived by summing a rank score of 0-2 assigned for each grade (total ranged between 0 to 6). Multivariable logistic regression examined the association between assigned frailty by score or scale and in-hospital mortality. RESULTS Among 143,722 older AMI patients, 108,059 (75.2%) were fit and/or well and 6,484 (4.5%) were vulnerable to frailty, while 7,527 (5.2%) had mild, 3,913 (2.7%) had moderate, 2,715 had (1.9%) severe, and 632 (0.4%) had very severe frailty according to the ACTION Frailty Scale, while 14,392 (10.0%) could not be categorized due to incomplete ascertainment. Frail patients were older, more frequently female, of non-white race and/or ethnicity, and less likely to be treated with guideline-recommended therapies. Increasing severity of frailty by this scale was associated with a step-wise higher risk for in-hospital mortality (P-trend < .001). Patient categories of the ACTION Frailty Score provided similar results. After adjustment, each 1-unit increase in Frailty Score was associated with a 12% higher mortality risk (OR 1.12, 95% CI 1.10-1.15). CONCLUSIONS Among older patients with acute myocardial infarction, frailty is common and independently associated with in-hospital mortality. These findings show the importance of pragmatic evaluation of frailty in hospital-level quality scores, guideline recommendations, and incorporation into other registry data collection efforts.
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Affiliation(s)
- Jacob A Udell
- Cardiovascular Division, Department of Medicine, Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, Canada; Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University, Durham, NC.
| | - Di Lu
- Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University, Durham, NC
| | - Akshay Bagai
- Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Canada
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles, Los Angeles, CA
| | - Abhinav Goyal
- Division of Cardiology, Emory Health Care, Emory School of Medicine, Atlanta, GA
| | - Kirk N Garratt
- Center for Heart and Vascular Health, ChristianaCare, Wilmington, DE
| | - Joseph Lucas
- Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University, Durham, NC
| | | | - Daniel E Forman
- Divisions of Geriatrics and Cardiology, Department of Medicine, University of Pittsburgh; Pittsburgh Geriatric, Research, Education, and Clinical Center (GRECC), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Matthew T Roe
- Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University, Durham, NC
| | - Karen P Alexander
- Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University, Durham, NC
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Mukhopadhyay A, Adhikari S, Li X, Dodson JA, Kronish IM, Ramatowski M, Chunara R, Blecker S. Abstract 39: Association Between Copay Amount And Medication Adherence For Angiotensin Receptor Neprilysin Inhibitors In Patients With Heart Failure. Circ Cardiovasc Qual Outcomes 2022. [DOI: 10.1161/circoutcomes.15.suppl_1.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Angiotensin receptor neprilysin inhibitors (ARNI) can significantly reduce mortality and hospitalization for patients with heart failure (HF). However, relatively high copayment costs for ARNI may contribute to shortfalls in adherence.
Methods:
We conducted a retrospective cohort study of patients within a large, diverse, multi-site health system. We included patients with: an active diagnosis of HF or ejection fraction (EF) ≤ 40% on echocardiogram; a prescription for ARNI between 11/20/2020-3/31/2021; and available pharmacy or pharmacy benefit manager copayment data. Our primary exposure variable was copay amount, categorized as: $0, $0.01-$10, $10.01-$100, >$100. Our primary outcome was adherence to ARNI, defined as the proportion of days covered (PDC) ≥ 80% over 6 months. We assessed the association between copay amount and PDC using multivariable logistic regression, adjusting for the following: age, sex, race, ethnicity, insurance type, socioeconomic status (based on AHRQ SES index), EF, prior hospitalizations, and prior emergency visits.
Results:
A total of 567 patients met inclusion criteria. Low copay amounts ($0.01-$10), as opposed to no copay or higher copay amounts ($10.01-$100, >$100), were more common for patients who were younger, of Black race, Hispanic/Latinx ethnicity, with Medicaid insurance, lower SES index, and lower EF (all p<0.01). Unadjusted rates of ARNI adherence varied significantly by copay amount (Figure 1A: p<0.01), and adjusted odds of ARNI adherence was significantly lower for patients with copay over $100 as compared to no copay (Figure 1B: OR 0.33, 95% CI 0.14-0.71, p<0.01). There was a graded association between copay amount and ARNI non-adherence.
Conclusions:
We found lower rates of ARNI adherence for patients with higher copay amount, which persisted after multivariable adjustment. Our findings support policy-level interventions to reduce copay amounts for ARNI.
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Faye AS, Dodson JA, Shaukat A. Safety and Efficacy of Anti-TNF Therapy in Older Adults With Ulcerative Colitis: A New Path Forward. Gastroenterology 2022; 162:1762-1764. [PMID: 34864071 DOI: 10.1053/j.gastro.2021.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Adam S Faye
- Department of Medicine, New York University School of Medicine, New York, New York
| | - John A Dodson
- Department of Medicine, New York University School of Medicine, New York, New York
| | - Aasma Shaukat
- Department of Medicine, New York University School of Medicine, New York, New York
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22
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Goldfarb MJ, Bechtel C, Capers Q, de Velasco A, Dodson JA, Jackson JL, Kitko L, Piña IL, Rayner-Hartley E, Wenger NK, Gulati M. Engaging Families in Adult Cardiovascular Care: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2022; 11:e025859. [PMID: 35446109 PMCID: PMC9238560 DOI: 10.1161/jaha.122.025859] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Family engagement empowers family members to become active partners in care delivery. Family members increasingly expect and wish to participate in care and be involved in the decision-making process. The goal of engaging families in care is to improve the care experience to achieve better outcomes for both patients and family members. There is emerging evidence that engaging family members in care improves person- and family-important outcomes. Engaging families in adult cardiovascular care involves a paradigm shift in the current organization and delivery of both acute and chronic cardiac care. Many cardiovascular health care professionals have limited awareness of the role and potential benefits of family engagement in care. Additionally, many fail to identify opportunities to engage family members. There is currently little guidance on family engagement in any aspect of cardiovascular care. The objective of this statement is to inform health care professionals and stakeholders about the importance of family engagement in cardiovascular care. This scientific statement will describe the rationale for engaging families in adult cardiovascular care, outline opportunities and challenges, highlight knowledge gaps, and provide suggestions to cardiovascular clinicians on how to integrate family members into the health care team.
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Dodson JA, Schoenthaler A, Sweeney G, Fonceva A, Pierre A, Whiteson J, George B, Marzo K, Drewes W, Rerisi E, Mathew R, Aljayyousi H, Chaudhry SI, Hajduk AM, Gill TM, Estrin D, Kovell L, Jennings LA, Adhikari S. Rehabilitation Using Mobile Health for Older Adults With Ischemic Heart Disease in the Home Setting (RESILIENT): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e32163. [PMID: 35238793 PMCID: PMC8931649 DOI: 10.2196/32163] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/29/2021] [Accepted: 12/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background Participation in ambulatory cardiac rehabilitation remains low, especially among older adults. Although mobile health cardiac rehabilitation (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments may limit older adults’ uptake, and efficacy data are currently lacking. Objective This study aims to describe the design of the rehabilitation using mobile health for older adults with ischemic heart disease in the home setting (RESILIENT) trial. Methods RESILIENT is a multicenter randomized clinical trial that is enrolling patients aged ≥65 years with ischemic heart disease in a 3:1 ratio to either an intervention (mHealth-CR) or control (usual care) arm, with a target sample size of 400 participants. mHealth-CR consists of a commercially available mobile health software platform coupled with weekly exercise therapist sessions to review progress and set new activity goals. The primary outcome is a change in functional mobility (6-minute walk distance), which is measured at baseline and 3 months. Secondary outcomes are health status, goal attainment, hospital readmission, and mortality. Among intervention participants, engagement with the mHealth-CR platform will be analyzed to understand the characteristics that determine different patterns of use (eg, persistent high engagement and declining engagement). Results As of December 2021, the RESILIENT trial had enrolled 116 participants. Enrollment is projected to continue until October 2023. The trial results are expected to be reported in 2024. Conclusions The RESILIENT trial will generate important evidence about the efficacy of mHealth-CR among older adults in multiple domains and characteristics that determine the sustained use of mHealth-CR. These findings will help design future precision medicine approaches to mobile health implementation in older adults. This knowledge is especially important in light of the COVID-19 pandemic that has shifted much of health care to a remote, internet-based setting. Trial Registration ClinicalTrials.gov NCT03978130; https://clinicaltrials.gov/ct2/show/NCT03978130 International Registered Report Identifier (IRRID) DERR1-10.2196/32163
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Affiliation(s)
- John A Dodson
- Geriatric Cardiology Program, Medicine and Population Health, Leon H Charney Division of Cardiology, NYU Grossman School of Medicine, New York, NY, United States
| | - Antoinette Schoenthaler
- Department of Population Health, Department of Medicine, NYU Grossman School of Medicine, New York, NY, United States
| | - Greg Sweeney
- Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York, NY, United States
| | - Ana Fonceva
- Leon H Charney Division of Cardiology, NYU Grossman School of Medicine, New York, NY, United States
| | - Alicia Pierre
- Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York, NY, United States
| | - Jonathan Whiteson
- Department of Rehabilitation Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, NY, United States
| | - Barbara George
- Division of Cardiology, Department of Medicine, NYU Long Island School of Medicine, Mineola, NY, United States
| | - Kevin Marzo
- Department of Medicine, Division of Cardiology, NYU Long Island School of Medicine, Mineola, NY, United States
| | - Wendy Drewes
- Division of Cardiology, NYU Langone Hospital Long Island, Mineola, NY, United States
| | - Elizabeth Rerisi
- Division of Cardiology, NYU Langone Hospital Long Island, Mineola, NY, United States
| | - Reena Mathew
- Division of Cardiology, NYU Langone Hospital Long Island, Mineola, NY, United States
| | - Haneen Aljayyousi
- Leon H Charney Division of Cardiology, NYU Grossman School of Medicine, New York, NY, United States
| | - Sarwat I Chaudhry
- Section of General Medicine, Yale University School of Medicine, New Haven, NY, United States
| | | | - Thomas M Gill
- Yale University School of Medicine, New Haven, CT, United States
| | - Deborah Estrin
- Cornell Tech and Weill Cornell Medicine, New York, NY, United States
| | - Lara Kovell
- Department of Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA, United States
| | - Lee A Jennings
- Reynolds Section of Geriatric Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Samrachana Adhikari
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
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Goldstein DW, Hajduk AM, Song X, Tsang S, Geda M, Dodson JA, Forman DE, Krumholz H, Chaudhry SI. Factors Associated With Cardiac Rehabilitation Participation in Older Adults After Myocardial Infarction: THE SILVER-AMI STUDY. J Cardiopulm Rehabil Prev 2022; 42:109-114. [PMID: 34799530 PMCID: PMC8881286 DOI: 10.1097/hcr.0000000000000627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Cardiac rehabilitation (CR) is a key aspect of secondary prevention following acute myocardial infarction (AMI). While there is growing evidence of unique benefits of CR in older adults, it remains underutilized. We aimed to examine specific demographic, clinical, and functional factors associated with utilization of CR among older adults hospitalized with AMI. METHODS Our project used data from the SILVER-AMI study, a nationwide prospective cohort study of patients age ≥75 yr hospitalized with AMI and followed them up for 6 mo after discharge. Extensive baseline data were collected on demographics, clinical and psychosocial factors, and functional and sensory impairments. The utilization of CR was collected by a survey at 6 mo. Backward selection was employed in a multivariable-adjusted logistic regression model to identify independent predictors of CR use. RESULTS Of the 2003 participants included in this analysis, 779 (39%) reported participating in CR within 6 mo of discharge. Older age, longer length of hospitalization, having ≤12 yr of education, visual impairment, cognitive impairment, and living alone were associated with decreased likelihood of CR participation; receipt of diagnostic and interventional procedures (ie, cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft) was associated with increased likelihood of CR participation. CONCLUSIONS Demographic and clinical factors, as well as select functional and sensory impairments common in aging, were associated with CR participation at 6 mo post-discharge in older AMI patients. These results highlight opportunities to increase CR usage among older adults and identify those at risk for not participating.
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Affiliation(s)
- David W Goldstein
- Department of Internal Medicine, Massachusetts General Hospital, Boston (Dr Goldstein); Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut (Drs Hajduk, Krumholz, and Chaudhry and Mss Tsang and Geda); Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut (Ms Song); Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York (Dr Dodson); Geriatric Cardiology Section, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Forman), and Section of Health Policy and Management, Yale School of Public Health, New Haven, and Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut (Dr Krumholz)
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Graves C, Schoenthaler A, Sweeney G, Fonceva A, Whiteson J, George BJ, Marzo KP, Rerisi E, Kovell L, Adhikari S, Dodson JA. PARTICIPANT CHARACTERISTICS AND PATTERNS OF ENGAGEMENT IN MOBILE HEALTH CARDIAC REHABILITATION. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02588-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Weerahandi H, Chaussee EL, Dodson JA, Dolansky M, Boxer RS. Disease Management in Skilled Nursing Facilities Improves Outcomes for Patients With a Primary Diagnosis of Heart Failure. J Am Med Dir Assoc 2022; 23:367-372. [PMID: 34478693 PMCID: PMC8885787 DOI: 10.1016/j.jamda.2021.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). Our objective was to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP). DESIGN This is a subgroup analysis of multisite, physician and practice blocked, cluster-randomized controlled trial of HF-DMP vs usual care for patients in SNF with an HF diagnosis. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by an HF nurse advocate. SETTING AND PARTICIPANTS Patients with a primary hospital discharge diagnosis of HF discharged to SNF. METHODS Composite outcome of all-cause hospitalization, emergency department visits, and mortality were evaluated at 30 and 60 days post SNF admission. Linear mixed models accounted for patient clustering at the physician level. RESULTS Of 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79 ± 10 years, 53% women, and mean ejection fraction 46% ± 15%. At 60 days post SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared with usual care (52%) (P = .02). The rate of the composite outcome at 30 days for the HF-DMP group was 18% vs 31% in the usual care group (P = .11). CONCLUSIONS AND IMPLICATIONS Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while cared for in an SNF had lower rates of the composite outcome at 60 days. Standardized HF management during SNF stays may be important for patients with a primary discharge diagnosis of HF.
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Affiliation(s)
- Himali Weerahandi
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA; Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA; Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, NY, USA.
| | | | - John A. Dodson
- Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, NY,Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY
| | - Mary Dolansky
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH
| | - Rebecca S. Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO,Division of Geriatric Medicine, University of Colorado, Aurora, CO
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Montgomery S, Miedema MD, Dodson JA. Aspirin and statin therapy for primary prevention of cardiovascular disease in older adults. Heart 2021; 108:1090-1097. [PMID: 34764212 DOI: 10.1136/heartjnl-2021-320154] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/29/2021] [Indexed: 11/03/2022] Open
Abstract
The value of primary preventative therapies for cardiovascular disease (CVD) in older adults (age ≥75 years) is less certain than in younger patients. There is a lack of quality evidence in older adults due to underenrolment in pivotal trials. While aspirin is no longer recommended for routine use in primary prevention of CVD in older adults, statins may be efficacious. However, it is unclear which patient subgroups may benefit most, and guidelines differ between expert panels. Three relevant geriatric conditions (cognitive impairment, functional impairment and polypharmacy) may influence therapeutic decision making; for example, baseline frailty may affect statin efficacy, and some have advocated for deprescription in this scenario. Evidence regarding statins and incident functional decline are mixed, and vigilance for adverse effects is important, especially in the setting of polypharmacy. However, aspirin has not been shown to affect incident cognitive or functional decline, and its lack of efficacy extends to patients with baseline cognitive impairment or frailty. Ultimately, the utility of primary preventative therapies for CVD in older adults depends on potential lifetime benefit. Rather than basing treatment decisions on absolute risk alone, consideration of comorbidities, polypharmacy and life expectancy should play a significant role in decision making. Coronary calcium score and new tools for risk stratification validated in older adults that account for the competing risk of death may aid in evaluating potential benefits. Given the complexity of therapeutic decisions in this context, shared decision making provides an important framework.
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Affiliation(s)
| | - Michael D Miedema
- Nolan Center For Cardiovascular Health, Minneapolis Heart Institute and Foundation, Minneapolis, Minnesota, USA
| | - John A Dodson
- NYU Grossman School of Medicine, NYU, New York, New York, USA
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28
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Mohanty AF, Levitan EB, King JB, Dodson JA, Vardeny O, Cook J, Herrick JS, He T, Patterson OV, Alba PR, Russo PA, Obi EN, Choi ME, Fang JC, Bress AP. Sacubitril/Valsartan Initiation Among Veterans Who Are Renin-Angiotensin-Aldosterone System Inhibitor Naïve With Heart Failure and Reduced Ejection Fraction. J Am Heart Assoc 2021; 10:e020474. [PMID: 34612065 PMCID: PMC8751890 DOI: 10.1161/jaha.120.020474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Sacubitril/valsartan, a first‐in‐class angiotensin receptor neprilysin inhibitor, received US Food and Drug Administration approval in 2015 for heart failure with reduced ejection fraction (HFrEF). Our objective was to describe the sacubitril/valsartan initiation rate, associated characteristics, and 6‐month follow‐up dosing among veterans with HFrEF who are renin‐angiotensin‐aldosterone system inhibitor (RAASi) naïve. Methods and Results Retrospective cohort study of veterans with HFrEF who are RAASi naïve defined as left ventricular ejection fraction (LVEF) ≤40%; ≥1 in/outpatient heart failure visit, first RAASi (sacubitril/valsartan, angiotensin‐converting enzyme inhibitor [ACEI]), or angiotensin‐II receptor blocker [ARB]) fill from July 2015 to June 2019. Characteristics associated with sacubitril/valsartan initiation were identified using Poisson regression models. From July 2015 to June 2019, we identified 3458 sacubitril/valsartan and 29 367 ACEI or ARB initiators among veterans with HFrEF who are RAASi naïve. Sacubitril/valsartan initiation increased from 0% to 26.5%. Sacubitril/valsartan (versus ACEI or ARB) initiators were less likely to have histories of stroke, myocardial infarction, or hypertension and more likely to be older and have diabetes mellitus and lower LVEF. At 6‐month follow‐up, the prevalence of ≥50% target daily dose for sacubitril/valsartan, ACEI, and ARB initiators was 23.5%, 43.2%, and 47.1%, respectively. Conclusions Sacubitril/valsartan initiation for HFrEF in the Veterans Administration increased in the 4 years immediately following Food and Drug Administration approval. Sacubitril/valsartan (versus ACEI or ARB) initiators had fewer baseline cardiovascular comorbidities and the lowest proportion on ≥50% target daily dose at 6‐month follow‐up. Identifying the reasons for lower follow‐up dosing of sacubitril/valsartan could support guideline recommendations and quality improvement strategies for patients with HFrEF.
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Affiliation(s)
- April F Mohanty
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Emily B Levitan
- Department of Epidemiology University of Alabama at Birmingham School of Public Health Birmingham AL
| | - Jordan B King
- Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT.,Institute for Health Research Kaiser Permanente Colorado Aurora CO
| | - John A Dodson
- Leon H. Charney Division of Cardiology Department of Medicine New York University School of Medicine New York NY
| | - Orly Vardeny
- University of Minnesota Medical School Minneapolis MN
| | - James Cook
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Jennifer S Herrick
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Tao He
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Olga V Patterson
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Patrick R Alba
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Patricia A Russo
- US Health Economics & Outcomes Research Novartis Pharmaceuticals CorporationEast Hanover NJ
| | - Engels N Obi
- US Health Economics & Outcomes Research Novartis Pharmaceuticals CorporationEast Hanover NJ
| | | | - James C Fang
- Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Adam P Bress
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT.,Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT
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Blecker S, Adhikari S, Zhang H, Dodson JA, Desai SM, Anzisi L, Pazand L, Schoenthaler AM, Mann DM. Validation of EHR medication fill data obtained through electronic linkage with pharmacies. J Manag Care Spec Pharm 2021; 27:1482-1487. [PMID: 34595945 PMCID: PMC8759289 DOI: 10.18553/jmcp.2021.27.10.1482] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Recent linkages between electronic health records (EHRs) and pharmacy data hold opportunity for up-to-date assessment of medication adherence at the point of care. OBJECTIVE: To validate linked EHR-pharmacy data, which can be used for point-of-care interventions for concordance with insurance claims data for patients in a large health care delivery system. METHODS: We performed a retrospective cohort study of adult patients with an active antihypertensive medication order and seen as outpatients between August 25, 2019, and August 31, 2019. Pharmacy fill information was obtained from the EHR via linkages with Surescripts pharmacy and pharmacy benefit manager data, as well as from insurance claims available at our institution. We matched antihypertensive medication fills observed in the linked EHR-pharmacy database with available fills in the insurance claims database and calculated the percentage of medication fills that were available in each database. We estimated medication adherence using proportion of days covered in the linked EHR-pharmacy database and in the insurance claims database. RESULTS: Of 26,679 patients with hypertension, 23,348 (87.5%) had at least 1 antihypertensive medication fill recorded in the linked EHR-pharmacy database. Of 1,501 patients matched with the insurance database and with a documented medication fill, a fill was present for 1,484 (98.9%) and 1,259 (83.9%) patients in the linked EHR-pharmacy and insurance databases, respectively. Of 12,109 medication fills recorded in the insurance data, we found an overlap of 11,060 (91.3%) fills with the linked EHR-pharmacy database. The linked EHR-pharmacy database also contained 18,232 of 19,281 (94.6%) medication fills present in either database. Measured medication adherence was higher for patients when based on linked EHR-pharmacy data compared with insurance claims data (42% vs 30%, P < 0.001). CONCLUSIONS: Linked EHR-pharmacy data captured medication fills for the vast majority of patients and resulted in higher estimates of adherence than insurance claims. Our results suggest that pharmacy fill data available in the EHR have sufficient reliability to be used for point-of-care assessment of medication adherence. DISCLOSURES: This study was supported by grant R01HL155149 from the National Heart, Lung, and Blood Institute. Allen Thorpe provided funding for the NYU Langone Health Learning Health System Program, which helped fund this project. The authors have nothing to disclose.
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Affiliation(s)
- Saul Blecker
- Department of Population Health and Department of Medicine, NYU School of Medicine, New York, NY
| | | | - Hanchao Zhang
- Department of Population Health, NYU School of Medicine, New York, NY
| | - John A Dodson
- Department of Population Health and Department of Medicine, NYU School of Medicine, New York, NY
| | - Sunita M Desai
- Department of Population Health, NYU School of Medicine, New York, NY
| | - Lisa Anzisi
- NYU Network Integration, NYU Langone Health, New York, NY
| | - Lily Pazand
- Department of Managed Care, NYU Langone Health, New York, NY
| | | | - Devin M Mann
- Department of Population Health and Department of Medicine, NYU School of Medicine, New York, NY
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30
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Flynn CR, Orkaby AR, Valsdottir LR, Kramer DB, Ho KK, Dodson JA, Yeh RW, Strom JB. Relation of the Number of Cardiovascular Conditions and Short-term Symptom Improvement After Percutaneous Coronary Intervention for Stable Angina Pectoris. Am J Cardiol 2021; 155:1-8. [PMID: 34281673 DOI: 10.1016/j.amjcard.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/26/2021] [Accepted: 06/01/2021] [Indexed: 01/09/2023]
Abstract
With aging of the population, cardiovascular conditions (CC) are increasingly common in individuals undergoing PCI for stable angina pectoris (AP). It is unknown if the overall burden of CCs associates with diminished symptom improvement after PCI for stable AP. We prospectively administered validated surveys assessing AP, dyspnea, and depression to patients undergoing PCI for stable AP at our institution, 2016-2018. The association of CC burden and symptoms at 30-days post-PCI was assessed via linear mixed effects models. Included individuals (N = 121; mean age 68 ± 10 years; response rate = 42%) were similar to non-included individuals. At baseline, greater CC burden was associated with worse dyspnea, depression, and physical limitations due to AP, but not AP frequency or quality of life. PCI was associated with small improvements in AP and dyspnea (p ≤ 0.001 for both), but not depression (p = 0.15). After multivariable adjustment, including for baseline symptoms, CC burden was associated with a greater improvement in AP physical limitations (p = 0.01) and depression (p = 0.002), albeit small, but not other symptom domains (all p ≥ 0.05). In patients undergoing PCI for stable AP, increasing CC burden was associated with worse dyspnea, depression, and AP physical limitations at baseline. An increasing number of CCs was associated with greater improvements, though small, in AP physical limitations and depression. In conclusion, the overall number of cardiovascular conditions should not be used to exclude patients from PCI for stable AP on the basis of an expectation of less symptom improvement.
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Affiliation(s)
- Christopher R Flynn
- Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Ariela R Orkaby
- Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System; Division of Aging, Brigham & Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Linda R Valsdottir
- Harvard Medical School, Boston, Massachusetts; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Division of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel B Kramer
- Harvard Medical School, Boston, Massachusetts; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Division of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kalon K Ho
- Harvard Medical School, Boston, Massachusetts; Division of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - John A Dodson
- New York University School of Medicine, New York, New York
| | - Robert W Yeh
- Harvard Medical School, Boston, Massachusetts; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Division of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jordan B Strom
- Harvard Medical School, Boston, Massachusetts; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Division of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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31
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Hajduk AM, Saczynski JS, Tsang S, Geda ME, Dodson JA, Ouellet GM, Goldberg RJ, Chaudhry SI. Presentation, Treatment, and Outcomes of Older Adults Hospitalized for Acute Myocardial Infarction According to Cognitive Status: The SILVER-AMI Study. Am J Med 2021; 134:910-917. [PMID: 33737057 PMCID: PMC8243828 DOI: 10.1016/j.amjmed.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/12/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND While survival after acute myocardial infarction has improved substantially, older adults remain at heightened risk for hospital readmissions and death. Evidence for the role of cognitive impairment in older myocardial infarction survivors' risk for these outcomes is limited. METHODS 3041 patients aged ≥75 years hospitalized with acute myocardial infarction (mean age 82 ± 5 years, 56% male) recruited from 94 US hospitals. Cognition was assessed using the Telephone Interview for Cognitive Status; scores of <27 and <22 indicated mild and moderate/severe impairment, respectively. Readmissions and death at 6 months post-discharge were ascertained via participant report and medical record review. Associations between cognition and outcomes were evaluated with multivariable-adjusted logistic regression. RESULTS Mild and moderate/severe cognitive impairment were present in 11% and 6% of the cohort, respectively. Readmission and death at 6 months occurred in 41% and 9% of participants, respectively. Mild and moderate/severe cognitive impairment were associated with increased risk of readmission (odds ratio [OR] 1.36; 95% confidence interval [CI], 1.08-1.72 and OR 1.58; 95% CI, 1.18-2.12, respectively) and death (OR 2.19; 95% CI, 1.54-3.11 and OR 3.82; 95% CI, 2.63-5.56, respectively) in unadjusted analyses. Significant associations between moderate/severe cognitive impairment and death (OR 1.69; 95% CI, 1.10-2.59) persisted after adjustment for demographics, myocardial infarction characteristics, comorbidity burden, functional status, and depression, but not for readmissions. CONCLUSIONS Moderate-to-severe cognitive impairment is associated with heightened risk of death in older acute myocardial infarction patients in the months after hospitalization, but not with readmission. Routine cognitive screening may identify older myocardial infarction survivors at risk for poor outcomes who may benefit from closer oversight and support in the post-discharge period.
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Affiliation(s)
- Alexandra M Hajduk
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn.
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Science, Northeastern School of Pharmacy, Boston, Mass
| | - Sui Tsang
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Mary E Geda
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, NY
| | - Gregory M Ouellet
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Sarwat I Chaudhry
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
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Banco D, Dodson JA, Berger JS, Smilowitz NR. Perioperative cardiovascular outcomes among older adults undergoing in-hospital noncardiac surgery. J Am Geriatr Soc 2021; 69:2821-2830. [PMID: 34176124 DOI: 10.1111/jgs.17320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Older adults undergoing noncardiac surgery have a high risk of major adverse cardiovascular events (MACE). This study aims to estimate the magnitude of increased perioperative risk, and examine national trends in perioperative MACE following in-hospital noncardiac surgery in older adults compared to middle-aged adults. DESIGN Time-series analysis of retrospective longitudinal data. SETTING The United States Agency for Healthcare Research and Quality National Inpatient Sample (NIS). PARTICIPANTS Hospitalizations for major noncardiac surgery among adults age ≥45 years between January 2004 and December 2014. MEASUREMENTS Inpatient perioperative MACE was defined as a composite of in-hospital death, myocardial infarction (MI), and ischemic stroke. In hospital death was determined from the NIS discharge disposition. MI and ischemic stroke were defined by International Classification of Diseases, Ninth Revision codes. RESULTS Of an estimated 55,349,978 surgical hospitalizations, 26,423,039 (47.7%) were for adults age 45-64, 14,231,386 (25.7%) age 65-74, 10,621,029 (19.2%) age 75-84 years, and 4,074,523 (7.4%) age ≥85 years. MACE occurred in 1,601,022 surgical hospitalizations (2.9%). Adults 65-74 (2.8%; aOR 1.16, 95% CI 1.14-1.17), 75-84 years (4.5%; aOR 1.30, 95% CI 1.28-1.32), and ≥85 years (6.9%; aOR 1.55, 95% CI 1.52-1.57) had greater risk of MACE than those 45-64 years (1.7%). From 2004 to 2014, MACE declined among adults 65-74 (3.1-2.5%, p < 0.001), 75-85 years (4.9-3.9%, p < 0.001), and ≥85 years (7.7-6.1%, p < 0.001), but was unchanged for adults age 45-64. Declines in MACE were driven by decreased MI and mortality despite increased stroke. CONCLUSION Older adults accounted for half of hospitalizations, but experienced the majority of MACE. Older adults had greater adjusted odds of MACE than younger individuals. The proportion of perioperative MACE declined over time, despite increases in ischemic stroke. These data highlight risks of noncardiac surgery in older adults that warrant increased attention to improve perioperative outcomes.
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Affiliation(s)
- Darcy Banco
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA.,Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA.,Department of Surgery, New York University School of Medicine, New York, New York, USA
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA.,Division of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York, New York, USA
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Dodson JA, Hajduk A, Arnold S, Spertus J, Dreyer R, Murphy T, Krumholz H, Chaudhry S. PREDICTORS OF RESIDUAL ANGINA 6 MONTHS AFTER HOSPITALIZATION FOR ACUTE MYOCARDIAL INFARCTION: FINDINGS FROM THE SILVER-AMI STUDY. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01396-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Covello AL, Horwitz LI, Singhal S, Blaum CS, Li Y, Dodson JA. Cardiovascular disease and cumulative incidence of cognitive impairment in the Health and Retirement Study. BMC Geriatr 2021; 21:274. [PMID: 33902466 PMCID: PMC8074515 DOI: 10.1186/s12877-021-02191-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/30/2021] [Indexed: 11/30/2022] Open
Abstract
Background We sought to examine whether people with a diagnosis of cardiovascular disease (CVD) experienced a greater incidence of subsequent cognitive impairment (CI) compared to people without CVD, as suggested by prior studies, using a large longitudinal cohort. Methods We employed Health and Retirement Study (HRS) data collected biennially from 1998 to 2014 in 1305 U.S. adults age ≥ 65 newly diagnosed with CVD vs. 2610 age- and gender-matched controls. Diagnosis of CVD was adjudicated with an established HRS methodology and included self-reported coronary heart disease, angina, heart failure, myocardial infarction, or other heart conditions. CI was defined as a score < 11 on the 27-point modified Telephone Interview for Cognitive Status. We examined incidence of CI over an 8-year period using a cumulative incidence function accounting for the competing risk of death. Results Mean age at study entry was 73 years, 55% were female, and 13% were non-white. Cognitive impairment developed in 1029 participants over 8 years. The probability of death over the study period was greater in the CVD group (19.8% vs. 13.8%, absolute difference 6.0, 95% confidence interval 2.2 to 9.7%). The cumulative incidence analysis, which adjusted for the competing risk of death, showed no significant difference in likelihood of cognitive impairment between the CVD and control groups (29.7% vs. 30.6%, absolute difference − 0.9, 95% confidence interval − 5.6 to 3.7%). This finding did not change after adjusting for relevant demographic and clinical characteristics using a proportional subdistribution hazard regression model. Conclusions Overall, we found no increased risk of subsequent CI among participants with CVD (compared with no CVD), despite previous studies indicating that incident CVD accelerates cognitive decline. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02191-0.
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Affiliation(s)
- Allyson L Covello
- New York University Grossman School of Medicine, 550 First Avenue, New York, NY, USA.
| | - Leora I Horwitz
- Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Shreya Singhal
- NYU Steinhardt School of Culture, Education, and Human Development, New York, NY, USA
| | | | - Yi Li
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - John A Dodson
- Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.,Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
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Grant EV, Summapund J, Matlock DD, Vaughan Dickson V, Iqbal S, Patel S, Katz SD, Chaudhry SI, Dodson JA. Patient and Cardiologist Perspectives on Shared Decision Making in the Treatment of Older Adults Hospitalized for Acute Myocardial Infarction. Med Decis Making 2021; 40:279-288. [PMID: 32428431 DOI: 10.1177/0272989x20912293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Medical and interventional therapies for older adults with acute myocardial infarction (AMI) reduce mortality and improve outcomes in selected patients, but there are also risks associated with treatments. Shared decision making (SDM) may be useful in the management of such patients, but to date, patients' and cardiologists' perspectives on SDM in the setting of AMI remain poorly understood. Accordingly, we performed a qualitative study eliciting patients' and cardiologists' perceptions of SDM in this scenario. Methods. We conducted 20 in-depth, semistructured interviews with older patients (age ≥70) post-AMI and 20 interviews with cardiologists. The interviews were transcribed and analyzed using ATLAS.ti. Two investigators independently coded transcripts using the constant comparative method, and an integrative, team-based process was used to identify themes. Results. Six major themes emerged: 1) patients felt their only choice was to undergo an invasive procedure; 2) patients placed a high level of trust and gratitude toward physicians; 3) patients wanted to be more informed about the procedures they underwent; 4) for cardiologists, patients' age was not a major contraindication to intervention, while cognitive impairment and functional limitation were; 5) while cardiologists intuitively understood the concept of SDM, interpretations varied; and 6) cardiologists considered SDM to be useful in the setting of non-ST elevated myocardial infarction (NSTEMI) but not ST-elevated myocardial infarction (STEMI). Conclusions. Patients viewed intervention as "the only choice," whereas cardiologists saw a need for balancing risks and benefits in treating older adults post-NSTEMI. This discrepancy implies there is room to improve communication of risks and benefits to older patients. A decision aid informed by the needs of older adults could help to better convey patient-specific risk and increase choice awareness.
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Affiliation(s)
- Eleonore V Grant
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Szymonifka J, Conderino S, Cigolle C, Ha J, Kabeto M, Yu J, Dodson JA, Thorpe L, Blaum C, Zhong J. Cardiovascular disease risk prediction for people with type 2 diabetes in a population-based cohort and in electronic health record data. JAMIA Open 2021; 3:583-592. [PMID: 33623893 PMCID: PMC7886535 DOI: 10.1093/jamiaopen/ooaa059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/13/2020] [Accepted: 10/20/2020] [Indexed: 11/13/2022] Open
Abstract
Objective Electronic health records (EHRs) have become a common data source for clinical risk prediction, offering large sample sizes and frequently sampled metrics. There may be notable differences between hospital-based EHR and traditional cohort samples: EHR data often are not population-representative random samples, even for particular diseases, as they tend to be sicker with higher healthcare utilization, while cohort studies often sample healthier subjects who typically are more likely to participate. We investigate heterogeneities between EHR- and cohort-based inferences including incidence rates, risk factor identifications/quantifications, and absolute risks. Materials and methods This is a retrospective cohort study of older patients with type 2 diabetes using EHR from New York University Langone Health ambulatory care (NYULH-EHR, years 2009–2017) and from the Health and Retirement Survey (HRS, 1995–2014) to study subsequent cardiovascular disease (CVD) risks. We used the same eligibility criteria, outcome definitions, and demographic covariates/biomarkers in both datasets. We compared subsequent CVD incidence rates, hazard ratios (HRs) of risk factors, and discrimination/calibration performances of CVD risk scores. Results The estimated subsequent total CVD incidence rate was 37.5 and 90.6 per 1000 person-years since T2DM onset in HRS and NYULH-EHR respectively. HR estimates were comparable between the datasets for most demographic covariates/biomarkers. Common CVD risk scores underestimated observed total CVD risks in NYULH-EHR. Discussion and conclusion EHR-estimated HRs of demographic and major clinical risk factors for CVD were mostly consistent with the estimates from a national cohort, despite high incidences and absolute risks of total CVD outcome in the EHR samples.
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Affiliation(s)
- Jackie Szymonifka
- Division of Biostatistics, Department of Population Health, NYU Langone Health, New York, New York, USA
| | - Sarah Conderino
- Division of Epidemiology, Department of Population Health, NYU Langone Health, New York, New York, USA
| | - Christine Cigolle
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Geriatric Research, Education and Clinical Center (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jinkyung Ha
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Geriatric Research, Education and Clinical Center (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mohammed Kabeto
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Geriatric Research, Education and Clinical Center (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jaehong Yu
- Division of Biostatistics, Department of Population Health, NYU Langone Health, New York, New York, USA
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA.,Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Lorna Thorpe
- Division of Epidemiology, Department of Population Health, NYU Langone Health, New York, New York, USA
| | - Caroline Blaum
- Division of Geriatric Medicine and Palliative Care, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Judy Zhong
- Division of Biostatistics, Department of Population Health, NYU Langone Health, New York, New York, USA
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Kochar A, Summers MB, Benziger CP, Marquis-Gravel G, DeWalt DA, Pepine CJ, Gupta K, Bradley SM, Dodson JA, Lampert BC, Robertson H, Polonsky TS, Jones WS, Effron MB. Clinician engagement in the ADAPTABLE (Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness) trial. Clin Trials 2021; 18:449-456. [PMID: 33541120 DOI: 10.1177/1740774520988838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND ADAPTABLE (Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness) is a pragmatic clinical trial examining high-dose versus low-dose aspirin among patients with cardiovascular disease. ADAPTABLE is leveraging novel approaches for clinical trial conduct to expedite study completion and reduce costs. One pivotal aspect of the trial conduct is maximizing clinician engagement. METHODS/RESULTS Clinician engagement can be diminished by barriers including time limitations, insufficient research infrastructure, lack of research training, inadequate compensation for research activities, and clinician beliefs. We used several key approaches to boost clinician engagement such as empowering clinician champions, including a variety of clinicians, nurses and advanced practice providers, periodic newsletters and coordinated team celebrations, and deploying novel technological solutions. Specifically, some centers generated electronic health records-based best practice advisories and research dashboards. Future large pragmatic trials will benefit from standardization of the various clinician engagement strategies especially studies leveraging electronic health records-based approaches like research dashboards. Financial or academic "credit" for clinician engagement in clinical research may boost participation rates in clinical studies. CONCLUSION Maximizing clinician engagement is important for the success of clinical trials; the strategies employed in the ADAPTABLE trial may serve as a template for future pragmatic studies.
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Affiliation(s)
- Ajar Kochar
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mary B Summers
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Darren A DeWalt
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Kamal Gupta
- Department of Cardiovascular Medicine, University of Kansas Medical School, Kansas City, KS, USA
| | - Steven M Bradley
- Division of Cardiology, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - John A Dodson
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY, USA
| | - Brent C Lampert
- Division of Cardiovascular Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Holly Robertson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Tamar S Polonsky
- Department of Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - W Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Mark B Effron
- John Ochsner Heart and Vascular Institute, The University of Queensland Ochsner Clinical School, New Orleans, LA, USA
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Dodson JA, Hajduk AM, Murphy TE, Geda M, Krumholz HM, Tsang S, Nanna MG, Tinetti ME, Ouellet G, Sybrant D, Gill TM, Chaudhry SI. 180-day readmission risk model for older adults with acute myocardial infarction: the SILVER-AMI study. Open Heart 2021; 8:openhrt-2020-001442. [PMID: 33452007 PMCID: PMC7813425 DOI: 10.1136/openhrt-2020-001442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/11/2020] [Accepted: 12/13/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To develop a 180-day readmission risk model for older adults with acute myocardial infarction (AMI) that considered a broad range of clinical, demographic and age-related functional domains. METHODS We used data from ComprehenSIVe Evaluation of Risk in Older Adults with AMI (SILVER-AMI), a prospective cohort study that enrolled participants aged ≥75 years with AMI from 94 US hospitals. Participants underwent an in-hospital assessment of functional impairments, including cognition, vision, hearing and mobility. Clinical variables previously shown to be associated with readmission risk were also evaluated. The outcome was 180-day readmission. From an initial list of 72 variables, we used backward selection and Bayesian model averaging to derive a risk model (N=2004) that was subsequently internally validated (N=1002). RESULTS Of the 3006 SILVER-AMI participants discharged alive, mean age was 81.5 years, 44.4% were women and 10.5% were non-white. Within 180 days, 1222 participants (40.7%) were readmitted. The final risk model included 10 variables: history of chronic obstructive pulmonary disease, history of heart failure, initial heart rate, first diastolic blood pressure, ischaemic ECG changes, initial haemoglobin, ejection fraction, length of stay, self-reported health status and functional mobility. Model discrimination was moderate (0.68 derivation cohort, 0.65 validation cohort), with good calibration. The predicted readmission rate (derivation cohort) was 23.0% in the lowest quintile and 65.4% in the highest quintile. CONCLUSIONS Over 40% of participants in our sample experienced hospital readmission within 180 days of AMI. Our final readmission risk model included a broad range of characteristics, including functional mobility and self-reported health status, neither of which have been previously considered in 180-day risk models.
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Affiliation(s)
- John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA .,Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Alexandra M Hajduk
- Geriatrics Section, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terrence E Murphy
- Geriatrics Section, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mary Geda
- Geriatrics Section, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut, USA.,Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Sui Tsang
- Geriatrics Section, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael G Nanna
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Mary E Tinetti
- Geriatrics Section, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Gregory Ouellet
- Geriatrics Section, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Deborah Sybrant
- International Heart Institute of Montana, Missoula, Montana, USA
| | - Thomas M Gill
- Geriatrics Section, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sarwat I Chaudhry
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Gupta A, Tsang S, Hajduk A, Krumholz HM, Nanna MG, Green P, Dodson JA, Chaudhry SI. Presentation, Treatment, and Outcomes of the Oldest-Old Patients with Acute Myocardial Infarction: The SILVER-AMI Study. Am J Med 2021; 134:95-103. [PMID: 32805225 PMCID: PMC7752813 DOI: 10.1016/j.amjmed.2020.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 07/19/2020] [Accepted: 07/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Oldest-old patients (≥85 years) constitute half the acute myocardial infarction hospitalizations among older adults and more commonly have atypical presentation, under-treatment, and functional impairments. Yet this group has not been well characterized. We characterized differences in presentation, functional impairments, treatments, health status, and mortality among middle-old (75-84 years) and oldest-old patients with myocardial infarction. METHODS We analyzed data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study that enrolled 3041 patients ≥75 years of age from 94 hospitals across the US between 2013 and 2016. We performed Cox proportional hazards regression to examine the association between the oldest-old (n = 831) and middle-old (n = 2210) age categories with postdischarge 6-month case fatality rate adjusting for sociodemographic and clinical variables, and mobility impairment. RESULTS The oldest-old were less likely to present with chest pain (52.7% vs 57.7%) as their primary symptom or to receive coronary revascularization (58.1% vs 71.8) (P < .01 for both). The oldest-old were more likely to have functional impairments and had higher 6-month mortality compared with the middle-old patients (hazard ratio 1.78, 95% confidence interval, 1.39-2.28). This association was substantially attenuated after adjusting for mobility impairment (hazard ratio 1.29, confidence interval, 0.99-1.68). CONCLUSIONS There is considerable heterogeneity in presentation, treatment, and outcomes among older patients with myocardial infarction. Mobility impairment, a marker for frailty, modifies the association between advanced age and treatments as well as outcomes.
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Affiliation(s)
- Aakriti Gupta
- Section of Cardiovascular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn; Cardiovascular Research Foundation, New York, NY
| | - Sui Tsang
- Department of Internal Medicine, Geriatrics Section, and the Program on Aging
| | - Alexandra Hajduk
- Department of Internal Medicine, Geriatrics Section, and the Program on Aging
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Department of Health Policy and Management, Yale School of Public Health, New Haven, Conn
| | - Michael G Nanna
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Philip Green
- Section of Cardiovascular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY; Cardiovascular Research Foundation, New York, NY
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine; Department of Population Health, New York University School of Medicine, New York, NY
| | - Sarwat I Chaudhry
- Section of General Internal Medicine, Department of Internal Medicine, and the National Clinician Scholars Program, Yale School of Medicine, New Haven, Conn.
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40
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Affiliation(s)
- John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York.,Division of Healthcare Delivery Science, Department of Population Health, New York University Grossman School of Medicine, New York
| | - Daichi Shimbo
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Krishnaswami A, Beavers C, Dorsch MP, Dodson JA, Masterson Creber R, Kitsiou S, Goyal P, Maurer MS, Wenger NK, Croy DS, Alexander KP, Batsis JA, Turakhia MP, Forman DE, Bernacki GM, Kirkpatrick JN, Orr NM, Peterson ED, Rich MW, Freeman AM, Bhavnani SP. Gerotechnology for Older Adults With Cardiovascular Diseases: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 76:2650-2670. [PMID: 33243384 PMCID: PMC10436190 DOI: 10.1016/j.jacc.2020.09.606] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/18/2020] [Accepted: 09/21/2020] [Indexed: 12/19/2022]
Abstract
The growing population of older adults (age ≥65 years) is expected to lead to higher rates of cardiovascular disease. The expansion of digital health (encompassing telehealth, telemedicine, mobile health, and remote patient monitoring), Internet access, and cellular technologies provides an opportunity to enhance patient care and improve health outcomes-opportunities that are particularly relevant during the current coronavirus disease-2019 pandemic. Insufficient dexterity, visual impairment, and cognitive dysfunction, found commonly in older adults should be taken into consideration in the development and utilization of existing technologies. If not implemented strategically and appropriately, these can lead to inequities propagating digital divides among older adults, across disease severities and socioeconomic distributions. A systematic approach, therefore, is needed to study and implement digital health strategies in older adults. This review will focus on current knowledge of the benefits, barriers, and use of digital health in older adults for cardiovascular disease management.
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Affiliation(s)
- Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente Medical Center, San Jose, California.
| | - Craig Beavers
- Division of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Michael P Dorsch
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - John A Dodson
- NYU Langone Health, NYU Grossman School of Medicine, New York, New York
| | - Ruth Masterson Creber
- Weill Cornell Medicine, Department of Population Health Sciences, Division of Health Informatics, New York, New York
| | - Spyros Kitsiou
- Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mathew S Maurer
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Nanette K Wenger
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Karen P Alexander
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - John A Batsis
- Department of Medicine, Geisel School of Medicine and The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College and Dartmouth-Hitchcock, Lebanon, New Hampshire; Division of Geriatric Medicine, School of Medicine, Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Chapel Hill, North Carolina
| | - Mintu P Turakhia
- Center for Digital Health, Stanford University, Stanford, California; Palo Alto Veterans Administration Health Care System, Palo Alto, California
| | - Daniel E Forman
- Division of Geriatric Cardiology, University of Pittsburgh, Geriatric Research, Education and Clinical Center; VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Gwen M Bernacki
- Cardiovascular Division, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - James N Kirkpatrick
- Cardiovascular Division, Department of Medicine, Department of Bioethics and Humanities, University of Washington, Seattle, Washington
| | - Nicole M Orr
- Post-Acute Cardiology Care, LCC, Darien, Connecticut; Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Eric D Peterson
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Michael W Rich
- Cardiovascular Division, Washington University, St. Louis, Missouri
| | - Andrew M Freeman
- Division of Cardiology, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Sanjeev P Bhavnani
- Prebys Cardiovascular Institute, Scripps Clinic & Research Foundation, San Diego, California
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Hajduk AM, Dodson JA, Murphy TE, Tsang S, Geda M, Ouellet GM, Gill TM, Brush JE, Chaudhry SI. Risk Model for Decline in Activities of Daily Living Among Older Adults Hospitalized With Acute Myocardial Infarction: The SILVER-AMI Study. J Am Heart Assoc 2020; 9:e015555. [PMID: 33000681 PMCID: PMC7792390 DOI: 10.1161/jaha.119.015555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Functional decline (ie, a decrement in ability to perform everyday activities necessary to live independently) is common after acute myocardial infarction (AMI) and associated with poor long‐term outcomes; yet, we do not have a tool to identify older AMI survivors at risk for this important patient‐centered outcome. Methods and Results We used data from the prospective SILVER‐AMI (Comprehensive Evaluation of Risk Factors in Older Patients With Acute Myocardial Infarction) study of 3041 patients with AMI, aged ≥75 years, recruited from 94 US hospitals. Participants were assessed during hospitalization and at 6 months to collect data on demographics, geriatric impairments, psychosocial factors, and activities of daily living. Clinical variables were abstracted from the medical record. Functional decline was defined as a decrement in ability to independently perform essential activities of daily living (ie, bathing, dressing, transferring, and ambulation) from baseline to 6 months postdischarge. The mean age of the sample was 82±5 years; 57% were men, 90% were White, and 13% reported activity of daily living decline at 6 months postdischarge. The model identified older age, longer hospital stay, mobility impairment during hospitalization, preadmission physical activity, and depression as risk factors for decline. Revascularization during AMI hospitalization and ability to walk a quarter mile before AMI were associated with decreased risk. Model discrimination (c=0.78) and calibration were good. Conclusions We identified a parsimonious model that predicts risk of activity of daily living decline among older patients with AMI. This tool may aid in identifying older patients with AMI who may benefit from restorative therapies to optimize function after AMI.
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Affiliation(s)
| | - John A Dodson
- Leon H. Charney Division of Cardiology Department of Medicine New York University School of Medicine New York NY.,Division of Healthcare Delivery Science Department of Population Health New York University School of Medicine New York NY
| | - Terrence E Murphy
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Sui Tsang
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Mary Geda
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Gregory M Ouellet
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Thomas M Gill
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - John E Brush
- Sentara Healthcare and Eastern Virginia Medical School Norfolk VA
| | - Sarwat I Chaudhry
- Department of Internal Medicine Yale School of Medicine New Haven CT
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43
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Affiliation(s)
| | - John A. Dodson
- Department of Population Health, NYU School of Medicine, New York, New York
- Geriatric Cardiology Program, NYU School of Medicine, New York, New York
| | - Leora Horwitz
- Department of Population Health, NYU School of Medicine, New York, New York
- Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, New York
- Division of Healthcare Delivery Science, Department of Population Health, NYU School of Medicine, New York, New York
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Dodson JA, Hajduk AM, Murphy TE, Geda M, Krumholz HM, Tsang S, Nanna MG, Tinetti ME, Goldstein D, Forman DE, Alexander KP, Gill TM, Chaudhry SI. Thirty-Day Readmission Risk Model for Older Adults Hospitalized With Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2020; 12:e005320. [PMID: 31010300 DOI: 10.1161/circoutcomes.118.005320] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early readmissions among older adults hospitalized for acute myocardial infarction (AMI) are costly and difficult to predict. Aging-related functional impairments may inform risk prediction but are unavailable in most studies. Our objective was to, therefore, develop and validate an AMI readmission risk model for older patients who considered functional impairments and was suitable for use before hospital discharge. METHODS AND RESULTS SILVER-AMI (Comprehensive Evaluation of Risk in Older Adults with AMI) is a prospective cohort study of 3006 patients of age ≥75 years hospitalized with AMI at 94 US hospitals. Participants underwent in-hospital assessment of functional impairments including cognition, vision, hearing, and mobility. Other variables plausibly associated with readmissions were also collected. The outcome was all-cause readmission at 30 days. We used backward selection and Bayesian model averaging to derive (N=2004) a risk model that was subsequently validated (N=1002). Mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. Within 30 days, 547 participants (18.2%) were readmitted. Readmitted participants were older, had more comorbidities, and had a higher prevalence of functional impairments, including activities of daily living disability (17.0% versus 13.0%; P=0.013) and impaired functional mobility (72.5% versus 53.6%; P<0.001). The final risk model included 8 variables: functional mobility, ejection fraction, chronic obstructive pulmonary disease, arrhythmia, acute kidney injury, first diastolic blood pressure, P2Y12 inhibitor use, and general health status. Functional mobility was the only functional impairment variable retained but was the strongest predictor. The model was well calibrated (Hosmer-Lemeshow P value >0.05) with moderate discrimination (C statistics: 0.65 derivation cohort and 0.63 validation cohort). Functional mobility significantly improved performance of the risk model (net reclassification improvement index =20%; P<0.001). CONCLUSIONS In our final risk model, functional mobility, previously not included in readmission risk models, was the strongest predictor of 30-day readmission among older adults after AMI. The modest discrimination indicates that much of the variability in readmission risk among this population remains unexplained by patient-level factors. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01755052.
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Affiliation(s)
- John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine (J.A.D.)
| | - Alexandra M Hajduk
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine (J.A.D.)
| | - Terrence E Murphy
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine (J.A.D.)
| | - Mary Geda
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine (J.A.D.)
| | - Harlan M Krumholz
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine (J.A.D.)
| | - Sui Tsang
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine (J.A.D.)
| | - Michael G Nanna
- Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.G.N., K.P.A.)
| | - Mary E Tinetti
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine (J.A.D.)
| | - David Goldstein
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine (J.A.D.)
| | - Daniel E Forman
- Section of Geriatric Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, PA (D.E.F.)
| | - Karen P Alexander
- Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.G.N., K.P.A.)
| | - Thomas M Gill
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine (J.A.D.)
| | - Sarwat I Chaudhry
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine (J.A.D.)
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Ong C, Lui A, Dodson JA, Strom JB, Alviar C. Abstract 301: Differential Outcomes for Geriatric Patients in Cardiac Intensive Care Unit Compared to Medical Intensive Care Unit. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The number of older adults admitted to cardiac intensive care units (CICU) have been increasing over the past decade, but it is not known if outcomes vary between CICU and medical intensive care units (MICU). We aimed to describe survival and length of stay (LOS) in older adults admitted to CICU and MICU.
Methods:
All patients admitted to the CICU or MICU at Beth Israel Deaconess Medical Center from 2001-2012 were identified from MIMIC-III, a large single-center critical care database containing deidentified clinical data for 38,597 patients. Our primary outcomes were ICU mortality and ICU LOS. Regression analyses were performed adjusting for age, gender, ICU setting and Oxford Acute Severity of Illness Score (OASIS), a severity score developed and validated in critically ill patients for ICU mortality.
Results:
We included 21,088 MICU patients (48.3% female) and 7,726 CICU patients (42% female). Unadjusted mortality was 13.7% in MICU and 12.5% in CICU (p=0.11). When adjusted for age, gender and OASIS, there was no difference in mortality between MICU and CICU (OR 0.62, 95% CI 0.34-1.13, p=0.15). However, we found a significant interaction between older age and type of ICU with mortality (p=0.03) but not with ICU LOS (p=0.15). In patients >75 years (6,837 in MICU and 3,161 in CICU), each 5-year interval of older age was associated with higher mortality when adjusted for gender and OASIS in the CICU (OR 1.05, 95% CI 1.02-1.08 p=0.002), but not in the MICU (OR 1.01, 95% CI 0.99-1.03, p=0.15, Figure).
Conclusion:
Older adults admitted to the CICU had higher adjusted mortality by age group after age 75, as opposed to older MICU patients in whom mortality was high but remained unchanged after age 75.
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Affiliation(s)
| | - Albert Lui
- New York Univ Sch of Medicine, New York, NY
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Dodson JA, Summapund J, Iqbal SN, Spatz ES, Barnett M, Sibley R, Chaudhry SI, Dickson VV, Matlock DD. DEVELOPMENT OF A DECISION AID FOR OLDER ADULTS WITH NON ST ELEVATION MYOCARDIAL INFARCTION. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)34107-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Dodson JA, Hajduk A, Curtis JP, Murphy T, Krumholz HM, Alexander K, Clardy D, Tsang S, Geda M, Blaum C, Chaudhry SI. BLEEDING READMISSIONS AFTER ACUTE MYOCARDIAL INFARCTION IN OLDER ADULTS: THE SILVER-AMI STUDY. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)30678-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Bostrom J, Searcy R, Walia A, Rzucidlo J, Banco D, Quien M, Sweeney G, Pierre A, Tang Y, Mola A, Xia Y, Whiteson J, Dodson JA. Early Termination of Cardiac Rehabilitation Is More Common With Heart Failure With Reduced Ejection Fraction Than With Ischemic Heart Disease. J Cardiopulm Rehabil Prev 2020; 40:E26-E30. [PMID: 32084031 DOI: 10.1097/hcr.0000000000000495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Despite known benefits of cardiac rehabilitation (CR), early termination (failure to complete >1 mo of CR) attenuates these benefits. We analyzed whether early termination varied by referral indication in the context of recent growth in patients referred for heart failure with reduced ejection fraction (HFrEF). METHODS We reviewed records from 1111 consecutive patients enrolled in the NYU Langone Health Rusk CR program (2013-2017). Sessions attended, demographics, and comorbidities were abstracted, as well as primary referral indication: HFrEF or ischemic heart disease (IHD; including post-coronary revascularization, post-acute myocardial infarction, or chronic stable angina). We compared rates of early termination between HFrEF and IHD, and used multivariable logistic regression to determine whether differences persisted after adjusting for relevant characteristics (age, race, ethnicity, body mass index, smoking, hypertension, chronic obstructive pulmonary disease, and depression). RESULTS Mean patient age was 64 yr, 31% were female, and 28% were nonwhite. Most referrals (85%) were for IHD; 15% were for HFrEF. Early termination occurred in 206 patients (18%) and was more common in HFrEF (26%) than in IHD (17%) (P < .01). After multivariable adjustment, patients with HFrEF remained at higher risk of early termination than patients with IHD (unadjusted OR = 1.73, 95% CI, 1.17-2.54; adjusted OR = 1.53, 95% CI, 1.01-2.31). CONCLUSIONS Nearly 1 in 5 patients in our program terminated CR within 1 mo, with HFrEF patients at higher risk than IHD patients. While broad efforts at preventing early termination are warranted, particular attention may be required in patients with HFrEF.
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Affiliation(s)
- John Bostrom
- Departments of Medicine (Drs Bostrom, Rzucidlo, Banco, and Quien) and Rehabilitation Medicine (Drs Sweeney, Pierre, Mola, and Whiteson and Ms Tang), New York University School of Medicine, New York; University of North Carolina School of Medicine, Chapel Hill (Mr Searcy); Northeast Ohio Medical University, Rootstown (Ms Walia); Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York (Ms Xia and Dr Dodson); and Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York (Dr Dodson)
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Dodson JA, Hajduk AM, Geda M, Krumholz HM, Murphy TE, Tsang S, Tinetti ME, Nanna MG, McNamara R, Gill TM, Chaudhry SI. Predicting 6-Month Mortality for Older Adults Hospitalized With Acute Myocardial Infarction: A Cohort Study. Ann Intern Med 2020; 172:12-21. [PMID: 31816630 PMCID: PMC7695040 DOI: 10.7326/m19-0974] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Older adults with acute myocardial infarction (AMI) have higher prevalence of functional impairments, including deficits in cognition, strength, and sensory domains, than their younger counterparts. OBJECTIVE To develop and evaluate the prognostic utility of a risk model for 6-month post-AMI mortality in older adults that incorporates information about functional impairments. DESIGN Prospective cohort study. (ClinicalTrials.gov: NCT01755052). SETTING 94 hospitals throughout the United States. PARTICIPANTS 3006 persons aged 75 years or older who were hospitalized with AMI and discharged alive. MEASUREMENTS Functional impairments were assessed during hospitalization via direct measurement (cognition, mobility, muscle strength) or self-report (vision, hearing). Clinical variables associated with mortality in prior risk models were ascertained by chart review. Seventy-two candidate variables were selected for inclusion, and backward selection and Bayesian model averaging were used to derive (n = 2004 participants) and validate (n = 1002 participants) a model for 6-month mortality. RESULTS Participants' mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. There were 266 deaths (8.8%) within 6 months. The final risk model included 15 variables, 4 of which were not included in prior risk models: hearing impairment, mobility impairment, weight loss, and lower patient-reported health status. The model was well calibrated (Hosmer-Lemeshow P > 0.05) and showed good discrimination (area under the curve for the validation cohort = 0.84). Adding functional impairments significantly improved model performance, as evidenced by category-free net reclassification improvement indices of 0.21 (P = 0.008) for hearing impairment and 0.26 (P < 0.001) for mobility impairment. LIMITATION The model was not externally validated. CONCLUSION A newly developed model for 6-month post-AMI mortality in older adults was well calibrated and had good discriminatory ability. This model may be useful in decision making at hospital discharge. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute of the National Institutes of Health.
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Affiliation(s)
- John A Dodson
- New York University School of Medicine, New York, New York (J.A.D.)
| | - Alexandra M Hajduk
- Yale School of Medicine, New Haven, Connecticut (A.M.H., M.G., T.E.M., S.T., M.E.T., T.M.G., S.I.C.)
| | - Mary Geda
- Yale School of Medicine, New Haven, Connecticut (A.M.H., M.G., T.E.M., S.T., M.E.T., T.M.G., S.I.C.)
| | - Harlan M Krumholz
- Yale New Haven Hospital, Yale School of Medicine, and Yale School of Public Health, New Haven, Connecticut (H.M.K.)
| | - Terrence E Murphy
- Yale School of Medicine, New Haven, Connecticut (A.M.H., M.G., T.E.M., S.T., M.E.T., T.M.G., S.I.C.)
| | - Sui Tsang
- Yale School of Medicine, New Haven, Connecticut (A.M.H., M.G., T.E.M., S.T., M.E.T., T.M.G., S.I.C.)
| | - Mary E Tinetti
- Yale School of Medicine, New Haven, Connecticut (A.M.H., M.G., T.E.M., S.T., M.E.T., T.M.G., S.I.C.)
| | - Michael G Nanna
- Duke University School of Medicine, Durham, North Carolina (M.G.N.)
| | | | - Thomas M Gill
- Yale School of Medicine, New Haven, Connecticut (A.M.H., M.G., T.E.M., S.T., M.E.T., T.M.G., S.I.C.)
| | - Sarwat I Chaudhry
- Yale School of Medicine, New Haven, Connecticut (A.M.H., M.G., T.E.M., S.T., M.E.T., T.M.G., S.I.C.)
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Bostrom J, Sweeney G, Whiteson J, Dodson JA. Mobile health and cardiac rehabilitation in older adults. Clin Cardiol 2019; 43:118-126. [PMID: 31825132 PMCID: PMC7021651 DOI: 10.1002/clc.23306] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/22/2019] [Accepted: 11/08/2019] [Indexed: 12/16/2022] Open
Abstract
With the ubiquity of mobile devices, the availability of mobile health (mHealth) applications for cardiovascular disease (CVD) has markedly increased in recent years. Older adults represent a population with a high CVD burden and therefore have the potential to benefit considerably from interventions that utilize mHealth. Traditional facility-based cardiac rehabilitation represents one intervention that is currently underutilized for CVD patients and, because of the unique barriers that older adults face, represents an attractive target for mHealth interventions. Despite potential barriers to mHealth adoption in older populations, there is also evidence that older patients may be willing to adopt these technologies. In this review, we highlight the potential for mHealth uptake for older adults with CVD, with a particular focus on mHealth cardiac rehabilitation (mHealth-CR) and evidence being generated in this field.
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Affiliation(s)
- John Bostrom
- Department of Medicine, New York University School of Medicine, New York, New York
| | - Greg Sweeney
- Rusk Department of Rehabilitation Medicine, New York University Langone Health, New York, New York
| | - Jonathan Whiteson
- Rusk Department of Rehabilitation Medicine, New York University Langone Health, New York, New York
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York.,Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, New York
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