1
|
Romain G, Wang K, Scierka LE, Cleman J, Callegari S, Aboian E, Smolderen KG, Mena-Hurtado C. Variability in Short-term Mortality Following Repair of Ruptured Abdominal Aortic Aneurysms Across Centers and Physicians. J Vasc Surg 2024:S0741-5214(24)01103-0. [PMID: 38729585 DOI: 10.1016/j.jvs.2024.05.004] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/03/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Variation in the care management of repairs for ruptured infrarenal abdominal aortic aneurysms (rAAA) between centers and physicians, e.g., the procedural volumes may explain differences in mortality outcomes. First, we quantified the center and physician variability associated with 30- and 90-day mortality risk following open (rOSR) and endovascular (rEVAR) aneurysm repair. Second, we explored wheter part of this variability was attributable to procedural volume at the center and physician level. METHODS Two cohorts including rOSR and rEVAR procedures between 2013-2019 were analyzed from the Vascular Quality Initiative database. Thirty- and 90-day all-cause mortality was derived from linked Medicare claims data. The median odds ratio (MOR, median mortality risk from low- to high-risk cluster) and intraclass correlation (ICC, variability attributable to each cluster) for 30- and 90-day mortality risk associated with center and physician variability were derived using patient-level adjusted multilevel logistic regression models. Procedural volume was calculated at the center and physician levels and stratified by quartiles. The models were sequentially adjusted for volumes, and the difference in ICC (without vs. with accounting for volume) was calculated to describe the center and physician variability in mortality risk attributable to volumes. RESULTS We included 450 rOSRs (mean age=74.5±7.6 years; 23.5% female) and 752 rEVARs (76.4±8.4 years; 26.1% female). Following rOSRs, the 30- and 90-day mortality rates were 32.9% and 38.7%. No variability across centers and physicians was noted (30- and 90-day MORs ≈ 1 and ICCs ≈ 0%). Neither center nor physician volume was associated with 30-day(P=.477 and P=.796) or 90-day mortality (P=.098 and P=.559). Following rEVAR, the 30- and 90-day mortality rate was 21.3% and 25.5%, respectively. Significant center variability (30-day MOR=1.82 95%CI 1.33-2.22 and ICC=11% 95%CI 2%-36%; 90-day MOR=1.76 95%CI 1.37-2.09 and ICC=10% 95%CI 3%-30%), but negligeable variability across physicians (30- and 90-day MORs≈1 and ICCs ≈ 0%) were noted. Neither center nor physician volume was associated with 30- (P=.076 and P=.336) nor 90-day mortality risk (P=.066 and P=.584). The center variability attributable to procedural volumes was negligeable (difference in ICCs: 1% for 30-day; 0% for 90-day mortality). CONCLUSION Variability in practice from center-to-center was associated with short-term mortality outcomes in rEVAR, but not for rOSR. Physician variability was not associated with short-term mortality for rOSR or rEVAR. Annualized center and physician volumes did not significantly explain these associations. Further work is needed to identify center-level factors affecting the quality of care and outcomes for ruptured AAA.
Collapse
Affiliation(s)
- Gaëlle Romain
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kristy Wang
- Frank H. Netter MD School of Medicine, North Haven, Connecticut, USA
| | - Lindsey E Scierka
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jacob Cleman
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Santiago Callegari
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Edouard Aboian
- Section of Vascular Surgery, Department of Surgery, Yale University, New Haven, Connecticut, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Yale School of Medicine, New Haven, Connecticut, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
| |
Collapse
|
2
|
Cleman J, Sierra JG, Romain G, Capuano B, Scierka L, Callegari S, Jacque F, Peri-Okonny P, Nagpal S, Smolderen KG, Mena-Hurtado C. Comparison of mortality and amputation after lower extremity bypass versus peripheral vascular intervention in patients with chronic limb-threatening ischemia and comorbid chronic kidney disease. J Vasc Surg 2024:S0741-5214(24)00957-1. [PMID: 38608966 DOI: 10.1016/j.jvs.2024.04.016] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/25/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Comorbid chronic kidney disease (CKD) is associated with worse outcomes for patients with chronic limb-threatening ischemia (CLTI). However, comparative effectiveness data are limited for lower extremity bypass (LEB) vs peripheral vascular intervention (PVI) in patients with CLTI and CKD. We aimed to evaluate (1) 30-day all-cause mortality and amputation and (2) 5-year all-cause mortality and amputation for LEB vs PVI in patients with comorbid CKD. METHODS Individuals who underwent LEB and PVI were queried from the Vascular Quality Initiative with Medicare claims-linked outcomes data. Propensity scores were calculated using 13 variables, and a 1:1 matching method was used. The mortality risk at 30 days and 5 years in LEB vs PVI by CKD was assessed using Kaplan-Meier and Cox proportional hazards models, with interaction terms added for CKD. For amputation, cumulative incidence functions and Fine-Gray models were used to account for the competing risk of death, with interaction terms for CKD added. RESULTS Of 4084 patients (2042 per group), the mean age was 71.0 ± 10.8 years, and 69.0% were male. Irrespective of CKD status, 30-day mortality (hazard ratio [HR]: 0.94, 95% confidence interval [CI]: 0.63-1.42, P = .78) was similar for LEB vs PVI, but LEB was associated with a lower risk of 30-day amputation (sub-HR [sHR]: 0.66, 95% CI: 0.44-0.97, P = .04). CKD status, however, did not modify these results. Similarly, LEB vs PVI was associated with a lower risk of 5-year mortality (HR: 0.79, 95% CI: 0.71-0.88, P < .001) but no difference in 5-year amputation (sHR: 1.03, 95% CI: 0.89-1.20, P = .67). CKD status did not modify these results. CONCLUSIONS Regardless of CKD status, patients had a lower risk of 5-year all-cause mortality and 30-day amputation with LEB vs PVI. Results may help inform preference-sensitive treatment decisions on LEB vs PVI for patients with CLTI and CKD, who may commonly be deemed too high risk for surgery.
Collapse
Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Juan G Sierra
- Department of Internal Medicine, Division of Cardiology, Naples Healthcare System, Naples Heart Institute, Naples, FL
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Bella Capuano
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | | | - Francky Jacque
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | | | - Sameer Nagpal
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Internal Medicine, Division of Cardiology, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Internal Medicine, Division of Cardiology, Yale School of Medicine, New Haven, CT.
| |
Collapse
|
3
|
Smolderen KG, Romain G, Cleman J, Scierka L, Mena-Hurtado C. Variability in guideline-directed medical therapy across sites and operators and long-term mortality and amputation outcomes risk in patients undergoing peripheral vascular interventions. Am Heart J 2024; 270:75-85. [PMID: 38307364 DOI: 10.1016/j.ahj.2024.01.008] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND The use of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) decreases the risk of death and amputation and may decrease hospital readmissions. The variability of GDMT prescription across sites and operators and the proportionality of risk is not well understood. We aimed to study the association between variability of GDMT prescription at the site and operator level and outcomes (including 90-day readmissions and 24-month all-cause mortality and major amputation). METHODS We examined GDMT discharge rates in PVIs performed between 2017 and 2018 using Medicare-linked Vascular Quality Initiative registry. GDMT included a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-i/ARB) if hypertensive. Quartiles (Q1-4) of GDMT rates were documented by operators and sites and variability was quantified using median odds ratios (MOR) and intraclass correlation (ICC). The association between lower GDMT rates (per 10%) by sites and operators with 90-day readmission were calculated using logistic regression, and with 24-month mortality and major amputation using parametric survival model. Models were adjusted for patient-level factors and included sites and operators nested within sites as 2 random effects. RESULTS GDMT rates for 17,147 patients across 223 sites and 1,263 operators ranged from 0% to 38% (Q1, MOR 1.43, 95%CI 1.39-1.47, P ≤ .001) to 57%-100% (Q4, MOR 1.48, 95%CI 1.44-1.51, P ≤ .001). Four percent of variance in GDMT use was explained by sites (ICC 3.9, 95%CI 2.9-5.3) and operators (ICC 4.1, 95%CI 3.1-5.4). A dose-response relationship was noted between lower GDMT rates and increased risk of 90-day readmission risk by sites (P = .021) and operators (P < .001). Lower GDMT prescription by site was associated with higher risk of 24-month mortality (HR = 1.07, 95%CI 1.02-1.13) and major amputation (HR = 1.08, 95%CI 1.01-1.15). Similar associations were found for GDMT use by provider (mortality HR = 1.05, 95%CI 1.02-1.08 and amputation HR = 1.04, 95%CI 1.00-1.08). CONCLUSION Both at the operator and health system level, there was significant variability in GDMT prescription following PVI, proportionally translating into risk for readmission, mortality, and major amputation. Targeted quality efforts should prioritize both operator and site levels to improve GDMT use and outcomes for patients undergoing PVI.
Collapse
Affiliation(s)
- Kim G Smolderen
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Department of Psychiatry, Psychology Section, Yale University School of Medicine, New Haven, CT.
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Jacob Cleman
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
4
|
Cleman J, Romain G, Callegari S, Scierka L, Jacque F, Smolderen KG, Mena-Hurtado C. Evaluation of short-term mortality in patients with Medicare undergoing endovascular interventions for chronic limb-threatening ischemia. Vasc Med 2024; 29:172-181. [PMID: 38334045 DOI: 10.1177/1358863x231224335] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Patients with chronic limb-threatening ischemia (CLTI) have high mortality rates after revascularization. Risk stratification for short-term outcomes is challenging. We aimed to develop machine-learning models to rank predictive variables for 30-day and 90-day all-cause mortality after peripheral vascular intervention (PVI). METHODS Patients undergoing PVI for CLTI in the Medicare-linked Vascular Quality Initiative were included. Sixty-six preprocedural variables were included. Random survival forest (RSF) models were constructed for 30-day and 90-day all-cause mortality in the training sample and evaluated in the testing sample. Predictive variables were ranked based on the frequency that they caused branch splitting nearest the root node by importance-weighted relative importance plots. Model performance was assessed by the Brier score, continuous ranked probability score, out-of-bag error rate, and Harrell's C-index. RESULTS A total of 10,114 patients were included. The crude mortality rate was 4.4% at 30 days and 10.6% at 90 days. RSF models commonly identified stage 5 chronic kidney disease (CKD), dementia, congestive heart failure (CHF), age, urgent procedures, and need for assisted care as the most predictive variables. For both models, eight of the top 10 variables were either medical comorbidities or functional status variables. Models showed good discrimination (C-statistic 0.72 and 0.73) and calibration (Brier score 0.03 and 0.10). CONCLUSION RSF models for 30-day and 90-day all-cause mortality commonly identified CKD, dementia, CHF, need for assisted care at home, urgent procedures, and age as the most predictive variables as critical factors in CLTI. Results may help guide individualized risk-benefit treatment conversations regarding PVI.
Collapse
Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Santiago Callegari
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Francky Jacque
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| |
Collapse
|
5
|
Amenyedor K, Lee M, Algara M, Siddiqui WT, Hardt M, Romain G, Mena-Hurtado C, Smolderen KG. Impact of comorbid opioid use disorder and major depressive disorder on healthcare utilization outcomes in patients with peripheral artery disease: A National Readmission Database analysis. Vasc Med 2024; 29:163-171. [PMID: 38391134 DOI: 10.1177/1358863x241228540] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND Prior research has demonstrated that individuals with peripheral artery disease (PAD) often have comorbid opioid use disorder (OUD) and major depressive disorder (MDD), with limited data regarding their impact on readmission outcomes, length of stay, and cost. This study aimed to investigate these healthcare utilization outcomes in patients with PAD who have comorbid OUD and MDD. METHODS Data were obtained from the National Readmission Database from 2011 through 2018. The study population included all hospitalizations with PAD as the primary or secondary diagnosis, from which hospitalizations with OUD and MDD were extracted using appropriate ICD-9/10 diagnosis codes. Primary outcomes were 30-day and 90-day readmission, total cost, and total length of stay within the calendar year. We created hierarchical multivariable logistic regression models examining OUD with and without MDD, with a random effect for healthcare facility location. RESULTS From 2011 to 2018, 13,265,817 weighted admissions with PAD were identified. These admissions were segmented into four categories: No OUD/No MDD (12,056,466), OUD/No MDD (323,762), No OUD/MDD (867,641), and OUD/MDD (17,948). The group with No OUD/No MDD was used as the reference group for all subsequent comparisons. Regarding 30-day and 90-day readmissions, patients with OUD/MDD had odds of 1.14 (95% CI 1.10, 1.18) and 1.09 (95% CI 1.06, 1.13), respectively. Patients with OUD/No MDD bore the highest median cost of $64,354 (IQR $30,797-137,074), and patients with OUD/MDD marked the lengthiest median stay of 6.01 days (IQR 2.01-13.30). CONCLUSION This study found a significant association between these comorbidities and outcomes and therefore calls for targeted interventions and pain management strategies.
Collapse
Affiliation(s)
- Kelvin Amenyedor
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Megan Lee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Miguel Algara
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Madeleine Hardt
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Gaëlle Romain
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kim G Smolderen
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
6
|
Scierka LE, Bradley BA, Glynn E, Davis S, Hoffman M, Tam-Williams JB, Mena-Hurtado C, Smolderen KG. Chronic Cough: Characterizing and Quantifying Burden in Adults Using a Nationwide Electronic Health Records Database. J Healthc Inform Res 2024; 8:50-64. [PMID: 38273985 PMCID: PMC10805682 DOI: 10.1007/s41666-023-00150-5] [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: 01/10/2023] [Revised: 09/06/2023] [Accepted: 09/11/2023] [Indexed: 01/27/2024]
Abstract
Chronic cough is a common condition; until recently, no International Classification of Diseases (ICD) code for chronic cough existed; therefore, the true scope and burden of chronic cough is unclear. Using established algorithms, we examined chronic cough patients and their risk profiles, recurrent cough episodes, and subsequent 1-year health care utilization in the nationwide Cerner EHR data resource, compared with those with acute cough. An ICD-based algorithm was applied to the Cerner Health Facts EHR database to derive a phenotype of chronic cough defined as three ICD-based "cough" encounters 14-days apart over a 56-to-120-day period from 2015 to 2017. Demographics, comorbidities, and outcomes (1-year outpatient, emergency, and inpatient encounters) were collected for the chronic cough cohort and acute cough cohort. The chronic cough cohort was 61.5% female, 70.4% white, and 15.2% African American, with 13.7% being of Asian, Native American, or unknown race. Compared with the acute cough cohort, chronic cough patients were more likely to be older, female, and have chronic pulmonary disease, obesity, and depression. Predictors of recurrent chronic cough were older age and race. Those with chronic cough had more outpatient (2.48 ± 2.10 vs. 1.48 ± 0.99; SMD = 0.94), emergency (1.90 ± 2.26 vs. 1.23 ± 0.68; SMD = 0.82), and inpatient (1.11 ± 0.36 vs. 1.05 ± 0.24, SMD = 0.24) encounters compared with acute cough. While EHR-based data may provide a useful resource to identify chronic cough phenotypes, supplementary data approaches and screening methods for chronic cough can further identify the scope of the problem.
Collapse
Affiliation(s)
- Lindsey E Scierka
- Vascular Medicine Outcomes (VAMOS) Program, Department of Internal Medicine, Section of Cardiology, Yale University, New Haven, CT USA
| | - Brooklyn A Bradley
- Vascular Medicine Outcomes (VAMOS) Program, Department of Internal Medicine, Section of Cardiology, Yale University, New Haven, CT USA
- Department of Psychiatry, Yale University, 789 Howard Avenue, New Haven, CT 06519 USA
| | - Earl Glynn
- Children's Mercy Research Institute, Children's Mercy Hospital, Kansas City, MO USA
| | - Sierra Davis
- Children's Mercy Research Institute, Children's Mercy Hospital, Kansas City, MO USA
| | - Mark Hoffman
- Children's Mercy Research Institute, Children's Mercy Hospital, Kansas City, MO USA
| | - Jade B Tam-Williams
- Children's Mercy Research Institute, Children's Mercy Hospital, Kansas City, MO USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Department of Internal Medicine, Section of Cardiology, Yale University, New Haven, CT USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Department of Internal Medicine, Section of Cardiology, Yale University, New Haven, CT USA
- Department of Psychiatry, Yale University, 789 Howard Avenue, New Haven, CT 06519 USA
| |
Collapse
|
7
|
Cleman J, Romain G, Smolderen KG, Mena-Hurtado C. Reply. J Vasc Surg 2024; 79:456. [PMID: 38245191 DOI: 10.1016/j.jvs.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 01/22/2024]
Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | | |
Collapse
|
8
|
Aggarwal A, Markiel JT, Chandra N, Buller GK, Smolderen KG, Mena-Hurtado C. Successful percutaneous management of hypothenar hammer syndrome with thrombosuction and catheter-directed intra-arterial thrombolysis. J Vasc Surg Cases Innov Tech 2024; 10:101384. [PMID: 38205441 PMCID: PMC10777006 DOI: 10.1016/j.jvscit.2023.101384] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/13/2023] [Indexed: 01/12/2024] Open
Abstract
Hypothenar hammer syndrome (HHS) is a rare vascular disorder leading to ulnar artery thrombosis or aneurysm and causing acute or chronic limb ischemia. The optimal approaches to managing this condition lack a definitive consensus and are essentially empirical, typically necessitating conservative methods for symptomatic relief, with surgical intervention reserved for cases for which conservative measures prove inadequate or when acute limb ischemia ensues. Limited data are available on percutaneous management for this condition. We present the case of a 36-year-old male powerlifter who developed acute digital ischemia due to HHS in the left hand that was managed successfully through an innovative approach using antegrade left brachial artery access and combining percutaneous thrombosuction and intra-arterial thrombolysis. This comprehensive approach resulted in restoration of blood flow and resolution of acute limb ischemia. The patient was subsequently prescribed short-term anticoagulation therapy and remained symptom free at 3 months of follow-up. This innovative strategy challenges traditional surgical approaches in HHS management, underscoring the importance of using minimally invasive techniques as a promising alternative and highlighting potential avenues for further research.
Collapse
Affiliation(s)
- Abhinav Aggarwal
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT
- Vascular Medicine Outcomes Program, Division of Cardiology, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Jan T Markiel
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT
| | - Nishith Chandra
- Department of Cardiology, Fortis Escorts Heart Institute, New Delhi, India
| | - Gregory K Buller
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Division of Cardiology, Department of Medicine, Yale University School of Medicine, New Haven, CT
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Division of Cardiology, Department of Medicine, Yale University School of Medicine, New Haven, CT
- Section of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
9
|
Scierka LE, Peri-Okonny PA, Romain G, Cleman J, Spertus JA, Fitridge R, Secemsky E, Patel MR, Gosch KL, Mena-Hurtado C, Smolderen KG. Psychosocial and socioeconomic factors are most predictive of health status in patients with claudication. J Vasc Surg 2024:S0741-5214(24)00081-8. [PMID: 38266885 DOI: 10.1016/j.jvs.2024.01.021] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND As a key treatment goal for patients with symptomatic peripheral artery disease (PAD), improving health status has also become an important end point for clinical trials and performance-based care. An understanding of patient factors associated with 1-year PAD health status is lacking in patients with PAD. METHODS The health status of 1073 consecutive patients with symptomatic PAD in the international multicenter PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry was measured at baseline and 1 year with the Peripheral Artery Questionnaire (PAQ). The association of 47 patient characteristics with 1-year PAQ scores was assessed using a random forest algorithm. Variables of clinical significance were retained and included in a hierarchical multivariable linear regression model predicting 1-year PAQ summary scores. RESULTS The mean age of patients was 67.7 ± 9.3 years, and 37% were female. Variables with the highest importance ranking in predicting 1-year PAQ summary score were baseline PAQ summary score, Patient Health Questionnaire-8 depression score, Generalized Anxiety Disorder-2 anxiety score, new onset symptom presentation, insurance status, current or prior diagnosis of depression, low social support, initial invasive treatment, duration of symptoms, and race. The addition of 19 clinical variables in an extended model marginally improved the explained variance in 1-year health status (from R2 0.312 to 0.335). CONCLUSIONS Patients' 1-year PAD-specific health status, as measured by the PAQ, can be predicted from 10 mostly psychosocial and socioeconomic patient characteristics including depression, anxiety, insurance status, social support, and symptoms. These characteristics should be validated and tested in other PAD cohorts so that this model can inform risk adjustment and prediction of PAD health status in comparative effectiveness research and performance-based care.
Collapse
Affiliation(s)
- Lindsey E Scierka
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Poghni A Peri-Okonny
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Gaelle Romain
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Jacob Cleman
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO; Departments of Biomedical and Health Informatics and Internal Medicine, Section of Cardiovascular Disease, University of Missouri-Kansas City, Kansas City, MO
| | - Robert Fitridge
- Vascular Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Eric Secemsky
- Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT; Department of Psychiatry, Section of Psychology, Yale University, New Haven, CT.
| |
Collapse
|
10
|
Grubman S, Algara M, Smolderen KG, Luna P, Walenczyk K, Scierka L, Cleman J, Siddiqui WT, Romain G, Mena‐Hurtado C. Examining Outcomes in Patients Admitted With Comorbid Peripheral Artery Disease and Microvascular Disease. J Am Heart Assoc 2024; 13:e030710. [PMID: 38166496 PMCID: PMC10863818 DOI: 10.1161/jaha.123.030710] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 11/03/2023] [Indexed: 01/04/2024]
Abstract
BACKGROUND Peripheral artery disease (PAD) and microvascular disease (MVD) are highly prevalent conditions that share common risk factors. This observational study aimed to characterize patients with both conditions and determine the impact of comorbid PAD/MVD on outcomes. METHODS AND RESULTS Patients admitted across 31 states January 2011 through December 2018 with a primary or secondary diagnosis of PAD or MVD were included from the National Readmissions Database and weighted to approximate a national sample. Those age <18 years or with nonatherosclerotic leg injuries were excluded. Patients were divided into 3 groups: PAD-only, MVD-only, or comorbid PAD/MVD. Multiple logistic regression was used to evaluate associations with major and minor amputations, major adverse cardiac events, and in-hospital mortality. Cox regression was used to evaluate associations with readmission within 1 year. The PAD group was used as reference. The final cohort included 33 972 772 admissions: 9.1 million with PAD, 21.3 million with MVD, and 3.6 million with both. Annual admissions for PAD/MVD increased to >500 000 in 2018. Major and minor amputations increased ≈50% for PAD/MVD between 2011 and 2018. Compared with PAD-only, PAD/MVD was associated with a higher risk for major amputation (odds ratio [OR], 1.30 [95% CI, 1.28-1.32]), minor amputation (OR, 2.15 [95% CI, 2.12-2.18]), major adverse cardiac events (OR, 1.04 [95% CI, 1.03-1.04]), in-hospital mortality (OR, 1.07 [95% CI, 1.05-1.09]), and readmission (hazard ratio, 1.02 [95% CI, 1.02-1.02]) after adjustment for baseline factors. CONCLUSIONS Comorbid MVD is present in a large and growing number of patients with PAD and is associated with augmented risk for adverse outcomes. Further prospective research is merited to understand this vulnerable population.
Collapse
Affiliation(s)
- Scott Grubman
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of MedicineYale School of MedicineNew HavenCT
| | - Miguel Algara
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of MedicineYale School of MedicineNew HavenCT
- Department of Internal MedicineHarvard Medical SchoolBostonMA
| | - Kim G. Smolderen
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of MedicineYale School of MedicineNew HavenCT
- Department of PsychiatryYale School of MedicineNew HavenCT
| | - Paulina Luna
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of MedicineYale School of MedicineNew HavenCT
- Department of Internal MedicineWeill Cornell MedicineNew YorkNY
| | - Kristie Walenczyk
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of MedicineYale School of MedicineNew HavenCT
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of MedicineYale School of MedicineNew HavenCT
| | - Jacob Cleman
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of MedicineYale School of MedicineNew HavenCT
| | - Waleed Tariq Siddiqui
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of MedicineYale School of MedicineNew HavenCT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of MedicineYale School of MedicineNew HavenCT
| | - Carlos Mena‐Hurtado
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of MedicineYale School of MedicineNew HavenCT
| |
Collapse
|
11
|
Cleman J, Xia K, Haider M, Nikooie R, Scierka L, Romain G, Attaran RR, Grimshaw A, Mena-Hurtado C, Smolderen KG. A state-of-the-art review of quality-of-life assessment in venous disease. J Vasc Surg Venous Lymphat Disord 2023:101725. [PMID: 38128828 DOI: 10.1016/j.jvsv.2023.101725] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/14/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Chronic venous disease is a common condition and has a significant impact on patients' health status. Validated patient-reported outcome measures (PROMs) used to assess health status are needed to measure health status. This state-of-the-art review summarizes the current validation evidence for disease-specific PROMs for chronic venous disease and provides a framework for their use in the clinical setting. METHODS A literature search in OVID Embase and Medline was conducted to identify relevant English-language studies of chronic venous disease that used disease-specific PROMs between January 1, 1993, and June 30, 2022. Abstracts and titles from identified studies were screened by four investigators, and full-text articles were subsequently screened for eligibility. Data on validation of disease-specific PROMs was abstracted from each included article. Classical test theory was used as a framework to examine a priori defined validation criteria for content validity, reliability (construct validity, internal reliability, and test-retest reliability), responsiveness, and expansion of the validation evidence base (use in randomized controlled trials and comparative effectiveness research, cultural or linguistic translations, predictive validity, or establishing the minimal clinically important difference threshold, defined as smallest amount an outcome or measure is perceived as a meaningful change to patients). The PROMs were categorized into three groups based on the manifestations of disease of the population for which they were developed. The overall validity of each PROM was assessed across three stages of validation including content validity (phase 1); construct validity, reliability, and responsiveness (phase 2); and expansion of the validation evidence base (phase 3). RESULTS Of 2338 unique studies screened, 112 studies (4.8%) met inclusion criteria. The eight disease-specific PROMs identified were categorized into three groups: (1) overall chronic venous disease (C1 to C6); (2) C1 to C4 disease; and (3) C5 to C6 disease. Assessed by group, the Chronic Venous Insufficiency Questionnaire met criteria for validation at all three phases for patients with C1 to C4 disease, and the Charing Cross Venous Ulcer Questionnaire met criteria for validation at all three phases for patients with C5 to C6 disease. There were no PROMs that met all criteria for validation for use in overall chronic venous disease (C1 to C6). CONCLUSIONS Of the eight PROMs assessed in this review, only two met prespecified criteria at each phase for validation. The Chronic Venous Insufficiency Questionnaire and Charing Cross Venous Ulcer Questionnaire should be considered for use in patients with chronic venous disease without venous ulcers and with venous ulcers, respectively.
Collapse
Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Kevin Xia
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT
| | - Moosa Haider
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Roozbeh Nikooie
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | | | - Alyssa Grimshaw
- Department of Library and Information Science, Yale University, New Haven, CT
| | | | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT.
| |
Collapse
|
12
|
McDermott MM, Ho KJ, Alabi O, Criqui MH, Goodney P, Hamburg N, McNeal DM, Pollak A, Smolderen KG, Bonaca M. Disparities in Diagnosis, Treatment, and Outcomes of Peripheral Artery Disease: JACC Scientific Statement. J Am Coll Cardiol 2023; 82:2312-2328. [PMID: 38057074 DOI: 10.1016/j.jacc.2023.09.830] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 12/08/2023]
Abstract
Disparities by sex, race, socioeconomic status, and geography exist in diagnosis, treatment, and outcomes for people with lower extremity peripheral artery disease (PAD). PAD prevalence is similar in men and women, but women have more atypical symptoms and undergo lower extremity revascularization at older ages compared to men. People who are Black have an approximately 2-fold higher prevalence of PAD, compared to people who are White and have more atypical symptoms, greater mobility loss, less optimal medical care, and higher amputation rates. Although fewer data are available for other races, people with PAD who are Hispanic have higher amputation rates than White people. Rates of amputation also vary by geography in the United States, with the highest rates of amputation in the southeastern United States. To improve PAD outcomes, intentional actions to eliminate disparities are necessary, including clinician education, patient education with culturally appropriate messaging, improved access to high-quality health care, science focused on disparity elimination, and health policy changes.
Collapse
Affiliation(s)
- Mary M McDermott
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Karen J Ho
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Olamide Alabi
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael H Criqui
- University of California-San Diego, School of Medicine, La Jolla, California, USA
| | - Philip Goodney
- Dartmouth School of Medicine, Hanover, New Hampshire, USA
| | | | - Demetria M McNeal
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amy Pollak
- Mayo Clinic Jacksonville, Jacksonville, Florida, USA
| | - Kim G Smolderen
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marc Bonaca
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
13
|
Skov O, Johansen JB, Nielsen JC, Larroudé CE, Riahi S, Melchior TM, Vinther M, Skovbakke SJ, Rottmann N, Wiil UK, Brandt CJ, Smolderen KG, Spertus JA, Pedersen SS. Efficacy of a web-based healthcare innovation to advance the quality of life and care of patients with an implantable cardioverter defibrillator (ACQUIRE-ICD): a randomized controlled trial. Europace 2023; 25:euad253. [PMID: 38055845 PMCID: PMC10700011 DOI: 10.1093/europace/euad253] [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: 06/07/2023] [Accepted: 08/08/2023] [Indexed: 12/08/2023] Open
Abstract
AIMS Modern clinical management of patients with an implantable cardioverter defibrillator (ICD) largely consists of remote device monitoring, although a subset is at risk of mental health issues post-implantation. We compared a 12-month web-based intervention consisting of goal setting, monitoring of patients' mental health-with a psychological intervention if needed-psychoeducational support from a nurse, and an online patient forum, with usual care on participants' device acceptance 12 months after implantation. METHODS AND RESULTS This national, multi-site, two-arm, non-blinded, randomized, controlled, superiority trial enrolled 478 first-time ICD recipients from all 6 implantation centres in Denmark. The primary endpoint was patient device acceptance measured by the Florida Patient Acceptance Survey (FPAS; general score range = 0-100, with higher scores indicating higher device acceptance) 12 months after implantation. Secondary endpoints included symptoms of depression and anxiety. The primary endpoint of device acceptance was not different between groups at 12 months [B = -2.67, 95% confidence interval (CI) (-5.62, 0.29), P = 0.08]. Furthermore, the secondary endpoint analyses showed no significant treatment effect on either depressive [B = -0.49, 95% CI (-1.19; 0.21), P = 0.17] or anxiety symptoms [B = -0.39, 95% CI (-0.96; 0.18), P = 0.18]. CONCLUSION The web-based intervention as supplement to usual care did not improve patient device acceptance nor symptoms of anxiety and depression compared with usual care. This specific web-based intervention thus cannot be recommended as a standardized intervention in ICD patients.
Collapse
Affiliation(s)
- Ole Skov
- Department of Psychology, University of Southern Denmark, Campusvej 55, DK-5230 Odense, Denmark
| | | | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Thomas M Melchior
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Michael Vinther
- Department of Cardiology B, Rigshospitalet, Copenhagen, Denmark
| | - Søren Jensen Skovbakke
- Department of Psychology, University of Southern Denmark, Campusvej 55, DK-5230 Odense, Denmark
| | - Nina Rottmann
- Department of Psychology, University of Southern Denmark, Campusvej 55, DK-5230 Odense, Denmark
| | - Uffe Kock Wiil
- SDU Health Informatics and Technology, The Maersk Mc-Kinney Moller Institute, University of Southern Denmark, Odense, Denmark
| | - Carl Joakim Brandt
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Kim G Smolderen
- Department of Internal Medicine, Vascular Medicine Outcomes Program, Yale School of Medicine, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - John A Spertus
- Kansas City’s Healthcare Institute for Innovations in Quality and Saint Luke’s Mid America Heart Institute, University of Missouri, Kansas City, MO, USA
| | - Susanne S Pedersen
- Department of Psychology, University of Southern Denmark, Campusvej 55, DK-5230 Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
14
|
Smolderen KG, Samaan Z, Decker C, Collins T, Lazar RM, Itoga NK, Mena-Hurtado C. Association Between Mental Health Burden, Clinical Presentation, and Outcomes in Individuals With Symptomatic Peripheral Artery Disease: A Scientific Statement From the American Heart Association. Circulation 2023; 148:1511-1528. [PMID: 37781785 DOI: 10.1161/cir.0000000000001178] [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: 10/03/2023]
Abstract
Along with the rising burden of peripheral artery disease (PAD), mental health concerns are increasingly being recognized as a comorbidity to address in the chronic disease management of symptomatic PAD. Apart from a high prevalence of comorbid mental health conditions, the role of pain and changing health behaviors and the broader impacts of illness and adaptation to living with PAD require specialized behavioral health expertise. This scientific statement builds a case that this expertise should be integrated within the multidisciplinary PAD team. Furthermore, areas such as cognitive dysfunction and palliative care are highlighted as needing psychological interventions. Although much of the evidence of the efficacy of psychological and psychotropic interventions has been extrapolated from other cardiovascular populations, evidence for the role of psychological interventions for behavior change, for example, uptake of exercise regimens, is increasingly being accrued within PAD. Areas for behavioral health needs and interactions with PAD treatment are discussed, including the use of opioids, depression management, anxiety and stress reduction interventions, the use of benzodiazepines and antidepressants, smoking cessation, rehabilitation trajectories after amputation, and the role of cognitive decline for PAD treatment and outcomes. A case summary highlights the stigma around mental health and vascular disease and the fragmentation of care. This scientific statement provides remarks for building a road map for integrated behavioral PAD care and potential solutions to overcome these barriers. Instrumental to reaching these changes are interprofessional advocacy efforts and initiatives that help break down the stigma around mental health and promote evidence-based collaborative, nonhierarchical, and multidisciplinary PAD care.
Collapse
|
15
|
Smolderen KG, Romain G, Gosch K, Arham A, Provance JB, Spertus JA, Poosala AB, Shishehbor M, Safley D, Scott K, Stone N, Mena-Hurtado C. Patient knowledge and preferences for peripheral artery disease treatment. Vasc Med 2023; 28:397-403. [PMID: 37638882 PMCID: PMC10591804 DOI: 10.1177/1358863x231181613] [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] [Indexed: 08/29/2023]
Abstract
BACKGROUND Shared medical decision making requires patients' understanding of their disease and its treatment options. Peripheral artery disease (PAD) is a condition for which preference-sensitive treatments are available, but for which little is known about patients' knowledge and treatment preferences as it relates to specific treatment goals. METHODS In a prospective, multicenter registry that involved patients with PAD experiencing claudication, the PORTRAIT Knowledge and Preferences Survey was administered at 1 year. It asks questions about PAD treatment choices, symptom relief options, disease management, and secondary prevention. PAD treatment preferences were also queried, and patients ranked 10 PAD treatment goals (1-10 Likert scale; 10 being most important). RESULTS Among 281 participants completing the survey (44.8% women, mean age 69.6 ± 9.0 years), 54.1% knew that there was more than one way to treat PAD symptoms and 47.1% were offered more than one treatment option. Most (82.4%) acknowledged that they had to manage their PAD for the rest of their life. 'Avoid loss of toes or legs,' 'decreased risk of heart attack/stroke,' 'long-lasting treatment benefit,' 'living longer,' 'improved quality of life,' and 'doing what the doctor thinks I should do' had mean ratings > 9.0 (SD ranging between 1.21 and 2.00). More variability occurred for 'avoiding surgery.' 'cost of treatment,' 'timeline of pain relief,' and 'return to work' (SD ranging between 2.76 and 3.58). The single most important treatment goal was 'improving quality of life' (31.3%). CONCLUSIONS Gaps exist in knowledge for patients with PAD who experience claudication, and there is a need for increased efforts to improve support for shared decision-making frameworks for symptomatic PAD.(ClinicalTrials.gov Identifier: NCT01419080).
Collapse
Affiliation(s)
- Kim G. Smolderen
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kensey Gosch
- Saint Luke’s Mid America Heart Institute/University of Missouri – Kansas City, Kansas City, Missouri
| | - Ahmad Arham
- Nuvance Health Medical Practices, Danbury, Connecticut
| | - Jeremy B Provance
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute/University of Missouri – Kansas City, Kansas City, Missouri
- University of Missouri, Kansas City, Missouri
| | - Anwesh B. Poosala
- Internal Medicine & Preventive Medicine, Griffin Health, Derby, Connecticut
| | | | - David Safley
- Saint Luke’s Mid America Heart Institute/University of Missouri – Kansas City, Kansas City, Missouri
| | - Kate Scott
- Saint Luke’s Mid America Heart Institute/University of Missouri – Kansas City, Kansas City, Missouri
| | - Nancy Stone
- Saint Luke’s Mid America Heart Institute/University of Missouri – Kansas City, Kansas City, Missouri
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
16
|
Cleman J, Romain G, Grubman S, Guzman RJ, Smolderen KG, Mena-Hurtado C. Comparison of lower extremity bypass and peripheral vascular intervention for chronic limb-threatening ischemia in the Medicare-linked Vascular Quality Initiative. J Vasc Surg 2023; 78:745-753.e6. [PMID: 37207790 PMCID: PMC10964324 DOI: 10.1016/j.jvs.2023.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/14/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE There is a relative lack of comparative effectiveness research on revascularization for patients with chronic limb-threatening ischemia (CLTI). We examined the association between lower extremity bypass (LEB) vs peripheral vascular intervention (PVI) for CLTI and 30-day and 5-year all-cause mortality and 30-day and 5-year amputation. METHODS Patients undergoing LEB and PVI of the below-the-knee popliteal and infrapopliteal arteries between 2014 and 2019 were queried from the Vascular Quality Initiative, and outcomes data were obtained from the Medicare claims-linked Vascular Implant Surveillance and Interventional Outcomes Network database. Propensity scores were calculated on 15 variables using a logistic regression model to control for imbalances between treatment groups. A 1:1 matching method was used. Kaplan-Meier survival curves and hierarchical Cox proportional hazards regression with a random intercept for site and operator nested in site to account for clustered data compared 30-day and 5-year all-cause mortality between groups. Thirty-day and 5-year amputation were subsequently compared using competing risk analysis to account for the competing risk of death. RESULTS There was a total of 2075 patients in each group. The overall mean age was 71 ± 11 years, 69% were male, and 76% were white, 18% were black, and 6% were of Hispanic ethnicity. Baseline clinical and demographic characteristics in the matched cohort were balanced between groups. There was no association between all-cause mortality over 30 days and LEB vs PVI (cumulative incidence, 2.3% vs 2.3% by Kaplan Meier; log-rank P-value = .906; hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.62-1.44; P-value = .80). All-cause mortality over 5 years was lower for LEB vs PVI (cumulative incidence, 55.9% vs 60.1% by Kaplan Meier; log-rank P-value < .001; HR, 0.77; 95% CI, 0.70-0.86; P-value < .001). Accounting for competing risk of death, amputation over 30 days was also lower in LEB vs PVI (cumulative incidence function, 1.9% vs 3.0%; Fine and Gray P-value = .025; subHR, 0.63; 95% CI, 0.42-0.95; P-value = .025). There was no association between amputation over 5 years and LEB vs PVI (cumulative incidence function, 22.6% vs 23.4%; Fine and Gray P-value = .184; subHR, 0.91; 95% CI, 0.79-1.05; P-value = .184). CONCLUSIONS In the Vascular Quality Initiative-linked Medicare registry, LEB vs PVI for CLTI was associated with a lower risk of 30-day amputation and 5-year all-cause mortality. These results will serve as a foundation to validate recently published randomized controlled trial data, and to broaden the comparative effectiveness evidence base for CLTI.
Collapse
Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Scott Grubman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | | |
Collapse
|
17
|
Bager LGV, Petersen JK, Havers-Borgersen E, Resch T, Smolderen KG, Mena-Hurtado C, Eiberg J, Køber L, Fosbøl EL. The use of evidence-based medical therapy in patients with critical limb-threatening ischaemia. Eur J Prev Cardiol 2023; 30:1092-1100. [PMID: 36708037 DOI: 10.1093/eurjpc/zwad022] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/30/2022] [Accepted: 01/24/2023] [Indexed: 01/29/2023]
Abstract
AIMS To describe the practice patterns of evidence-based medical therapy (EBM) and overall mortality in high-risk patients with critical limb-threatening ischaemia (CLTI), compared with patients with myocardial infarction (MI). METHODS AND RESULTS Using Danish registries, we identified patients 40-100 years of age with a first-time hospitalization for CLTI or MI from 2008-2018 and grouped them into CLTI, MI, and CLTI and history of MI (CLTI + MI). We examined the likelihood of filling prescriptions with EBM [i.e. antiplatelets (Aps), lipid-lowering agents (LLAs), angiotensin-converting enzyme inhibitor (ACEi), or angiotensin II-receptor blockers (ARBs)] within 3 months after discharge among survivors. Further, we assessed the adjusted 3-year mortality rates. We included 92 845 patients: 14 941 with CLTI (54.7% male), 74 830 with MI (64.6% male) and 3,074 with CLTI + MI (65.2% male). Patients with CLTI and CLTI + MI were older and had more comorbidities than patients with MI. Compared with patients with MI, the unadjusted odds ratios of filling prescriptions were 0.15 [confidence interval (CI): 0.14-0.15] for AP, 0.26 (CI: 0.25-0.27) for LLA, and 0.71 (CI: 0.69-0.74) for ARB/ACEi in patients with CLTI, and 0.22 (CI: 0.20-0.24) for AP, 0.38 (CI: 0.35-0.42) for LLA, and 1.17 (CI: 1.08-1.27) for ARB/ACEi in patients with CLTI + MI. Adjusted analyses showed similar results. Compared with patients with MI, adjusted 3-year hazard ratios for mortality were 1.69 (CI: 1.64-1.74) in patients with CLTI and 1.60 (CI: 1.51-1.69) in patients with CLTI + MI. CONCLUSION Patients with CLTI were undertreated with EBM and carried a more adverse prognosis, as compared with patients with MI, despite similar guidelines.
Collapse
Affiliation(s)
- Lucas Grove Vejlstrup Bager
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jeppe Kofoed Petersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Eva Havers-Borgersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Timothy Resch
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Kim G Smolderen
- Yale Medicine, Department of Internal Medicine, Section of Cardiovascular Medicine, 789 Howard Avenue, New Haven, CT 06519, USA
- Yale Medicine, Department of Psychiatry, Section of Psychology, 789 Howard Avenue, New Haven, CT 06519, USA
| | - Carlos Mena-Hurtado
- Yale Medicine, Department of Internal Medicine, Section of Cardiovascular Medicine, 789 Howard Avenue, New Haven, CT 06519, USA
| | - Jonas Eiberg
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Copenhagen Academy of Medical Education and Simulation (CAMES), Capital Region of Denmark, Ryesgade 53B, 2100 Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| |
Collapse
|
18
|
Yazgan I, Bartlett V, Romain G, Cleman J, Petersen-Crair P, Spertus JA, Hardt M, Mena-Hurtado C, Smolderen KG. Longitudinal Pathways Between Physical Activity, Depression, and Perceived Stress in Peripheral Artery Disease. Circ Cardiovasc Qual Outcomes 2023; 16:544-553. [PMID: 37470195 PMCID: PMC10561081 DOI: 10.1161/circoutcomes.122.009840] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 06/14/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND One-fifth of the patients with peripheral artery disease (PAD) experience depression and stress. Depression and stress may impact patients' abilities to be physically active, a key recommendation for supporting overall PAD management to improve symptoms and reduce the risk of cardiovascular events. We aimed to study interrelationships between 1-year longitudinal trajectories of depression, stress, and physical activity following a PAD diagnosis. METHODS Patients with new or worsening PAD symptoms enrolled at 10 US PORTRAIT study (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) vascular specialty clinics (CT, LA, MI, MO, NC, OH, and RI) were assessed at baseline, 3, 6, and 12 months between June 2, 2011 and December 3, 2015. Depressive symptoms were measured with the 8-item Patient Health Questionnaire, perceived stress with the 4-item Perceived Stress Scale and physical activity with items from the INTERHEART study. Path analysis was used to examine the longitudinal relationship between depression and physical activity and perceived stress and physical activity. RESULTS A total of 766 patients were included (mean age of 68.2 [±9.4] years; 57.7% male). Overall, 17.8% reported significant depressive symptoms, 36.0% experienced increased perceived stress, and 44.1% were sedentary upon PAD diagnosis. A decrease in physical activity preceded a rise in subsequent depressive symptoms (β ranges -0.45 [95% CI, -0.80 to -0.09]; -0.81 [95% CI, -1.19 to 0.42]) over the course of 1 year. Low physical activity scores at the initial presentation were followed by high perceived stress at 3 months (β=-0.44 [95% CI, -0.80 to -0.07]). CONCLUSIONS In symptomatic PAD, a decrease in physical activity was followed by an increased risk of depressive symptoms and perceived stress at subsequent intervals over the course of 1 year following PAD diagnosis and treatment. Integrated behavioral health approaches for PAD, addressing physical activity and managing depression or distress, are indicated as collective PAD treatment goals.
Collapse
Affiliation(s)
- Idil Yazgan
- Yale School of Medicine, New Haven, CT (I.Y., G.R., J.C., C.M.-H., K.G.S.)
| | | | - Gaëlle Romain
- Yale School of Medicine, New Haven, CT (I.Y., G.R., J.C., C.M.-H., K.G.S.)
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (G.R., J.C., C.M.-H., K.G.S.)
| | - Jacob Cleman
- Yale School of Medicine, New Haven, CT (I.Y., G.R., J.C., C.M.-H., K.G.S.)
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (G.R., J.C., C.M.-H., K.G.S.)
| | - Pamela Petersen-Crair
- Department of Psychiatry, Section of Psychology, Yale School of Medicine, New Haven, CT (P.P.-C., M.A.H., K.G.S.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.)
- Department of Biomedical and Health Informatics, School of Medicine, University of Missouri Kansas City, Kansas City, MO (J.A.S.)
| | - Madeleine Hardt
- Department of Psychiatry, Section of Psychology, Yale School of Medicine, New Haven, CT (P.P.-C., M.A.H., K.G.S.)
| | - Carlos Mena-Hurtado
- Yale School of Medicine, New Haven, CT (I.Y., G.R., J.C., C.M.-H., K.G.S.)
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (G.R., J.C., C.M.-H., K.G.S.)
| | - Kim G Smolderen
- Yale School of Medicine, New Haven, CT (I.Y., G.R., J.C., C.M.-H., K.G.S.)
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (G.R., J.C., C.M.-H., K.G.S.)
- Department of Psychiatry, Section of Psychology, Yale School of Medicine, New Haven, CT (P.P.-C., M.A.H., K.G.S.)
| |
Collapse
|
19
|
Schenck CS, Strand E, Smolderen KG, Romain G, Nagpal S, Cleman J, Blume PA, Mena-Hurtado C. Community distress and risk of adverse outcomes after peripheral vascular intervention. J Vasc Surg 2023; 78:166-174.e3. [PMID: 36944389 DOI: 10.1016/j.jvs.2023.03.027] [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: 01/06/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/22/2023]
Abstract
INTRODUCTION Community distress is associated with adverse outcomes in patients with cardiovascular disease; however, its impact on clinical outcomes after peripheral vascular intervention (PVI) is uncertain. The Distressed Communities Index (DCI) is a composite measure of community distress measured at the zip code level. We evaluated the association between community distress, as measured by the DCI, and 24-month mortality and major amputation after PVI. METHODS We used the Vascular Quality Initiative database, linked with Medicare claims data, to identify patients who underwent initial femoropopliteal PVI between 2017 and 2018. DCI scores were assigned using patient-level zip code data. The primary outcomes were 24-month mortality and major amputation. We used time-dependent receiver operating characteristic curve analysis to determine an optimal DCI value to stratify patients into risk categories for 24-month mortality and major amputation. Mixed Cox regression models were constructed to estimate the association of DCI with 24-month mortality and major amputation. RESULTS The final cohort consisted of 16,864 patients, of whom 4734 (28.1%) were classified as having high community distress (DCI ≥70). At 24 months, mortality was elevated in patients with high community distress (30.7% vs 29.5%, P = .02), as was major amputation (17.2% vs 13.1%, P <.001). After adjusting for demographic and clinical characteristics, a 10-point higher DCI score was associated with increased risk of mortality (hazard ratio: 1.01; 95% confidence interval: 1.00-1.03) and major amputation (hazard ratio: 1.02; 95% confidence interval: 1.00-1.04). CONCLUSIONS High community distress is associated with increased risk of mortality and major amputation after PVI.
Collapse
Affiliation(s)
| | - Eric Strand
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Sameer Nagpal
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jacob Cleman
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Peter A Blume
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
| |
Collapse
|
20
|
Castro-Dominguez Y, Mena-Hurtado C, Algara M, Obas V, Ahmed Z, Romain G, Solaru KW, Smolderen KG. Representativeness of Peripheral Artery Disease Randomized Clinical Trials Supporting Current Guidelines. Am J Cardiol 2023; 201:166-169. [PMID: 37385170 DOI: 10.1016/j.amjcard.2023.05.053] [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] [Received: 03/19/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 07/01/2023]
Abstract
Women, older adults, and racial/ethnic minorities are differentially affected by lower extremity peripheral artery disease (PAD), yet their representation in randomized controlled trials (RCTs) on which current PAD guidelines are based is not known. We therefore evaluated whether RCTs supporting most recent American Heart Association/American College of Cardiology lower extremity PAD guidelines proportionately represent the spectrum of demographic groups affected by PAD. All PAD-specific RCTs cited in the guidelines were included. From 409 references, 78 RCTs were included, representing 101,359 patients. Pooled proportion of women enrolled was 33% (95% confidence interval 29% to 37%) versus 57.5% in US PAD epidemiologic studies. Pooled mean age of all trial participants was 67.4 ± 0.8 years, in comparison with global estimates of PAD, in which 29.4% of the global population with PAD is >70 years old. Race/ethnicity distribution was reported in 27% of studies (21 of 78). In conclusion, in trials supporting current PAD guidelines, women and older adults patients are underrepresented, and different race and ethnic groups are underreported across the spectrum of studies. Underrepresentation of these groups differentially affected by PAD may limit the generalizability of the evidence supporting PAD guidelines.
Collapse
Affiliation(s)
- Yulanka Castro-Dominguez
- Harrington Heart & Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Miguel Algara
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Vanessa Obas
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Zain Ahmed
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Gaelle Romain
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Khendi White Solaru
- Harrington Heart & Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program (VAMOS), Division of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut.
| |
Collapse
|
21
|
Pokharel Y, Kokkinidis DG, Wang J, Gosch KL, Safley DM, Spertus JA, Mena-Hurtado C, Smolderen KG. Predictors of Revascularization in Lower-Extremity Peripheral Artery Disease: Insights From the PORTRAIT Study. J Endovasc Ther 2023:15266028231179574. [PMID: 37309164 DOI: 10.1177/15266028231179574] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Peripheral artery disease (PAD) guidelines recommend revascularization only for patients with lifestyle-limiting claudication that is refractory to goal-directed medical therapy (class IIA, level of evidence A). However, real-world invasive treatment patterns and predictors of revascularization in patients with symptomatic lower-extremity PAD are still largely unknown. AIM We aimed to examine rates, patient-level predictors, and site variability of early revascularization in patients with new or worsening PAD symptoms. METHODS Among patients with new-onset or recent exacerbation of PAD in the 10-center Patient-centered Outcomes Related to TReatment practices in peripheral Arterial disease: Investigating Trajectories (PORTRAIT) study enrolled between June 2011 and September 2015, we classified early revascularization (endovascular or surgical) as procedures being performed within 3 months of presentation. Hierarchical logistic regression was used to identify patient characteristics associated with early revascularization. Variability across sites was estimated using the median odds ratio (OR). RESULTS Among 797 participants, early revascularization procedures were performed in 224 (28.1%). Rutherford class 3 (vs Rutherford class 1; OR=1.86, 95% confidence interval [CI] 1.04-3.33) and having lesions in both iliofemoral and below-the-knee arterial segments (vs below the knee only; OR=1.75, 95% CI: 1.15-2.67) were associated with a higher odds of revascularization. Longer PAD duration >12 months (vs 1-6 months; OR=0.50, 95% CI: 0.32-0.77), higher ankle-brachial index scores (per 0.1 unit increase; OR=0.86, 95% CI: 0.78-0.96), and higher Peripheral Artery Questionnaire Summary scores (per 10 unit increase; OR=0.89, 95% CI: 0.80-0.99) were associated with a lower odds of revascularization. The raw rates for revascularization in different sites ranged from 6.25% to 66.28%, and the median OR was 1.88, 95% CI: 1.38-3.57. CONCLUSIONS About 1 in 3 patients with symptomatic PAD received early revascularization. A more extensive disease and symptom burden were the main predictors of receiving early revascularization in PAD. There was significant site variability in revascularization patterns, and further studies will better understand the source of this variability and optimal selection criteria for early revascularization. CLINICAL IMPACT Real world patterns and predictors of early revascularization in peripheral artery disease are not well understood. In this retrospective analysis of the POTRAIT study, about 1 out of 3 patients with PAD symptoms received early revascularization, with significant site variability. A more extensive disease and symptom burden were the main predictors of receiving early revascularization in PAD.
Collapse
Affiliation(s)
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital and Yale School of Medicine, Yale University, New Haven, CT, USA
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Medicine and Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Jingyan Wang
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MI, USA
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MI, USA
| | - David M Safley
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MI, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MI, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Medicine and Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Medicine and Yale School of Medicine, Yale University, New Haven, CT, USA
| |
Collapse
|
22
|
Lee M, Smolderen KG, Ionescu C, Hillegass WB, Romain G, Mena-Hurtado C. Lower extremity symptoms and ankle-brachial index screening as predictors of cardiovascular outcomes in Black adults. Vasc Med 2023; 28:197-204. [PMID: 37293738 DOI: 10.1177/1358863x231151729] [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] [Indexed: 11/18/2023]
Abstract
BACKGROUND The prevalence of peripheral artery disease (PAD) and leg symptoms are higher in Black than White adults. We studied the effects of self-reported lower extremity symptoms and ankle-brachial indices (ABI) groups on outcomes. METHODS Black participants in the Jackson Heart Study with baseline ABI and PAD symptom assessments (exertional leg pain by the San Diego Claudication questionnaire) were included. Abnormal ABI was < 0.90 or > 1.40. Participants were divided into (1) normal ABI, asymptomatic, (2) normal ABI, symptomatic, (3) abnormal ABI, asymptomatic, and (4) abnormal ABI, symptomatic to examine their associations with MACE (stroke, myocardial infarction, fatal coronary heart disease) and all-cause mortality, using Kaplan-Meier survival curves and stepwise Cox proportional hazard models adjusting for Framingham risk factors. RESULTS Of 4586 participants, mean age was 54.6 ± 12.6 years, with 63% women. Compared with participants with normal ABI who were asymptomatic, participants with abnormal ABI and leg symptoms had highest risk of MACE (adjusted HR 2.28; 95% CI 1.62, 3.22) and mortality (aHR 1.82; 95% CI 1.32, 2.56). Participants with abnormal ABI without leg symptoms had higher risk for MACE (aHR 1.49; 95% CI 1.06, 2.11) and mortality (aHR 1.44; 95% CI 1.12, 1.99). Participants with normal ABI and no leg symptoms did not have higher risks. CONCLUSION Among Black adults, the highest risk for adverse outcomes were in symptomatic participants with abnormal ABIs, followed by asymptomatic participants with abnormal ABIs. These findings underscore the need for further studies to screen for PAD and develop preventative approaches in Black adults with asymptomatic disease.
Collapse
Affiliation(s)
- Megan Lee
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kim G Smolderen
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Costin Ionescu
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - William B Hillegass
- Departments of Data Science and Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Gaelle Romain
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
23
|
Smolderen KG, Heath K, Ameli O, Spencer D, Natwick T, Musich S, Miedico TM, Mena-Hurtado C. In-home Visits and Subsequent Health Outcomes in Medicare Advantage Beneficiaries With Coronary Artery Disease, Diabetes, Hypertension, and Depression. Med Care 2023; 61:366-376. [PMID: 37167558 DOI: 10.1097/mlr.0000000000001850] [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: 05/13/2023]
Abstract
BACKGROUND Coronary artery disease, diabetes, hypertension, and depression are common burdensome conditions. OBJECTIVES To examine whether multidimensional preventive in-home visits were associated with fewer emergency and inpatient care episodes and higher quality of care. RESEARCH DESIGN An observational, retrospective data analysis. SUBJECTS A nationwide Medicare Advantage population from the Optum Labs Data Warehouse. MEASURES We compared beneficiaries with 1 or more of the conditions with an in-home visit in 2018 ("Exposure") with those without a visit in 2018 but with a future visit in 2019 ("Wait List Control") using a difference-in-differences analysis. Primary outcomes were 1-year all-cause inpatient care and emergency visit counts. Secondary outcomes included primary care visits, major adverse cardiovascular events, and select quality-of-care metrics. An exploratory outcome was the time-to-first primary care visit after the index date. RESULTS Among those eligible to receive an in-home visit, a total of 48,566 patients had an in-home visit in 2018 (the "Exposure" group), and 36,549 beneficiaries constituted the "Wait List" control group. Receiving an in-home visit early was associated with a greater decrease in inpatient stays for all 4 conditions (change score range for any stay: -5.22% to -2.47%) (P<0.001, depression <0.05); decrease in emergency visits (change score range for any stay: -4.39% to -3.67%) (P<0.0.001, depression <0.05); and fewer major adverse cardiovascular events for coronary artery disease and depression (P<0.001 and <0.025, respectively) 1 year later. Minimal differences were noted for change in ambulatory and primary care visits, with no consistent increase in quality-of-care metrics. Time-to-first primary care visit was shorter for the "Exposure" versus the Wait List control group in all conditions (difference between 2.45 and 4.95 d). CONCLUSIONS The feasibility and impact of a nationwide multidimensional preventive in-home visit were demonstrated, targeting common and high morbidity conditions. Benefits were observed against a Wait List control group, resulting in less resource-intense care.
Collapse
Affiliation(s)
- Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Department of Internal Medicine, Cardiovascular Medicine Section, Yale School of Medicine, New Haven, CT
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | | | | | | | | | | | | | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Department of Internal Medicine, Cardiovascular Medicine Section, Yale School of Medicine, New Haven, CT
| |
Collapse
|
24
|
Castro-Dominguez Y, Smolderen KG, Mena-Hurtado C. The problem of disparities in vascular health. Vasc Med 2023; 28:179-181. [PMID: 37293740 DOI: 10.1177/1358863x231178044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Yulanka Castro-Dominguez
- Harrington Heart & Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - Kim G Smolderen
- Department of Medicine, Division of Cardiology, Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Department of Medicine, Division of Cardiology, Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
25
|
Scierka LE, Peri-Okonny PA, Romain G, Mena-Hurtado C, Smolderen KG. Obesity prevalence and variability in management practices for patients with symptomatic peripheral artery disease. Obes Res Clin Pract 2023:S1871-403X(23)00039-X. [PMID: 37225553 DOI: 10.1016/j.orcp.2023.05.002] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/26/2023]
Abstract
Obesity has been associated with poor disease outcomes in patients with lower extremity peripheral arterial disease (PAD). Given evolving treatments for obesity, evaluating its prevalence and treatment practices are key to develop a holistic management of PAD. We aimed to examine prevalence of obesity and variability of management strategies in symptomatic PAD patients enrolled in the international multicenter PORTRAIT registry from 2011 to 2015. Obesity management strategies studied included weight and/or dietary counseling and prescription of weight loss medications (orlistat, lorcaserin, phentermine-topiramate, naltrexone-buproprion, and liraglutide). Use frequency of obesity management strategies were calculated by country and compared across centers using adjusted median odds ratios (MOR). Of 1002 patients included, 36 % had obesity. No patients received weight loss medications. Weight and/or dietary counseling was prescribed in only 20 % of patients with obesity with significant variability in practices between centers (range 0.0-39.7 %; MOR 3.6, 95 % CI 2.04-9.95, p = < 0.001). In conclusion, obesity is a prevalent modifiable comorbidity in PAD that is hardly addressed during PAD management, with significant variability across practices. As obesity prevalence rates are growing, along with treatment modalities to treat it, especially in those with PAD, building systems to integrate systematic evidence-based weight and dietary management strategies in PAD are essential to close this gap in care.
Collapse
Affiliation(s)
- Lindsey E Scierka
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, United States of America
| | - Poghni A Peri-Okonny
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, United States of America
| | - Gaelle Romain
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, United States of America
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, United States of America
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, United States of America; Department of Psychiatry, Yale University, New Haven, CT, United States of America.
| |
Collapse
|
26
|
Hanna J, Smolderen KG, Castro‐Dominguez Y, Romain G, Lee M, Turner J, Mena‐Hurtado C. Drug-Coated Balloon and Drug-Eluting Stent Safety in Patients With Femoropopliteal and Severe Chronic Kidney Disease. J Am Heart Assoc 2023; 12:e028622. [PMID: 36974774 PMCID: PMC10122876 DOI: 10.1161/jaha.122.028622] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/22/2023] [Indexed: 03/29/2023]
Abstract
Background Patients with severe-stage chronic kidney disease (CKD) were excluded from femoropopliteal disease trials evaluating drug-coated balloons (DCBs) and drug-eluting stents (DESs) versus plain balloon angioplasty (POBA) and bare metal stents (BMSs). We examined the interaction between CKD status and device type for the association with 24-month all-cause mortality and major amputation risk. Methods and Results We studied patients undergoing femoropopliteal interventions (September 2016-December 2018) from Medicare-linked VQI (Vascular Quality Initiative) registry data. We compared outcomes for: (1) early-stage CKD (stages 1-3) receiving DCB/DES, (2) early-stage CKD receiving POBA/BMS, (3) severe-stage (4 and 5) CKD receiving DCB/DES, and (4) severe-stage CKD receiving POBA/BMS. We studied 8799 patients (early-stage CKD: 94%; severe-stage: 6%). DCB/DES use was 57% versus 51% in patients with early-stage versus severe-stage CKD. Twenty-four-month mortality risk for patients with early-stage CKD receiving DCB/DES (reference) was 21% versus 28% (hazard ratio [HR], 1.47 [95% CI, 1.31-1.65]) for those receiving POBA/BMS; patients with severe-stage CKD: those receiving DCB/DES had a 49% (HR, 2.61 [95% CI, 2.06-3.31]) mortality risk versus 52% (HR, 3.64 [95% CI, 2.91-4.55]) for those receiving POBA/BMS (interaction P<0.001). Adjusted analyses attenuated these results. For severe-stage CKD, DCB/DES versus POBA/BMS mortality risk was not significant at 24 months (post hoc comparison P=0.06) but was higher for the POBA/BMS group at 18 months (post hoc P<0.05). Patients with early-stage CKD receiving DCB/DES had the lowest 24-month amputation risk (6%), followed by 11% for early-stage CKD-POBA/BMS, 15% for severe-stage CKD-DCB/DES, and 16% for severe-stage CKD-POBA/BMS (interaction P<0.001). DCB/DES versus POBA/BMS amputation rates in patients with severe-stage CKD did not differ (post hoc P=0.820). Conclusions DCB/DES versus POBA/BMS use in patients with severe-stage CKD was associated with lower mortality and no difference in amputation outcomes.
Collapse
Affiliation(s)
- Jonathan Hanna
- Department of MedicineYale School of MedicineNew HavenCTUSA
| | - Kim G. Smolderen
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of MedicineYale School of MedicineNew HavenCTUSA
- Department of PsychiatryYale School of MedicineNew HavenCTUSA
| | - Yulanka Castro‐Dominguez
- Harrington Heart & Vascular InstituteUniversity Hospitals, Case Western Reserve UniversityClevelandOHUSA
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of MedicineYale School of MedicineNew HavenCTUSA
| | - Megan Lee
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of MedicineYale School of MedicineNew HavenCTUSA
| | - Jeffrey Turner
- Section of Nephrology, Department of Internal MedicineYale School of MedicineNew HavenCTUSA
| | - Carlos Mena‐Hurtado
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of MedicineYale School of MedicineNew HavenCTUSA
- Section of Cardiovascular Medicine, Department of Internal MedicineYale School of MedicineNew HavenCTUSA
| |
Collapse
|
27
|
Smolderen KG, Samaan Z, Ward-Zimmerman B, Fucito L, Goodney P, Le V, Abu Daya H, McNeal DM, Bonaca M, Mena-Hurtado C. Integrating Psychosocial Care in the Management of Patients With Vascular Disease. J Am Coll Cardiol 2023; 81:1201-1204. [PMID: 36948738 PMCID: PMC10514776 DOI: 10.1016/j.jacc.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/04/2023] [Accepted: 01/19/2023] [Indexed: 03/24/2023]
Affiliation(s)
- Kim G Smolderen
- School of Medicine, Department of Internal Medicine, Cardiovascular Medicine Section, Vascular Medicine Outcomes Program, Yale University, New Haven, Connecticut, USA; School of Medicine, Department of Psychiatry, Psychology Section, Yale University, New Haven, Connecticut, USA.
| | - Zainab Samaan
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Barbara Ward-Zimmerman
- CT Psychological Association's Health Care Reform Task Force, North Haven, Connecticut, USA
| | - Lisa Fucito
- School of Medicine, Department of Psychiatry, Psychology Section, Yale University, New Haven, Connecticut, USA
| | - Philip Goodney
- Department of Surgery, The Dartmouth Institute, Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Viet Le
- Department of Cardiovascular Research, Intermountain Healthcare, Intermountain Heart Institute, Murray, Utah, USA
| | - Hussein Abu Daya
- Department of Internal Medicine, Cardiovascular Diseases Division, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Demetria M McNeal
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Marc Bonaca
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Carlos Mena-Hurtado
- School of Medicine, Department of Internal Medicine, Cardiovascular Medicine Section, Vascular Medicine Outcomes Program, Yale University, New Haven, Connecticut, USA. https://twitter.com/CarlosMenaYale
| |
Collapse
|
28
|
Lee M, Pichert MD, Tran AT, Farooq A, Heyligers JM, de Vries JPPM, Spertus JA, Guzman RJ, Thomas M, Mena-Hurtado CI, Smolderen KG. Real-world abdominal aorta aneurysm screening patterns among patients with new or worsening of symptomatic peripheral artery disease. Int J Cardiol 2023; 375:94-97. [PMID: 36577485 PMCID: PMC10371801 DOI: 10.1016/j.ijcard.2022.12.042] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/23/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) have an increased risk of abdominal aortic aneurysms (AAA), but it remains unclear whether practitioners are screening patients for AAA as part of routine PAD management. METHODS The Patient-centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease (PORTRAIT) Registry is an international prospective registry of patients with new or worsening PAD symptoms presenting to 16 specialty centers in the United States, Netherlands, and Australia, from June 2011 to December 2015. Patients were stratified by AAA screening or AAA positivity. An adjusted median odds ratio was calculated for AAA screening rates across sites. RESULTS Of the 1275 patients in the study, 871 (68%) were screened for AAA, with 53 (6.1%) having AAA. AAA screening rates did not differ significantly by country (p = 0.36), but there was a large variation across sites for documentation of AAA screening with an adjusted median odds ratio 12.0 (95% CI 4.7-93.1), with AAA screening rates ranging from 7% to 100% across vascular specialty centers. CONCLUSIONS Among patients with PAD in a multicenter registry, over two-thirds were screened for AAA, with 6% having documented aneurysms. A large variation was seen across clinical sites, suggesting efforts are needed to increase awareness for guideline implementation and establish new benefit-risk evidence inclusive of high-risk populations such as patients with PAD.
Collapse
Affiliation(s)
- Megan Lee
- Vascular Medicine Outcomes Program at Yale University, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Matthew D Pichert
- Vascular Medicine Outcomes Program at Yale University, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Andy T Tran
- Cardiovascular Research, St Luke's Mid America Heart Institute, Kansas City, MO, United States of America; School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States of America
| | - Awais Farooq
- Department of Medicine, Southeast Health Medical Center, Dothan, AL, United States of America
| | - Jan M Heyligers
- Department of Vascular Surgery, Elisabeth TweeSteden Hospital, Tilburg, the Netherlands
| | | | - John A Spertus
- Cardiovascular Research, St Luke's Mid America Heart Institute, Kansas City, MO, United States of America; School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States of America
| | - Raul J Guzman
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States of America
| | - Merrill Thomas
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States of America
| | - Carlos I Mena-Hurtado
- Vascular Medicine Outcomes Program at Yale University, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program at Yale University, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States of America.
| |
Collapse
|
29
|
Smolderen KG, Romain G, Provance JB, Scierka LE, Mao J, Goodney PP, Henke PK, Sedrakyan A, Mena-Hurtado C. Guideline-Directed Medical Therapy and Long-Term Mortality and Amputation Outcomes in Patients Undergoing Peripheral Vascular Interventions. JACC Cardiovasc Interv 2023; 16:332-343. [PMID: 36792257 PMCID: PMC10359106 DOI: 10.1016/j.jcin.2022.09.022] [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: 06/22/2022] [Revised: 08/29/2022] [Accepted: 09/13/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Lack of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) may increase mortality and amputation risk. OBJECTIVES The authors sought to study the association between GDMT and mortality/amputation and to examine GDMT variability among providers and health systems. METHODS We performed an observational study using patients in the Vascular Quality Initiative registry undergoing PVI between 2017 and 2018. Two-year all-cause mortality and major amputation data were derived from Medicare claims data. Compliance with GDMT was defined as receiving a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker if hypertensive. Propensity 1:1 matching was applied for GDMT vs no GDMT and survival analyses were performed to compare outcomes between groups. RESULTS Of 15,891 patients undergoing PVIs, 48.8% received GDMT and 6,120 patients in each group were matched. Median follow-up was 9.6 (IQR: 4.5-16.2) months for mortality and 8.4 (IQR: 3.5-15.4) for amputation. Mean age was 72.0 ± 9.9 years. Mortality risk was higher among patients who did not receive GDMT versus those on GDMT (31.2% vs 24.5%; HR: 1.37, 95% CI: 1.25-1.50; P < 0.001), as well as, risk of amputation (16.0% vs 13.2%; HR: 1.20; 95% CI: 1.08-1.35; P < 0.001). GDMT rates across sites and providers ranging from 0% to 100%, with lower performance translating into higher risk. CONCLUSIONS Almost one-half of the patients receiving PVI in this national quality registry were not on GDMT, and this was associated with increased risk of mortality and major amputation. Quality improvement efforts in vascular care should focus on GDMT in patients undergoing PVI.
Collapse
Affiliation(s)
- Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Psychology Section, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeremy B Provance
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lindsey E Scierka
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jialin Mao
- Population Health Sciences, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Phillip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Dartmouth College, Lebanon, New Hampshire, USA
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Art Sedrakyan
- Population Health Sciences, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
30
|
Harris KM, Mena-Hurtado C, Burg MM, Vriens PW, Heyligers J, Smolderen KG. Association of depression and anxiety disorders with outcomes after revascularization in chronic limb-threatening ischemia hospitalizations nationwide. J Vasc Surg 2023; 77:480-489. [PMID: 36115521 DOI: 10.1016/j.jvs.2022.09.008] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/01/2022] [Accepted: 09/03/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Patients with chronic limb-threatening ischemia (CLTI), the end stage of peripheral artery disease, often present with comorbid depression and anxiety disorders. The prevalence of these comorbidities in the inpatient context over time, and their association with outcomes after revascularization and resource usage is unknown. METHODS Using the 2011 to 2017 National Inpatient Sample, two cohorts were created-CLTI hospitalizations with endovascular revascularization and CLTI hospitalizations with surgical revascularization. Within each cohort, the annual prevalence of depression and anxiety disorder diagnoses was determined, and temporal trends were evaluated using the Cochran-Mantel-Haenszel test. Hierarchical multivariable logistic and linear regression analyses were used to examine the association of depression and anxiety disorder diagnoses with inpatient major amputation, mortality, length of stay (LOS), and cost, adjusting for illness severity, comorbidities, and potential bias in the documentation of depression and anxiety disorder diagnoses stratified by patient sociodemographic data. RESULTS Across the study period were a total of 245,507 CLTI-related hospitalizations with endovascular revascularization and 138,922 with surgical revascularization. Hospitalizations with a depression or anxiety disorder diagnosis increased from 10.8% in 2011 to 15.3% in 2017 in the endovascular revascularization cohort and from 11.7% in 2011 to 14.4% in 2017 in the surgical revascularization cohort (Ptrend < .001). In the endovascular revascularization cohort, depression was associated with higher odds of major amputation (odds ratio, 1.15; 95% confidence interval, 1.03-1.30). In addition, depression (9 vs 8 days [P < .001]; $105,754 vs $102,481 [P = .018]) and anxiety disorder (9 vs 8 days [P < .001]; $109,496 vs $102,324 [P < .001]) diagnoses were associated with a longer median LOS and higher median costs. In the surgical revascularization cohort, depression was associated with a higher odds of major amputation (odds ratio, 1.33; 95% confidence interval, 1.13-1.58) and a longer LOS (median, 9 vs 9 days; P = .004). CONCLUSIONS Depression and anxiety disorder diagnoses have become increasingly prevalent among CLTI hospitalizations including revascularizations. When present, these psychiatric comorbidities are associated with an increased risk of amputation and greater resource usage.
Collapse
Affiliation(s)
- Kristie M Harris
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Matthew M Burg
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Department of Cardiology, Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Patrick W Vriens
- Department of Surgery, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands; Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Jan Heyligers
- Department of Surgery, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT.
| |
Collapse
|
31
|
Luna P, Harris K, Castro-Dominguez Y, Algara M, Severiche-Mena C, Smolderen KG, Mena-Hurtado C. Risk profiles, access to care, and outcomes in Hispanics hospitalized for lower extremity peripheral artery disease. J Vasc Surg 2023; 77:216-224.e15. [PMID: 36037965 DOI: 10.1016/j.jvs.2022.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 06/23/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Previous studies have shown that Hispanics have worse clinical outcomes for lower extremity peripheral artery disease (PAD) than non-Hispanic White (NHWs). Using a national database, this study aimed to document the contemporary burden of PAD in Hispanics by evaluating their risk profiles, access to care, and outcomes compared with NHWs. METHODS Hospitalizations of Hispanics and NHWs with a primary diagnosis of PAD were identified using 2011-2017 National Inpatient Sample data. Patient sociodemographic characteristics, comorbidities, whether the admission was through the emergency department (ED) or elective, length of stay, and costs accrued were compared by ethnicity. Temporal trends in revascularizations, amputations, and ED admissions by year were evaluated with the Cochran-Mantel-Haenszel test and stratified by ethnicity. Data were combined across years and multivariable logistic regression was used to evaluate the association of ethnicity with inpatient revascularization, amputation, and mortality, adjusting for sociodemographic and cardiovascular risk factors. RESULTS From 2011 to 2017, there were a total of 1,018,220 PAD hospitalizations among Hispanics (13.9%) and NHWs (86.1%) between 2011 and 2017. Hispanics were more often low income and uninsured and presented with higher burden of comorbidities including diabetes, renal failure, prior amputations, and chronic limb-threatening ischemia compared with NHWs. Most Hispanics were admitted via the ED compared with NHWs (58.0% vs 36.7%; d = 0.48), and median length of stay was almost a day longer (4.5 days vs 3.7 days). Hispanic ethnicity was associated with lower odds of surgical (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.57-0.67) and endovascular revascularization (OR, 0.94; 95% CI, 0.89-0.996) and mortality (OR, 0.83; 95% CI, 0.75-0.93), but higher odds of minor (OR, 1.25; 95% CI, 1.20-1.31) and major (OR, 1.08; 95% CI, 1.03-1.14) amputation. CONCLUSIONS Two tiers of health care consumption for inpatient PAD care and outcomes manifested among Hispanics and NHWs. First, Hispanics with PAD had a more vulnerable socioeconomic profile and presented with more severe PAD than NHWs. Second, they sought care more disproportionately through the ED and underwent more amputations than NHWs. To eradicate these inequities in PAD care and risk, strategies that improve access to outpatient care and expand health care coverage, as well as targeted management of risk factors in these vulnerable minority groups are needed.
Collapse
Affiliation(s)
- Paulina Luna
- Yale University School of Medicine, New Haven, CT; Weill Cornell Medicine, New York, NY
| | | | - Yulanka Castro-Dominguez
- Yale University School of Medicine, New Haven, CT; Case Western Reserve University, Cleveland, OH
| | | | | | | | | |
Collapse
|
32
|
Scierka LE, Mena-Hurtado C, Ahmed ZV, Yousef S, Arham A, Grimshaw AA, Harris KM, Burg M, Vriens PW, Heyligers J, Lee M, Yazgan I, Smolderen KG. The association of depression with mortality and major adverse limb event outcomes in patients with peripheral artery disease: A systematic review and meta-analysis. J Affect Disord 2023; 320:169-177. [PMID: 36179780 DOI: 10.1016/j.jad.2022.09.098] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 02/14/2022] [Revised: 08/28/2022] [Accepted: 09/20/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Peripheral artery disease (PAD) is highly prevalent and associated with poor outcomes. Depression is a risk factor for adverse outcomes in patients with coronary artery disease. Despite evidence showing that depression is common in patients with PAD, less is known about its association with adverse prognostic outcomes. To address this, we conducted a systematic review and meta-analysis to summarize the association between depression and outcomes in patients with PAD. METHODS We performed a systematic search of eight databases to January 2022 including studies that reported a risk estimate for the association of depression or depressive symptoms with all-cause mortality or major adverse limb events (MALE) in patients with PAD and pooled results in a meta-analysis. Risk of bias was assessed using ROBINS-I. RESULTS Of the 7048 articles screened, 5 observational studies with 119,123 patients were included. A total of 16.2 % had depression or depressive symptoms. Depression was associated with a statistically significant increased risk of all-cause mortality (HR 1.24, confidence interval 1.07-1.25, p = .005). The association between depression and MALE was not significant but trended toward a positive association. LIMITATIONS Due to lack of data, results were limited by a single study with a large sample size, overrepresentation of men, and lack of information of depression severity or treatment status. CONCLUSION Depression or depressive symptoms are associated with a 24 % increased risk of all-cause mortality in patients with PAD. Future work should explore the mechanisms and directionality of this association and identify depression as an important comorbidity to address for patients with PAD. REGISTRATION PROSPERO CRD 42021223694.
Collapse
Affiliation(s)
- Lindsey E Scierka
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Zain V Ahmed
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sameh Yousef
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ahmad Arham
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Alyssa A Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Kristie M Harris
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Matthew Burg
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Patrick W Vriens
- Department of Surgery, St. Elisabeth Hospital, Tilburg, the Netherlands
| | - Jan Heyligers
- Department of Surgery, St. Elisabeth Hospital, Tilburg, the Netherlands
| | - Megan Lee
- Yale School of Medicine, New Haven, CT, USA
| | | | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
33
|
Luna P, Lee M, Vergara Greeno R, DeLucia N, London Y, Hoffman P, Burg M, Harris K, Spatz ES, Mena-Hurtado C, Smolderen KG. Telehealth care before and during COVID-19: trends and quality in a large health system. JAMIA Open 2022; 5:ooac079. [PMID: 36204596 PMCID: PMC9531686 DOI: 10.1093/jamiaopen/ooac079] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 07/26/2022] [Accepted: 09/29/2022] [Indexed: 11/14/2022] Open
Abstract
Objective COVID-19 accelerated telehealth use to ensure care delivery, but there is limited data on the patient perspective. This study aimed to examine telehealth visit uptake before and during COVID-19 and correlates of patient satisfaction and interest in future telehealth visits. Materials and Methods This was a cross-sectional observational study between October 2019 and April 2020. Participants included patients who completed satisfaction surveys following telehealth visits. Results A total of 8930 patients completed the satisfaction survey using 4-point Likert Scales. Multivariable, hierarchical, cumulative logit models were constructed to examine correlates of satisfaction with quality of care and interest in future telehealth visits. Most patients were satisfied with the patient portal, video quality, and instructions (92.7%-96.8%). Almost half reported saving 1-2 h (46.9%). Correlates positively associated with quality of care and interest in future telehealth visits were ease of patient portal (odds ratio [OR], 1.43, 95% confidence interval [CI], 1.30-1.58; OR, 1.56, 95% CI, 1.41-1.73, respectively), video quality (OR, 1.62, 95% CI, 1.50-1.75; OR, 1.26, 95% CI, 1.16-1.37, respectively), instructions (OR, 5.62, 95% CI, 5.05-6.26; OR, 1.80, 95% CI, 1.62-2.01, respectively), and time saved (>4 h: OR, 1.69, 95%,CI, 1.22-2.34; OR, 3.49, 95% CI, 2.47-4.93, respectively). Being seen after the COVID-19 surge in telehealth (OR, 0.76, 95% CI, 0.63-0.93) or by providers with higher visit volume (OR, 0.71, 95% CI, 0.60-0.85) was associated with lower interest in future telehealth visits. Conclusions Patients expressed relatively high satisfaction levels with telehealth. Better technical quality, quality of instructions, and greater time saved were associated with higher satisfaction ratings. To maintain interest in future telehealth use and improve the patient experience, we must enhance the quality of telehealth delivery platforms and instructions provided to patients.
Collapse
Affiliation(s)
- Paulina Luna
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Megan Lee
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Pamela Hoffman
- Department of Child Psychiatry, Yale University, New Haven, Connecticut, USA
| | - Matthew Burg
- Department of Internal Medicine—Cardiology, Yale University, New Haven, Connecticut, USA
| | - Kristie Harris
- Department of Internal Medicine—Cardiology, Yale University, New Haven, Connecticut, USA
| | - Erica S Spatz
- Department of Internal Medicine—Cardiology, Yale University, New Haven, Connecticut, USA
| | - Carlos Mena-Hurtado
- Department of Internal Medicine—Cardiology, Yale University, New Haven, Connecticut, USA
| | - Kim G Smolderen
- Corresponding Author: Kim G. Smolderen, PhD, Department of Internal Medicine, Section of Cardiovascular Medicine, Vascular Medicine Outcomes Program (VAMOS), Yale University, 789 Howard Ave, New Haven, CT 06520, USA;
| |
Collapse
|
34
|
Smolderen KG, Mena-Hurtado C, Eikelboom JW, Bosch J, Xie F, Ramasundarahettige C, Bhatt DL, Anand SS. Health Status and Cognitive Function for Risk Stratification in Chronic Coronary and Peripheral Artery Disease. Eur J Prev Cardiol 2022; 30:535-545. [PMID: 36444513 DOI: 10.1093/eurjpc/zwac282] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/21/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS It is unclear whether health status and cognitive function assessments can augment traditional coronary artery disease (CAD) and peripheral artery disease (PAD) biomedical risk prediction frameworks. We examined the association between health status and cognitive function and subsequent adverse cardiovascular and limb events in CAD and PAD. METHODS Stable CAD and PAD patients from the international, multi-center COMPASS trial completed the visual analogue scale, (VAS) of the EQ-5D-3L to assess overall health status, and the Digit Symbol Substitution test (DSST) to assess cognitive function. Main outcomes were incident development of major adverse cardiovascular events, and the combined endpoint major adverse cardiovascular or limb events. The EQ VAS (per 10 unit increase) and DSST (per 5 unit increase) were added to fully adjusted (medications, demographics, cardiovascular history and risk factors) hierarchical Cox regression models. RESULTS A total of 23,433 patients were in the CAD cohort and 6,899 in the PAD cohort. Among both the CAD and PAD groups, higher scores on the EQ VAS (CAD: HR = 0.89, 95%CI 0.88-0.89; PAD HR = 0.89, 95%CI 0.88-0.89) and DSST (CAD HR = 0.95, 95%CI 0.94-0.95) (PAD HR = 0.95, 95%CI 0.94-0.95) were associated with a lower risk of a major adverse cardiovascular or limb events. Population attributable risks associated with the lower two quartiles vs. upper quartiles for the EQ-5D and DSST scores were 7% and 16%, respectively in the CAD cohort; and for PAD, at 14% and 18%, respectively. CONCLUSIONS Adding health status and cognitive functioning information to biomedical evaluations can augment cardiovascular risk-stratification in CAD and PAD.
Collapse
Affiliation(s)
- Kim G Smolderen
- Yale University, School of Medicine, Department of Internal Medicine, Vascular Medicine Outcomes Program, New Haven, CT @KimGSmolderen.,Yale University, School of Medicine, Department of Psychiatry, New Haven, CT
| | - Carlos Mena-Hurtado
- Yale University, School of Medicine, Department of Internal Medicine, Vascular Medicine Outcomes Program, New Haven, CT @CarlosMenaYale
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University @johneikelboom
| | - Jackie Bosch
- Department of Medicine McMaster University, Hamilton Ontario.,School of Rehabilitation Science, McMaster University, Hamilton, Ontario
| | - Feng Xie
- Population Health Research Institute, Hamilton Health Sciences, McMaster University.,Centre for Health Economics and Policy Analysis, McMaster University, Ontario, Canada
| | - Chinthanie Ramasundarahettige
- Population Health Research Institute, Hamilton Health Sciences, McMaster University.,McMaster University, Department of Health Evidence and Impact, Hamilton, Ontario
| | - Deepak L Bhatt
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts @DLBhattMD
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences, McMaster University @DrSoniaAnand1.,Department of Medicine McMaster University, Hamilton Ontario.,McMaster University, Department of Health Evidence and Impact, Hamilton, Ontario
| |
Collapse
|
35
|
Smolderen KG, Alabi O, Collins TC, Dennis B, Goodney PP, Mena-Hurtado C, Spertus JA, Decker C. Advancing Peripheral Artery Disease Quality of Care and Outcomes Through Patient-Reported Health Status Assessment: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e286-e297. [PMID: 36252117 DOI: 10.1161/cir.0000000000001105] [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: 01/24/2023]
Abstract
Peripheral artery disease (PAD) is chronic in nature, and individualized chronic disease management is a central focus of care. To accommodate this reality, tools to measure the impact and quality of the PAD care delivered are necessary. Patient-reported outcomes (PROs) and instruments to measure them, that is, PRO measures, have been well studied in the research and clinical trial context, but a shift toward integrating them into clinical practice has yet to take place. A framework to use PRO measures as indicators of the quality of PAD care delivered, that is, PRO performance measures (PRO-PMs), is provided in this scientific statement. Measurement goals to consider by PAD clinical phenotypes are provided, as well as an overview of potential benefits of adopting PRO-PMs in the clinical practice of PAD care, including reducing unwanted variability and promoting health equity. A central discussion with considerations for risk adjustment of PRO-PMs, individualized PAD care, and the need for patient engagement strategies is offered. Furthermore, necessary conditions in terms of required competencies and training to handle PRO-PM data are discussed because the interpretation and handling of these data come with great responsibility and consequences for designing care that adopts a broader framework of risk that goes beyond the inclusion of biomedical variables. To conclude, health system perspectives and an agenda to reach the next steps in the implementation of PRO-PMs in PAD care are offered.
Collapse
|
36
|
Lee M, Ahmed ZV, Huang J, Brice A, Arham A, Castro-Dominguez Y, Aboian E, Nagpal S, Smolderen KG, Mena-Hurtado C. Antiplatelet regimens following carotid artery revascularization. Am Heart J 2022; 253:48-52. [PMID: 35863439 DOI: 10.1016/j.ahj.2022.07.004] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
Dual antiplatelet therapy (DAPT) is indicated following carotid artery stenting (CAS) and single antiplatelet therapy (SAPT) following carotid endarterectomy (CEA), but it remains unknown how providers adhere to these guidelines in real-world clinical practice. Using the Vascular Quality Initiative New England data, we found that of 12,257 patients, 82% patients were discharged on DAPT following CAS and 66% were discharged on SAPT following CEA. While a high percentage of patients undergoing CAS appropriately receive DAPT, the use of SAPT following CEA exists with more variability and lower adherence rates.
Collapse
Affiliation(s)
- Megan Lee
- Yale School of Medicine, Yale New Haven Health System, CT
| | - Zain V Ahmed
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Jiaming Huang
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Aaron Brice
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Ahmad Arham
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Yulanka Castro-Dominguez
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Edouard Aboian
- Department of Vascular Surgery, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Sameer Nagpal
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Department of Vascular Surgery, Yale New Haven Health System, Yale School of Medicine, New Haven, CT; Department of Psychiatry, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT.
| |
Collapse
|
37
|
Malik AO, Jones PG, Mena-Hurtado C, Burg MM, Shishehbor MH, Hejjaji V, Tran A, Spertus JA, Smolderen KG. Derivation and validation of a predictive model for chronic stress in patients with cardiovascular disease. PLoS One 2022; 17:e0275729. [PMID: 36256655 PMCID: PMC9578618 DOI: 10.1371/journal.pone.0275729] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/22/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Chronic stress in patients with cardiovascular disease (CVD), including peripheral artery disease (PAD), is independently associated worse outcomes. A model that can reliably identify factors associated with risk of chronic stress in patients with CVD is needed. METHODS In a prospective myocardial infarction (MI) registry (TRIUMPH), we constructed a logistic regression model using 27 patient demographic, socioeconomic, and clinical factors, adjusting for site, to identify predictors of chronic stress over 1 year. Stress at baseline and at 1-, 6- and 12-month follow-up was measured using the 4-item Perceived Stress Scale (PSS-4) [range 0-16, scores ≥6 depicting high stress]. Chronic stress was defined as at least 2 follow-up PSS-4 scores ≥6. We identified and validated this final model in another prospective registry of patients with symptomatic PAD, the PORTRAIT study. RESULTS Our derivation cohort consisted of 4,340 patients with MI (mean age 59.1 ± 12.3 years, 33% females, 30% non-white), of whom 30% had chronic stress at follow-up. Of the 27 factors examined, female sex, current smoking, socioeconomic status, and economic burden due to medical care were positively associated with chronic stress, and ENRICHD Social Support Instrument (ESSI) score and age were inversely related to chronic stress. In the validation cohort of 797 PAD patients (mean age 68.6±9.7 years, 42% females, 28% non-white, 18% chronic stress) the c-statistic for the model was 0.77 and calibration was excellent. CONCLUSIONS We can reliably identify factors that are independently associated with risk of chronic stress in patients with CVD. As chronic stress is associated with worse outcomes in this population, our work identifies potential targets for interventions to as well as the patients that could benefit from these.
Collapse
Affiliation(s)
- Ali O. Malik
- Saint Luke’s’ Mid America Heart Institute, Kansas City, MO, United States of America
- University of Missouri Kansas City, Kansas City, MO, United States of America
| | - Philip G. Jones
- Saint Luke’s’ Mid America Heart Institute, Kansas City, MO, United States of America
- University of Missouri Kansas City, Kansas City, MO, United States of America
| | | | - Matthew M. Burg
- Yale School of Medicine, New Haven, CO, United States of America
| | | | - Vittal Hejjaji
- Saint Luke’s’ Mid America Heart Institute, Kansas City, MO, United States of America
- University of Missouri Kansas City, Kansas City, MO, United States of America
| | - Andy Tran
- Saint Luke’s’ Mid America Heart Institute, Kansas City, MO, United States of America
- University of Missouri Kansas City, Kansas City, MO, United States of America
| | - John A. Spertus
- Saint Luke’s’ Mid America Heart Institute, Kansas City, MO, United States of America
- University of Missouri Kansas City, Kansas City, MO, United States of America
| | - Kim G. Smolderen
- Yale School of Medicine, New Haven, CO, United States of America
- * E-mail:
| |
Collapse
|
38
|
Nagpal S, Scierka LE, Castro-Dominguez Y, Kansal D, Kunnirickal S, Hussain Y, Love K, Aboian E, Smolderen KG, Mena-Hurtado C. Real-world VASCADE closure device versus manual compression use and outcomes in patients with severe common femoral artery disease. Catheter Cardiovasc Interv 2022; 100:776-784. [PMID: 36129818 DOI: 10.1002/ccd.30405] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/01/2022] [Accepted: 09/06/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND The VASCADE closure device deploys an extravascular collagen plug. Its use in those with access site disease undergoing peripheral vascular intervention (PVI) is unknown. We aimed to evaluate the efficacy and safety of the VASCADE closure device compared to manual compression (MC) in patients with moderate femoral access site disease. METHODS We performed a single-center, retrospective review of patients undergoing PVI with at least moderate access site disease. Our institutional database was linked to the Vascular Quality Initiative database, and 200 patients were selected from a 1:1 propensity-matched cohort. Data on procedural metrics and outcomes up to 30-days were abstracted. RESULTS There were 103 procedures that used VASCADE and 97 used MC. Baseline variables were similar between groups. The mean age was 68.2 ± 11.2 years and 37.6% were women. Closing mean activated clotting time (ACT) was shorter in VASCADE (198 s VASCADE vs. 213 s MC; p = 0.018). There was a nonsignificant decrease in external compression device use with VASCADE (VASCADE 19.0% vs. MC 28.1%; p = 0.15). At 30-days, there was a nonsignificant reduction in hematoma with VASCADE (3.8% vs. 7.8% MC; p = 0.25) and no difference in retroperitoneal bleeding (0.5%). Pseudoaneurysm rate was similar (1.3% VASCADE vs. 1.7% MC; p = 0.79). The 30-day mortality rate was similar between the two groups and not related to the procedure (1.3% VASCADE vs. 0.9% MC; p = 0.79). CONCLUSION In patients undergoing PVI with at least moderate access site disease, safety and efficacy after using VASCADE was comparable with MC.
Collapse
Affiliation(s)
- Sameer Nagpal
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Lindsey E Scierka
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Yulanka Castro-Dominguez
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Dhruv Kansal
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Steffne Kunnirickal
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Yasin Hussain
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Keith Love
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Edouard Aboian
- Department of Vascular Surgery, Yale University, New Haven, Connecticut, USA
| | - Kim G Smolderen
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Yale University, New Haven, Connecticut, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Carlos Mena-Hurtado
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| |
Collapse
|
39
|
Smolderen KG, Ameli O, Chaisson CE, Heath K, Mena-Hurtado C. Peripheral Artery Disease Screening in the Community and 1-Year Mortality, Cardiovascular Events, and Adverse Limb Events. AJPM Focus 2022; 1:100016. [PMID: 37791014 PMCID: PMC10546509 DOI: 10.1016/j.focus.2022.100016] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction This study aimed to examine all-cause mortality, 1- and 2-year major cardiovascular events, and major adverse limb events in individuals aged ≥65 years who received an in-home health visit with peripheral artery disease screening. In addition, we compared 1-year healthcare utilization before and after peripheral artery disease screening for those who screened positive. Setting/Participants Medicare Advantage beneficiaries aged ≥65 years participating in the Optum HouseCalls program in the U.S. between April 1, 2017 and February 1, 2019 were included. Intervention The intervention consisted of a peripheral artery disease screening program using a plethysmography system. Main outcome measures One-year all-cause mortality as a landmark analysis, 1- and 2-year major cardiovascular events, and major adverse limb events after screening were compared by peripheral artery disease screen status using claims data. We compared cardiovascular medications and revascularization procedures between the year before and after the peripheral artery disease screening event for those with peripheral artery disease. Results Of 192,500 beneficiaries, 27.7% screened positive. One-year all-cause mortality rates for those who screened positive for peripheral artery disease versus those who screened negative were higher (1.51% vs 0.89%; p<0.001; adjusted hazard ratio=1.21; 95% CI=1.08, 1.36) as well as 1-year major cardiovascular events (5.54% vs 3.60%; adjusted hazard ratio= 1.22; 95% CI=1.15, 1.30) and major adverse limb events (0.23% vs 0.04%; adjusted hazard ratio=3.15; 95% CI=2.10, 4.73). Similar risks were observed for 2-year results. Before and after peripheral artery disease screening, medications remained stable for those who screened positive (e.g., statin therapy=54.2% vs 56.6%); rates of peripheral vascular interventions remained stable (0.0% vs 0.1%). Conclusions A national peripheral artery disease screening effort is feasible. Detecting previously undiagnosed peripheral artery disease is a way to risk stratify a population that would benefit from further cardiovascular risk management.
Collapse
Affiliation(s)
- Kim G. Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Cardiovascular Medicine Section, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Cardiovascular Medicine Section, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
40
|
Rome D, Sales A, Leeds R, Usseglio J, Cornelius T, Monk C, Smolderen KG, Moise N. A Narrative Review of the Association Between Depression and Heart Disease Among Women: Prevalence, Mechanisms of Action, and Treatment. Curr Atheroscler Rep 2022; 24:709-720. [PMID: 35751731 PMCID: PMC9398966 DOI: 10.1007/s11883-022-01048-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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] [Accepted: 05/26/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Sex and gender differences exist with regard to the association between depression and cardiovascular disease (CVD). This narrative review describes the prevalence, mechanisms of action, and management of depression and CVD among women, with a particular focus on coronary heart disease (CHD). RECENT FINDINGS Women versus men with incident and established CHD have a greater prevalence of depression. Comorbid depression and CHD in women may be associated with greater mortality, and treatment inertia. Proposed mechanisms unique to the association among women of depression and CHD include psychosocial, cardiometabolic, behavioral, inflammatory, hormonal, and autonomic factors. The literature supports a stronger association between CHD and the prevalence of depression in women compared to men. It remains unclear whether depression treatment influences cardiovascular outcomes, or if treatment effects differ by sex and/or gender. Further research is needed to establish underlying mechanisms as diagnostic and therapeutic targets.
Collapse
Affiliation(s)
- Danielle Rome
- Department of Medicine, Columbia University Irving Medical Center/New York Presbyterian, New York, NY, USA
| | | | - Rebecca Leeds
- Center for Family and Community Medicine, Columbia University Irving Medical Center/New York Presbyterian, New York, NY, USA
| | - John Usseglio
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Talea Cornelius
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Catherine Monk
- Departments of OB/GYN and Psychiatry, School of Physicians and Surgeons, Columbia University Vagelos, New York, NY, USA
| | - Kim G Smolderen
- Departments of Internal Medicine and Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Nathalie Moise
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.
| |
Collapse
|
41
|
Brahmandam A, Lee M, Bellamkonda K, Provance JB, Sumpio B, Ochoa Chaar CI, Smolderen KG, Mena-Hurtado C, Guzman RJ. Variability in Antithrombotic Therapy After Infrainguinal Lower Extremity Bypass. Ann Vasc Surg 2022; 88:51-62. [DOI: 10.1016/j.avsg.2022.08.016] [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] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/01/2022]
|
42
|
Angraal S, Hejjaji V, Tang Y, Gosch KL, Patel MR, Heyligers J, White CJ, Tutein Nolthenius R, Mena-Hurtado C, Aronow HD, Moneta GL, Fitridge R, Soukas PA, Abbott JD, Secemsky EA, Spertus JA, Smolderen KG. One-Year Health Status Outcomes Following Early Invasive and Noninvasive Treatment in Symptomatic Peripheral Artery Disease. Circ Cardiovasc Interv 2022; 15:e011506. [PMID: 35579010 DOI: 10.1161/circinterventions.121.011506] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Lifestyle changes and medications are recommended as the first line of treatment for claudication, with revascularization considered for treatment-resistant symptoms, based on patients' preferences. Real-world evidence comparing health status outcomes of early invasive with noninvasive management strategies is lacking. METHODS In the international multicenter prospective observational PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry, disease-specific health status was assessed by the Peripheral Artery Questionnaire in patients with new-onset or worsening claudication at presentation and 3, 6, and 12 months later. One-year health status trajectories were compared by early revascularization versus noninvasive management on a propensity-matched sample using hierarchical generalized linear models for repeated measures adjusted for baseline health status. RESULTS In a propensity-matched sample of 1000 patients (67.4±9.3 years, 62.8% male, and 82.4% White), 297 (29.7%) underwent early revascularization and 703 (70.3%) were managed noninvasively. Over 1 year of follow-up, patients who underwent early invasive management reported significantly higher health status than patients managed noninvasively (interaction term for time and treatment strategy; P<0.001 for all Peripheral Artery Questionnaire domains). The average 1-year change in Peripheral Artery Questionnaire summary scores was 30.8±25.2 in those undergoing early invasive, compared with 16.7±23.4 in those treated noninvasively (P<0.001). CONCLUSIONS Patients with claudication undergoing early invasive treatment had greater health status improvements over the course of 1 year than those treated noninvasively. These data can be used to support shared decision-making with patients. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01419080.
Collapse
Affiliation(s)
- Suveen Angraal
- Department of Internal Medicine, University of Missouri Kansas City School of Medicine (S.A.)
| | - Vittal Hejjaji
- Department of Cardiology, Saint Luke's Mid America Heart Institute (V.H., J.A.S.), University of Missouri-Kansas City
| | - Yuanyuan Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO (Y.T., K.L.G.)
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO (Y.T., K.L.G.)
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P.)
| | - Jan Heyligers
- Department of Vascular Surgery, St. Elisabeth Hospital, Tilburg, the Netherlands (J.H.)
| | - Christopher J White
- Department of Cardiology, Ochsner Clinical School, University of Queensland, AU, and Ochsner Health, New Orleans, LA (C.J.W.)
| | - Rudolf Tutein Nolthenius
- Department of (vascular) Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands (R.T.N.)
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (C.M.-H., K.G.S.)
| | - Herbert D Aronow
- Division of Cardiology, Lifespan Cardiovascular Institute, Alpert Medical School of Brown University, Providence, RI (H.D.A.)
| | - Gregory L Moneta
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland (H.D.A., G.L.M.)
| | - Robert Fitridge
- Departments of Vascular Surgery, Royal Adelaide and The Queen Elizabeth Hospital, Australia (R.F.)
| | - Peter A Soukas
- Division of Cardiovascular Medicine, The Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (P.A.S., J.D.A.)
| | - J Dawn Abbott
- Division of Cardiovascular Medicine, The Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (P.A.S., J.D.A.)
| | - Eric A Secemsky
- Division of Cardiology (E.A.S.), Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.,Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (E.A.S.), Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - John A Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute (V.H., J.A.S.), University of Missouri-Kansas City
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (C.M.-H., K.G.S.)
| |
Collapse
|
43
|
Smolderen KG, Heath K, Scherr T, Bauzon SR, Howell AN, Mena-Hurtado C. The Nevada peripheral artery disease screening effort in a Medicare Advantage population and subsequent mortality and major adverse cardiovascular event risk. Eur J Vasc Endovasc Surg 2022. [DOI: 10.1016/j.ejvs.2022.06.013] [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] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
44
|
Provance JB, Spertus JA, Jones PG, Hoffman MA, Bunte MC, Vogel TR, Mena-Hurtado C, Smolderen KG. Variability in 30-day major amputation rates following endovascular peripheral vascular intervention for critical limb ischemia. Vasc Med 2022; 27:350-357. [PMID: 35603755 DOI: 10.1177/1358863x221098097] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Patients with critical limb ischemia (CLI) can undergo endovascular peripheral vascular intervention (PVI) to restore blood flow and decrease risk of amputation. As a potential indicator of quality for CLI care, we sought to describe 30-day major amputation rates following PVI. We also examined rate variability, and patient-level and site-level factors predicting amputations, using a national electronic health record (EHR) database. Methods: Using the Cerner Health Facts de-identified EHR database, patients with CLI diagnosis codes undergoing PVI were identified. The rate of amputation within 30 days of PVI was calculated. Risk ratios predicting amputation were derived using a mixed effects Poisson regression model adjusting for 16 patient and clinical factors. Median risk ratios (MRRs) were calculated to quantify site-level variability in amputations. Results: A total of 20,204 PVI procedures for CLI from 179 healthcare sites were identified. Mean age at procedure was 69.0 ± 12.6 years, 58.0% were male, and 29.6% were persons of color. Amputation within 30 days of PVI occurred after 570 (2.8%) procedures. Malnutrition, previous amputation, diabetes, and being of Black race were predictors of amputation. Amputation rates across sites ranged from 0.0% to 10.0%. The unadjusted MRR was 1.40 (95% CI 1.35-1.46), which was attenuated after adjusting for patient-level factors (MRR 1.30, 95% CI 1.26-1.34) and site characteristics (MRR 1.11, 95% CI 1.09-1.13). Conclusions: Among PVI procedures for CLI treatment, 30-day amputation rates varied across institutions. Although patient-level factors explained some variability, site-level factors explained most variation in the rates of these outcomes.
Collapse
Affiliation(s)
- Jeremy B Provance
- Vascular Medicine Outcomes (VAMOS) Research Group, Department of Internal Medicine, Cardiovascular Medicine Section, Yale University, New Haven, CT, USA
| | - John A Spertus
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Saint Luke's Mid-America Heart Institute, Kansas City, MO, USA
| | - Philip G Jones
- Saint Luke's Mid-America Heart Institute, Kansas City, MO, USA
| | - Mark A Hoffman
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Children's Mercy Research Institute, Children's Mercy Hospital, Kansas City, MO, USA
| | - Matthew C Bunte
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Saint Luke's Mid-America Heart Institute, Kansas City, MO, USA
| | - Todd R Vogel
- Division of Vascular Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Research Group, Department of Internal Medicine, Cardiovascular Medicine Section, Yale University, New Haven, CT, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Research Group, Department of Internal Medicine, Cardiovascular Medicine Section, Yale University, New Haven, CT, USA.,Department of Psychiatry, Yale University, New Haven, CT, USA
| |
Collapse
|
45
|
Al-Damluji MS, Smolderen KG, Meng C, Dai F, Nanna MG, Sumpio B, Henke P, Mena-Hurtado C. Frailty and outcomes following revascularization of lower-extremity peripheral artery disease: Insights from the Vascular Quality Initiative (VQI). Vasc Med 2022; 27:251-257. [PMID: 35485400 DOI: 10.1177/1358863x221083701] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 12/21/2022]
Abstract
BACKGROUND Multiple frailty screening tools are implemented; however, it is unclear whether they perform in a comparable way for both frailty detection and prediction of perioperative outcomes in patients undergoing lower-extremity revascularization. METHODS Patients undergoing lower-extremity revascularization were identified from the Vascular Quality Initiative (VQI) national database. Two cohorts were established based on the revascularization type (percutaneous vascular interventions (PVI) or lower-extremity bypass). Frailty was assessed by the 5-item modified frailty index (mFI-5) and the VQI-derived risk analysis index (RAI). RESULTS Out of 134,081 patients undergoing PVI, frailty was identified in 67% by mFI-5 and 28% by RAI. Similarly, out of 41,316 patients in the bypass cohort, frailty was identified in 69% by mFI-5 and 16% by RAI. There was little agreement between the two frailty tools for both vascular cohorts (PVI: kappa: 0.17; bypass: kappa: 0.13). In an adjusted analysis, frailty as assessed by mFI-5 and RAI was associated with higher odds of mortality in both cohorts (p < 0.001). A significant association between frailty and unplanned amputations was only noted in the bypass cohort when RAI was applied (OR: 1.50, p < 0.01). The addition of frailty to traditional PAD risk factors marginally improved model performance to predict mortality and unplanned major amputations. CONCLUSION There was significant variation in frailty detection by mFI-5 and RAI. Although frailty was associated with mortality, the predictive value of these tools in predicting outcomes in PAD was limited. Future research should focus on designing new frailty screening tools specific to the PAD population.
Collapse
Affiliation(s)
| | - Kim G Smolderen
- Department of Cardiology, Yale University, New Haven, CT, USA.,Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Can Meng
- Yale Center for Analytical Sciences, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Feng Dai
- Yale Center for Analytical Sciences, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Michael G Nanna
- Department of Cardiology, Yale University, New Haven, CT, USA
| | - Bauer Sumpio
- Department of Vascular Surgery, Yale University, New Haven, CT, USA
| | - Peter Henke
- Department of Vascular Surgery, University of Michigan, Ann Arbor, MI, USA
| | | |
Collapse
|
46
|
Friberg JE, Qazi AH, Boyle B, Franciscus C, Vaughan-Sarrazin M, Westerman D, Patterson OV, Parr SK, Matheny ME, Arya S, Smolderen KG, Lund BC, Gobbel GT, Girotra S. Ankle- and Toe-Brachial Index for Peripheral Artery Disease Identification: Unlocking Clinical Data Through Novel Methods. Circ Cardiovasc Interv 2022; 15:e011092. [PMID: 35176872 PMCID: PMC10807980 DOI: 10.1161/circinterventions.121.011092] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite its high prevalence and clinical impact, research on peripheral artery disease (PAD) remains limited due to poor accuracy of billing codes. Ankle-brachial index (ABI) and toe-brachial index can be used to identify PAD patients with high accuracy within electronic health records. METHODS We developed a novel natural language processing (NLP) algorithm for extracting ABI and toe-brachial index values and laterality (right or left) from ABI reports. A random sample of 800 reports from 94 Veterans Affairs facilities during 2015 to 2017 was selected and annotated by clinical experts. We trained the NLP system using random forest models and optimized it through sequential iterations of 10-fold cross-validation and error analysis on 600 test reports and evaluated its final performance on a separate set of 200 reports. We also assessed the accuracy of NLP-extracted ABI and toe-brachial index values for identifying patients with PAD in a separate cohort undergoing ABI testing. RESULTS The NLP system had an overall precision (positive predictive value) of 0.85, recall (sensitivity) of 0.93, and F1 measure (accuracy) of 0.89 to correctly identify ABI/toe-brachial index values and laterality. Among 261 patients with ABI testing (49% PAD), the NLP system achieved a positive predictive value of 92.3%, sensitivity of 83.1%, and specificity of 93.1% to identify PAD when compared with a structured chart review. The above findings were consistent in a range of sensitivity analysis. CONCLUSIONS We successfully developed and validated an NLP system for identifying patients with PAD within the Veterans Affairs electronic health record. Our findings have broad implications for PAD research and quality improvement.
Collapse
Affiliation(s)
- Julia E. Friberg
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Abdul H. Qazi
- Division of Cardiovascular Diseases, Massachusetts General Hospital, Boston
| | - Brenden Boyle
- Division of Cardiovascular Medicine, University of Minnesota, Minneapolis
| | - Carrie Franciscus
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Mary Vaughan-Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
- General Internal Medicine, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Dax Westerman
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Sharidan K. Parr
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Michael E. Matheny
- Tennessee Valley Healthcare System, Nashville
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Shipra Arya
- Department of Surgery, Palo Alto Veterans Affairs Medical Center and Stanford University, CA
| | - Kim G. Smolderen
- Department of Medicine and Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Brian C. Lund
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Glenn T. Gobbel
- Tennessee Valley Healthcare System, Nashville
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Saket Girotra
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
- Division of Cardiovascular Diseases, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| |
Collapse
|
47
|
Gaffey AE, Harris KM, Mena-Hurtado C, Sinha R, Jacoby DL, Smolderen KG. The Yale Roadmap for Health Psychology and Integrated Cardiovascular Care. Psychol Health 2022; 41:779-791. [PMID: 35201804 DOI: 10.1037/hea0001152] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Cardiovascular disease remains the leading cause of morbidity and mortality in industrialized nations. Many patients living with chronic cardiovascular disease suffer from complex multimorbidities requiring high-intensity care and behavioral risk factor management, and about a third copresent with a mental health disorder. These comanifestations are extremely taxing for patients and our health care system, complicate treatment, and increase the risk of adverse health outcomes. Health psychology emerged in response to a need for specialists who could design, deliver, and test evidence-based approaches to manage behavioral risk factors and the mental health burden of chronic diseases. We aimed to conduct a state-of-the-art review as to how health psychology emerged as a key specialty in delivering integrated care for cardiovascular populations, and to review challenges and opportunities that lie ahead of further integration of the specialty for integrated cardiovascular care. METHOD As our health care system embraces more patient-centered care and big data science to detect at-risk patients and predict outcomes, health psychologists should be at the forefront to apply their expertise and demonstrate their value in designing and applying intervention models to improve outcomes. We first review challenges, then illustrate this framework using the Wagner chronic care model, present business case considerations, and conclude with an action agenda to promote the integration of health psychology as a cotreating specialty into cardiovascular care. RESULTS To provide direction for this undertaking, we present a roadmap for the field of health psychology to sustainably extend existing holistic, integrated approaches in cardiovascular care. CONCLUSIONS To lessen the burden and improve outcomes in cardiovascular disease, care must shift away from siloed delivery models that are focused on traditional atherosclerotic risk factors to holistic, integrated approaches that address biological, psychological, social, and behavioral factors relevant to cardiovascular disease. Using the presented roadmap, health psychology can play a major role to address these needs of integrated cardiovascular care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
Collapse
|
48
|
Smolderen KG, Heath K, Scherr T, Bauzon SR, Howell AN, Mena-Hurtado C. The Nevada Peripheral Artery Disease Screening Effort in a Medicare Advantage Population and Subsequent Mortality and Major Adverse Cardiovascular Event Risk. J Vasc Surg 2022; 75:2054-2064.e3. [PMID: 35181520 DOI: 10.1016/j.jvs.2022.01.134] [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: 09/16/2021] [Accepted: 01/26/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION There is a lack of contemporary estimates of undetected asymptomatic lower-extremity peripheral artery disease (PAD) in the community and its association with adverse outcomes in the population. We aimed to study the long-term association between previously undetected PAD and subsequent all-cause mortality and major adverse cardiovascular events (MACE) in Medicare advantage beneficiaries 65 years and older in a large metropolitan area characterized by concentrations of atherosclerotic risk factors along with a more vulnerable socio-economic risk profile. METHODS Data was derived from electronic medical records and linked with claims outcomes data for 13,971 Medicare advantage beneficiaries 65 years and older who underwent PAD screening in 2016 as part of patients' routine annual health assessment in the greater Las Vegas, Nevada metropolitan area. PAD screenings were performed with their primary care provider using volume plethysmography system (VPS) methods. The association between PAD screen status and one-year and 3-year all-cause mortality and MACE rates was documented. RESULTS The cohort had a mean age of 75.3±6.6 years and 57.7% of them were female. A total of 4,351 out of 13,768 (31.6%) had a positive PAD screening result. Almost 60% had a lower socio-economic income level, with 15.1% living under the poverty level. The risk estimates associated with a positive vs. a negative PAD screening for both all-cause mortality and MACE was (unadjusted HR mortality=2.17, 95% Confidence Interval, 95%CI 1.79-2.63; unadjusted HR MACE=2.00, 95%CI 1.15-3.49) at 1 year, and (unadjusted HR mortality=2.04, 95%CI 1.84-2.26; unadjusted HR MACE=1.67, 95%CI 1.37-2.02) at 3 year, respectively. Following multivariable adjustment, all associations persisted (P-values <.001) ranging from 1.41-1.69, except for 1-year MACE (similar risk estimate, but P=0.09). CONCLUSION A positive screening result of previously undetected lower extremity PAD was independently associated with short-term and long-term increased risks for mortality and MACE in individuals aged 65 years and older living in a large, metropolitan area.
Collapse
Affiliation(s)
- Kim G Smolderen
- Yale School of Medicine, Department of Internal Medicine (Cardiovascular Medicine); Vascular Medicine Outcomes (VAMOS) Program; Yale School of Medicine, Department of Psychiatry, New Haven, CT.
| | | | | | | | | | - Carlos Mena-Hurtado
- Yale School of Medicine, Department of Internal Medicine (Cardiovascular Medicine); Vascular Medicine Outcomes (VAMOS) Program
| |
Collapse
|
49
|
Scierka LE, Mena-Hurtado C, Shishehbor MH, Spertus JA, Nagpal S, Babrowski T, Bunte MC, Politano A, Humphries M, Chung J, Kirksey L, Alabi O, Soukas P, Parikh S, Faizer R, Fitridge R, Provance J, Romain G, McMillan N, Stone N, Scott K, Fuss C, Pacheco CM, Gosch K, Harper-Brooks A, Smolderen KG. The shifting care and outcomes for patients with endangered limbs - Critical limb ischemia (SCOPE-CLI) registry overview of study design and rationale. Int J Cardiol Heart Vasc 2022; 39:100971. [PMID: 35198727 PMCID: PMC8850321 DOI: 10.1016/j.ijcha.2022.100971] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/26/2022] [Accepted: 02/02/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI), the most severe form of peripheral artery disease, is associated with pain, poor wound healing, high rates of amputation, and mortality (>20% at 1 year). Little is known about the processes of care, patients' preferences, or outcomes, as seen from patients' perspectives. The SCOPE-CLI study was co-designed with patients to holistically document patient characteristics, treatment preferences, patterns of care, and patient-centered outcomes for CLI. METHODS This 11-center prospective observational registry will enroll and interview 816 patients from multispecialty, interdisciplinary vascular centers in the United States and Australia. Patients will be followed up at 1, 2, 6, and 12 months regarding their psychosocial factors and health status. Hospitalizations, interventions, and outcomes will be captured for 12 months with vital status extending to 5 years. Pilot data were collected between January and July of 2021 from 3 centers. RESULTS A total of 70 patients have been enrolled. The mean age was 68.4 ± 11.3 years, 31.4% were female, and 20.0% were African American. CONCLUSIONS SCOPE-CLI is uniquely co-designed with patients who have CLI to capture the care experiences, treatment preferences, and health status outcomes of this vulnerable population and will provide much needed information to understand and address gaps in the quality of CLI care and outcomes.ClinicalTrials.gov identifier (NCT Number): NCT04710563 https://clinicaltrials.gov/ct2/show/NCT04710563.
Collapse
Affiliation(s)
- Lindsey E. Scierka
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Carlos Mena-Hurtado
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Mehdi H. Shishehbor
- Case Western University School of Medicine/Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, United States
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Sameer Nagpal
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | | | - Matthew C. Bunte
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Amani Politano
- Oregon Health & Science University, Portland, OR, United States
| | | | - Jayer Chung
- Baylor College of Medicine, Houston, TX, United States
| | - Lee Kirksey
- Cleveland Clinic, Cleveland, OH, United States
| | | | | | - Sahil Parikh
- Columbia University – Presbyterian, New York, NY, United States
| | - Rumi Faizer
- University of Minnesota, Minneapolis, MN, United States
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - Jeremy Provance
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Gaëlle Romain
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Neil McMillan
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - Nancy Stone
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Kate Scott
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Christine Fuss
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Christina M. Pacheco
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Kensey Gosch
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Avis Harper-Brooks
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Kim G. Smolderen
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
- Yale University, Department of Psychiatry, New Haven, CT, United States
- Corresponding author at: 789 Howard Avenue, New Haven, CT 06519, United States.
| | | |
Collapse
|
50
|
Tran AT, Spertus JA, Mena-Hurtado CI, Jones PG, Aronow HD, Safley DM, Malik AO, Peri-Okonny PA, Shishehbor MH, Labrosciano C, Smolderen KG. Association of Disease-Specific Health Status With Long-Term Survival in Peripheral Artery Disease. J Am Heart Assoc 2022; 11:e022232. [PMID: 35132874 PMCID: PMC9245831 DOI: 10.1161/jaha.121.022232] [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: 11/17/2022]
Abstract
Background While peripheral artery disease (PAD) is associated with increased cardiovascular morbidity with mortality remaining high and challenging to predict, accurate understanding of serial PAD‐specific health status around the time of diagnosis may prognosticate long‐term mortality risk. Methods and Results Patients with new or worsening PAD symptoms enrolled in the PORTRAIT Registry across 10 US sites from 2011 to 2015 were included. Health status was assessed by the Peripheral Artery Questionnaire (PAQ) Summary score at baseline, 3‐month, and change from baseline to 3‐month follow‐up. Kaplan‐Meier using 3‐month landmark and hierarchical Cox regression models were constructed to assess the association of the PAQ with 5‐year all‐cause mortality. Of the 711 patients (mean age 68.8±9.6 years, 40.9% female, 72.7% white; mean PAQ 47.5±22.0 and 65.9±25.0 at baseline and 3‐month, respectively), 141 (19.8%) died over a median follow‐up of 4.1 years. In unadjusted models, baseline (HR, 0.90 per‐10‐point increment; 95% CI, 0.84–0.97; P=0.008), 3‐month (HR [95% CI], 0.87 [0.82–0.93]; P<0.001) and change in PAQ (HR [95% CI], 0.92 [0.85–0.99]; P=0.021) were each associated with mortality. In fully adjusted models including combination of scores, 3‐month PAQ was more strongly associated with mortality than either baseline (3‐month HR [95% CI], 0.85 [0.78–0.92]; P<0.001; C‐statistic, 0.77) or change (3‐month HR [95% CI], 0.79 [0.72–0.87]; P<0.001). Conclusions PAD‐specific health status is independently associated with 5‐year survival in patients with new or worsening PAD symptoms, with the most recent assessment being most prognostic. Future work is needed to better understand how this information can be used proactively to optimize care.
Collapse
Affiliation(s)
- Andy T Tran
- Department of Medicine University of California Irvine School of Medicine Orange CA
| | - John A Spertus
- Cardiovascular Research Saint Luke's Mid America Heart Institute Kansas City MO.,Department of Biomedical and Health Informatics of Medicine University of Missouri-Kansas City Kansas City MO
| | - Carlos I Mena-Hurtado
- Vascular Medicine Outcomes Program Section of Cardiovascular Medicine Department of Internal Medicine Yale University New Haven CT
| | - Philip G Jones
- Cardiovascular Research Saint Luke's Mid America Heart Institute Kansas City MO.,Department of Biomedical and Health Informatics of Medicine University of Missouri-Kansas City Kansas City MO
| | - Herbert D Aronow
- Department of Medicine Alpert Medical School of Brown University Providence RI
| | - David M Safley
- Cardiovascular Research Saint Luke's Mid America Heart Institute Kansas City MO.,Department of Biomedical and Health Informatics of Medicine University of Missouri-Kansas City Kansas City MO
| | - Ali O Malik
- Cardiovascular Research Saint Luke's Mid America Heart Institute Kansas City MO.,Department of Biomedical and Health Informatics of Medicine University of Missouri-Kansas City Kansas City MO
| | - Poghni A Peri-Okonny
- Cardiovascular Research Saint Luke's Mid America Heart Institute Kansas City MO.,Department of Biomedical and Health Informatics of Medicine University of Missouri-Kansas City Kansas City MO
| | - Mehdi H Shishehbor
- Interventional Cardiovascular Center Case Western Reserve University School of Medicine Cleveland OH
| | - Clementine Labrosciano
- The Queen Elizabeth Hospital Adelaide Medical School University of Adelaide SA Australia
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program Section of Cardiovascular Medicine Department of Internal Medicine Yale University New Haven CT.,Department of Psychiatry School of Medicine, Yale University New Haven CT
| |
Collapse
|