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Swat SA, Helmkamp LJ, Tietbohl C, Thompson JS, Fitzgerald M, McIlvennan CK, Harger G, Ho PM, Ahmad FS, Ahmad T, Buttrick P, Allen LA. Clinical Inertia Among Outpatients With Heart Failure: Application of Treatment Nonintensification Taxonomy to EPIC-HF Trial. JACC Heart Fail 2023; 11:1579-1591. [PMID: 37589610 DOI: 10.1016/j.jchf.2023.06.022] [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] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The contribution of clinical inertia to suboptimal guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) remains unclear. OBJECTIVES This study examined reasons for GDMT nonintensification and characterized clinical inertia. METHODS In this secondary analysis of EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction), a randomized clinical trial evaluating a patient-activation tool on GDMT utilization, we performed a sequential, explanatory mixed-methods study. Reasons for nonintensification among 4 medication classes were assigned according to an expanded published taxonomy using structured chart reviews. Audio transcripts of clinic encounters were analyzed to further characterize nonintensification reasons. Integration occurred during the interpretation phase. RESULTS Among 292 HFrEF patients who completed a cardiology visit, 185 (63.4%) experienced no treatment intensification, of whom 90 (48.6%) had at least 1 opportunity for intensification of a medication class with no documented contraindication or barriers (ie, clinical inertia). Nonintensification reasons varied by medication class, and included heightened risk of adverse effects (range 18.2%-31.6%), patient nonadherence (range 0.8%-1.1%), patient preferences and beliefs (range 0.6%-0.9%), comanagement with other providers (range 4.6%-5.6%), prioritization of other issues (range 15.6%-31.8%), multiple categories (range 16.5%-22.7%), and clinical inertia (range 22.7%-31.6%). A qualitative analysis of 32 clinic audio recordings demonstrated common characteristics of clinical inertia: 1) clinician review of medication regimens without education or intensification discussions; 2) patient stability as justification for nonintensification; and 3) shorter encounters for nonintensification vs intensification. CONCLUSIONS In this comprehensive study exploring HFrEF prescribing, clinical inertia is a main contributor to nonintensification within an updated taxonomy classification for suboptimal GDMT prescribing. This approach should help target strategies overcoming GDMT underuse.
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Affiliation(s)
- Stanley A Swat
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura J Helmkamp
- Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Caroline Tietbohl
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jocelyn S Thompson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Monica Fitzgerald
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Colleen K McIlvennan
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Geoffrey Harger
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - P Michael Ho
- Rocky Mountain VA Regional Medical Center, Aurora, Colorado, USA
| | - Faraz S Ahmad
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tariq Ahmad
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peter Buttrick
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Larry A Allen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA.
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Hunt AR, Stuart CM, Gergen AK, Bang TJ, Reihman AE, Helmkamp LJ, Lin Y, Mitchell JD, Meguid RA, Scott CD, Wojcik BM. Long-Term Patient-Reported Symptom Improvement and Quality of Life after Transthoracic Diaphragm Plication in Adults. J Am Coll Surg 2023; 237:533-544. [PMID: 37194947 DOI: 10.1097/xcs.0000000000000762] [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] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Open and robotic-assisted transthoracic approaches for diaphragm plication are accepted surgical interventions for diaphragm paralysis and eventration. However, long-term patient-reported symptom improvement and quality of life (QOL) remains unclear. STUDY DESIGN A telephone-based survey was developed focusing on postoperative symptom improvement and QOL. Patients who underwent open or robotic-assisted transthoracic diaphragm plication (2008-2020) across three institutions were invited to participate. Patients who responded and provided consent were surveyed. Likert responses on symptom severity were dichotomized and rates before and after surgery were compared using McNemar's test. RESULTS Forty-one percent of patients participated (43 of 105 responded, mean age 61.0 years, 67.4% male, 37.2% robotic-assisted surgery), with an average time between surgery and survey of 4.1 ± 3.2 years. Patients reported significant improvement in dyspnea while lying flat (67.4% pre- vs 27.9% postoperative, p < 0.001), dyspnea at rest (55.8% pre- vs 11.6% postoperative, p < 0.001), dyspnea with activity (90.7% pre- vs 55.8% postoperative, p < 0.001), dyspnea while bending over (79.1% pre- vs 34.9% postoperative, p < 0.001), and fatigue (67.4% pre- vs 41.9% postoperative, p = 0.008). There was no statistical improvement in chronic cough. 86% of patients reported improved overall QOL, 79% had increased exercise capacity, and 86% would recommend surgery to a friend with a similar problem. Analysis comparing open and robotic-assisted approaches found no statistically significant differences in symptom improvement or QOL responses between the groups. CONCLUSIONS Patients report significantly improved dyspneic and fatigue symptoms after transthoracic diaphragm plication, regardless of open or robotic-assisted approach. The majority of patients report improved QOL and exercise capacity.
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Affiliation(s)
- Amanda R Hunt
- From the Division of Cardiothoracic Surgery, Department of Surgery (Hunt, Stuart, Gergen, Mitchell, Meguid), University of Colorado, Aurora, CO
| | - Christina M Stuart
- From the Division of Cardiothoracic Surgery, Department of Surgery (Hunt, Stuart, Gergen, Mitchell, Meguid), University of Colorado, Aurora, CO
| | - Anna K Gergen
- From the Division of Cardiothoracic Surgery, Department of Surgery (Hunt, Stuart, Gergen, Mitchell, Meguid), University of Colorado, Aurora, CO
| | - Tami J Bang
- Division of Cardiopulmonary Imaging, Department of Radiology (Bang), University of Colorado, Aurora, CO
| | - Anne E Reihman
- Critical Care and Pulmonary Sleep Associates, Aurora, CO (Reihman)
| | - Laura J Helmkamp
- Adult and Child Consortium for Health Outcomes Research, University of Colorado School of Medicine, Aurora, CO (Helmkamp)
| | - Yihan Lin
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA (Lin)
| | - John D Mitchell
- From the Division of Cardiothoracic Surgery, Department of Surgery (Hunt, Stuart, Gergen, Mitchell, Meguid), University of Colorado, Aurora, CO
| | - Robert A Meguid
- From the Division of Cardiothoracic Surgery, Department of Surgery (Hunt, Stuart, Gergen, Mitchell, Meguid), University of Colorado, Aurora, CO
| | - Christopher D Scott
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA (Scott)
| | - Brandon M Wojcik
- the Division of Cardiothoracic Surgery, Department of Surgery, Munson Medical Center, Traverse City, MI (Wojcik)
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Madsen HJ, Stuart CM, Wojcik BM, Dyas AR, Hunt A, Helmkamp LJ, Gergen AK, Weyant MJ, Randhawa SK, Mitchell JD, Meguid RA. Esophagram should be performed to diagnose esophageal perforation before inter-hospital transfer. J Thorac Dis 2023; 15:2984-2996. [PMID: 37426131 PMCID: PMC10323583 DOI: 10.21037/jtd-22-1798] [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] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/24/2023] [Indexed: 07/11/2023]
Abstract
Background Early recognition of esophageal perforation may prevent morbidity and mortality, and accurate diagnostic imaging facilitates triage. Stable patients with suspected perforation may be transferred to higher levels of care before appropriate work-up and diagnosis confirmation. We reviewed patients transferred for esophageal perforation to critically analyze the diagnostic workflow. Methods We performed a retrospective review of patients transferred to our tertiary care institution from 2015-2021 for suspected esophageal perforation. Demographics, referring site characteristics, diagnostic studies, and management were analyzed. Bivariate comparisons were performed using Wilcoxon-Mann-Whitney tests for continuous variables and chi-squared or Fisher's exact tests for categorical variables. Results Sixty-five patients were included. Etiology of suspected perforation was spontaneous in 53.8% and iatrogenic in 33.8%. Most patients were transferred within 24 hours from time of suspected perforation (66.2%). Transferring sites included seven states and were 101-300 miles (32.3%) or >300 miles (26.2%) away. CT imaging was obtained in 96.9% before transfer, most commonly demonstrating pneumomediastinum (46.2%). Only 21.5% of patients had an esophagram before transfer. Following transfer, 36.9% (n=24) were ultimately not found to have esophageal perforation, demonstrated by negative arrival esophagram in 79.1%. In patients with confirmed perforation (n=41), 58.5% had surgery, 26.8% endoscopic intervention, and 14.6% supportive care. Conclusions After transfer a proportion of patients were ultimately found to not have esophageal perforation, typically demonstrated by negative esophagram upon arrival. We conclude that a recommendation of performing esophagram at the presenting site, when possible, may prevent unnecessary transfers, and will likely reduce costs, conserve resources, and decrease management delays.
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Affiliation(s)
- Helen J. Madsen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christina M. Stuart
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brandon M. Wojcik
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R. Dyas
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amanda Hunt
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Laura J. Helmkamp
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anna K. Gergen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Simran K. Randhawa
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D. Mitchell
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A. Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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Stuart CM, Wojcik BM, Gergen AK, Wilkinson DA, Helmkamp LJ, Volker EE, Mitchell JD, Weyant MJ, Meguid RA, Scott CD. A comparison of short-term outcomes following robotic-assisted vs. open transthoracic diaphragm plication. J Robot Surg 2023:10.1007/s11701-023-01585-z. [PMID: 37071233 DOI: 10.1007/s11701-023-01585-z] [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] [Received: 02/14/2023] [Accepted: 03/26/2023] [Indexed: 04/19/2023]
Abstract
Diaphragm paralysis and eventration are rare conditions in adults. Symptomatic patients may benefit from surgical plication of the elevated hemidiaphragm. The objective of this study was to compare short-term outcomes and length of stay following robotic-assisted vs. open diaphragm plication. A multicenter retrospective study was conducted that identified patients undergoing unilateral hemidiaphragm plication from 5/2008 to 12/2020. The first RATS plication was performed in 11/2018. Electronic medical records were reviewed, and outcomes were compared between RATS and open approach. One hundred patients underwent diaphragm plication, including thirty-nine (39.0%) RATS and sixty-one (61.0%) open cases. Patients undergoing RATS diaphragm plication were older (64 years vs. 55 years, p = 0.01) and carried a higher burden of comorbidities (Charlson Comorbidity Index: 2.0 vs. 1.0, p = 0.02). The RATS group had longer median operative times (146 min vs. 99 min, p < 0.01), but shorter median hospital length of stays (3.0 days vs. 6.0 days, p < 0.01). There was a non-significant trend toward a decreased rate of 30-day postoperative complications (20.5% RATS vs. 32.8% open, p = 0.18) and 30-day unplanned readmissions (7.7% RATS vs. 9.8% open, p > 0.99). RATS is a technically feasible and safe option for performing diaphragm plications. This approach increases the surgical candidacy of older patients with a higher burden of comorbid disease without increasing complication rates, while reducing length of hospital stay.
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Affiliation(s)
- Christina M Stuart
- Division of Cardiothoracic Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue #6117, CO, 80045, Aurora, USA.
| | - Brandon M Wojcik
- Division of Cardiothoracic Surgery, Munson Medical Center, Traverse City, MI, USA
| | - Anna K Gergen
- Division of Cardiothoracic Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue #6117, CO, 80045, Aurora, USA
| | - Daniel A Wilkinson
- Division of Cardiothoracic Surgery, Albany Medical Center, Albany, NY, USA
| | - Laura J Helmkamp
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ellen E Volker
- Division of Pulmonology, National Jewish Hospital, Denver, CO, USA
- Division of Pulmonology, St. Joseph Hospital, Denver, CO, USA
| | - John D Mitchell
- Division of Cardiothoracic Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue #6117, CO, 80045, Aurora, USA
- Division of Specialty Services, National Jewish Hospital, Denver, CO, USA
- Department of Surgery, St. Joseph Hospital, Denver, CO, USA
| | - Michael J Weyant
- Division of Cardiothoracic Surgery, Inova Health System, Falls Church, VA, USA
| | - Robert A Meguid
- Division of Cardiothoracic Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue #6117, CO, 80045, Aurora, USA
- Division of Specialty Services, National Jewish Hospital, Denver, CO, USA
- Department of Surgery, St. Joseph Hospital, Denver, CO, USA
| | - Christopher D Scott
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, VA, USA
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Genelin MP, Helmkamp LJ, Steiner JF, Maertens JA, Hanratty R, Vupputuri S, Havranek EP, Dickinson LM, Blair IV, Daugherty SL. Patient Pill Organization Strategies and Adherence Measured in a Cross-Sectional Study of Hypertension. Patient Prefer Adherence 2023; 17:817-826. [PMID: 36992865 PMCID: PMC10042167 DOI: 10.2147/ppa.s399693] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/07/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND The strategies patients use to organize medications (eg, pill dispenser) may be reflected in adherence measured at follow-up. We studied whether medication organization strategies patients use at home are associated with adherence measured using pharmacy-fills, self-report, and pill counts. DESIGN Secondary analysis of data from a prospective randomized clinical trial. SETTING Eleven US safety-net and community primary care clinics. PATIENTS Of the 960 enrolled self-identified non-Hispanic Black and White patients prescribed antihypertensive medications, 731 patients reported pill organization strategies and were included. VARIABLE Patients were asked if they use any of the following medication organization strategies: finish previous refills first; use a pill dispenser; combine same prescriptions; or combine dissimilar prescriptions. OUTCOMES Adherence to antihypertensive medications using pill counts (range, 0.0-1.0% of the days covered), pharmacy-fill (proportion of days covered >90%), and self-report (adherent/non-adherent). RESULTS Of the 731 participants, 38.3% were men, 51.7% were age ≥65, 52.9% self-identified as Black or African American. Of the strategies studied, 51.7% finished previous refills first, 46.5% used a pill dispenser, 38.2% combined same prescriptions and 6.0% combined dissimilar prescriptions. Median (IQR) pill count adherence was 0.65 (0.40-0.87), pharmacy-fill adherence was 75.7%, and self-reported adherence was 63.2%. Those who combined same prescriptions had significantly lower measured pill count adherence than those who did not (0.56 (0.26-0.82) vs 0.70 (0.46-0.90), p<0.01) with no significant difference in pharmacy-fill (78.1% vs 74%, p=0.22) or self-reported adherence (63.0% vs 63.3%, p=0.93). CONCLUSION Self-reported medication organization strategies were common. Combining same prescriptions was associated with lower adherence as measured using pill counts but not pharmacy-fills or self-report. Clinicians and researchers should identify the pill organization strategies used by their patients to understand how these strategies may influence measures of patient adherence. TRIAL REGISTRATION ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).
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Affiliation(s)
- Matthew P Genelin
- University of Colorado School of Medicine, Aurora, CO, USA
- Correspondence: Matthew P Genelin, University of Colorado School of Medicine, 3500 Rockmont Drive, #15-209, Denver, CO, 80202, USA, Email
| | - Laura J Helmkamp
- Adult and Child Consortium for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO, USA
| | - John F Steiner
- University of Colorado School of Medicine, Aurora, CO, USA
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Julie A Maertens
- Adult and Child Consortium for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO, USA
| | - Rebecca Hanratty
- University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Edward P Havranek
- University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - L Miriam Dickinson
- University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Consortium for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO, USA
| | - Irene V Blair
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA
| | - Stacie L Daugherty
- University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Consortium for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO, USA
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
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Henderson KH, Helmkamp LJ, Steiner JF, Havranek EP, Vupputuri SX, Hanratty R, Blair IV, Maertens JA, Dickinson M, Daugherty SL. Relationship Between Social Vulnerability Indicators and Trial Participant Attrition: Findings From the HYVALUE Trial. Circ Cardiovasc Qual Outcomes 2022; 15:e007709. [PMID: 35418247 PMCID: PMC9117483 DOI: 10.1161/circoutcomes.120.007709] [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 Social vulnerability indicators are associated with health care inequities and may similarly impede ongoing participation in research studies. We evaluated the association of social vulnerability indicators and research participant attrition in a trial focused on reducing health disparities. METHODS Self-identified White or Black adults enrolled in the HYVALUE trial (Hypertension and VALUEs), a randomized trial testing a values-affirmation intervention on medication adherence, from February 2017 to September 2019 were included. The self-reported measures of social vulnerability indicators included: (1) Black race; (2) female gender; (3) no health insurance; (4) unemployment; (5) a high school diploma or less; and (6) financial-resource strain. Full attrition was defined as not completing at least one 3- or 6-month follow-up study visit. Log-binomial regression models adjusted for age, gender, race, medical comorbidities, and the other social vulnerability indicators to estimate the relative risk of each social vulnerability indicator with study attrition. RESULTS Among 825 participants, the mean age was 63.3 years (±11.7 years), 60% were women, 54% were Black, and 97% reported at least one social vulnerability. Overall, 21% participants had full attrition after study enrollment. After adjustment for all other social vulnerabilities, only financial-resource strain remained consistently associated with full attrition (relative risk, 1.71 [95% CI, 1.28-2.29]). In a secondary analysis of partial attrition (completed only one follow-up visit), financial-resource strain (relative risk, 1.40 [95% CI, 1.09-1.81]) and being uninsured (relative risk, 1.54 [95% CI, 1.01-2.34]) were associated with partial attrition. CONCLUSIONS In a trial aimed at reducing disparities in medication adherence, participants who reported financial-resource strain had a higher risk of participant attrition independent of race or gender. Our findings suggest that efforts to retain diverse populations in clinical trials should extend beyond race and gender to consider other social vulnerability indicators. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03028597.
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Affiliation(s)
- Kamal H Henderson
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO (K.H.H.).,Division of Cardiology (K.H.H., E.P.H., S.L.D.), University of Colorado School of Medicine, Aurora, CO
| | - Laura J Helmkamp
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (L.J.H., E.P.H., J.A.M., M.D., S.L.D.), University of Colorado School of Medicine, Aurora, CO
| | - John F Steiner
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO (J.F.S.)
| | - Edward P Havranek
- Division of Cardiology (K.H.H., E.P.H., S.L.D.), University of Colorado School of Medicine, Aurora, CO.,Adult and Child Consortium for Health Outcomes Research and Delivery Science (L.J.H., E.P.H., J.A.M., M.D., S.L.D.), University of Colorado School of Medicine, Aurora, CO.,Department of Medicine, Denver Health and Hospital Authority, CO (E.P.H., R.H.)
| | - Suma X Vupputuri
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, MD (S.X.V.)
| | - Rebecca Hanratty
- Department of Medicine, Denver Health and Hospital Authority, CO (E.P.H., R.H.)
| | - Irene V Blair
- Department of Psychology and Neuroscience, University of Colorado Boulder (I.V.B.)
| | - Julie A Maertens
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (L.J.H., E.P.H., J.A.M., M.D., S.L.D.), University of Colorado School of Medicine, Aurora, CO
| | - Miriam Dickinson
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (L.J.H., E.P.H., J.A.M., M.D., S.L.D.), University of Colorado School of Medicine, Aurora, CO
| | - Stacie L Daugherty
- Division of Cardiology (K.H.H., E.P.H., S.L.D.), University of Colorado School of Medicine, Aurora, CO.,Adult and Child Consortium for Health Outcomes Research and Delivery Science (L.J.H., E.P.H., J.A.M., M.D., S.L.D.), University of Colorado School of Medicine, Aurora, CO
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Lipsey JE, McIlvennan CK, Helmkamp LJ, Harger G, Matlock DD, Allen LA. Multimorbidity And Guideline-Directed Medical Therapy Intensification In Heart Failure: Findings From The EPIC-HF Trial. J Card Fail 2022. [DOI: 10.1016/j.cardfail.2022.03.037] [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: 10/18/2022]
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Allen LA, Venechuk G, McIlvennan CK, Page RL, Knoepke CE, Helmkamp LJ, Khazanie P, Peterson PN, Pierce K, Harger G, Thompson JS, Dow TJ, Richards L, Huang J, Strader JR, Trinkley KE, Kao DP, Magid DJ, Buttrick PM, Matlock DD. An Electronically Delivered Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure With Reduced Ejection Fraction: The EPIC-HF Trial. Circulation 2020; 143:427-437. [PMID: 33201741 DOI: 10.1161/circulationaha.120.051863] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Major gaps exist in the routine initiation and dose up-titration of guideline-directed medical therapies (GDMT) for patients with heart failure with reduced ejection fraction. Without novel approaches to improve prescribing, the cumulative benefits of heart failure with reduced ejection fraction treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients. METHODS The EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) trial randomized patients with heart failure with reduced ejection fraction from a diverse health system to usual care versus patient activation tools-a 3-minute video and 1-page checklist-delivered electronically 1 week before, 3 days before, and 24 hours before a cardiology clinic visit. The tools encouraged patients to work collaboratively with their clinicians to "make one positive change" in heart failure with reduced ejection fraction prescribing. The primary endpoint was the percentage of patients with GDMT medication initiations and dose intensifications from immediately preceding the cardiology clinic visit to 30 days after, compared with usual care during the same period. RESULTS EPIC-HF enrolled 306 patients, 290 of whom attended a clinic visit during the study period: 145 were sent the patient activation tools and 145 were controls. The median age of patients was 65 years; 29% were female, 11% were Black, 7% were Hispanic, and the median ejection fraction was 32%. Preclinic data revealed significant GDMT opportunities, with no patients on target doses of β-blocker, sacubitril/valsartan, and mineralocorticoid receptor antagonists. From immediately preceding the cardiology clinic visit to 30 days after, 49.0% in the intervention and 29.7% in the control experienced an initiation or intensification of their GDMT (P=0.001). The majority of these changes were made at the clinician encounter itself and involved dose uptitrations. There were no deaths and no significant differences in hospitalization or emergency department visits at 30 days between groups. CONCLUSIONS A patient activation tool delivered electronically before a cardiology clinic visit improved clinician intensification of GDMT. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334188.
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Affiliation(s)
- Larry A Allen
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Grace Venechuk
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Colleen K McIlvennan
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Robert L Page
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora (R.L.P., K.E.T.)
| | | | - Laura J Helmkamp
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Prateeti Khazanie
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Pamela N Peterson
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.).,Denver Health Medical Center, CO (P.N.P.)
| | - Kenneth Pierce
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Geoffrey Harger
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Jocelyn S Thompson
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Tristan J Dow
- University of Colorado Health Poudre Valley Hospital, Loveland (T.J.D., L.R.)
| | - Lance Richards
- University of Colorado Health Poudre Valley Hospital, Loveland (T.J.D., L.R.)
| | - Janice Huang
- University of Colorado Health Memorial Hospital, Colorado Springs (J.H., J.R.S.)
| | - James R Strader
- University of Colorado Health Memorial Hospital, Colorado Springs (J.H., J.R.S.)
| | - Katy E Trinkley
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.).,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora (R.L.P., K.E.T.)
| | - David P Kao
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - David J Magid
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Peter M Buttrick
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Daniel D Matlock
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
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9
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Venechuk GE, Khazanie P, Page RL, Knoepke CE, Helmkamp LJ, Peterson PN, Pierce K, Thompson JS, Huang J, Strader JR, Dow TJ, Richards L, Trinkley KE, Kao DP, McIlvennan CK, Magid DJ, Buttrick PM, Matlock DD, Allen LA. An Electronically delivered, Patient-activation tool for Intensification of medications for Chronic Heart Failure with reduced ejection fraction: Rationale and design of the EPIC-HF trial. Am Heart J 2020; 229:144-155. [PMID: 32866454 DOI: 10.1016/j.ahj.2020.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Heart failure with reduced ejection fraction (HFrEF) benefits from initiation and intensification of multiple pharmacotherapies. Unfortunately, there are major gaps in the routine use of these drugs. Without novel approaches to improve prescribing, the cumulative benefits of HFrEF treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients. HYPOTHESIS Encouraging patients to engage providers in HFrEF prescribing decisions will improve the use of guideline-directed medical therapies. DESIGN The Electronically delivered, Patient-activation tool for Intensification of Chronic medications for Heart Failure with reduced ejection fraction (EPIC-HF) trial randomizes patients with HFrEF to usual care versus patient-activation tools-a 3-minute video and 1-page checklist-delivered prior to cardiology clinic visits that encourage patients to work collaboratively with their clinicians to intensify HFrEF prescribing. The study assesses the effectiveness of the EPIC-HF intervention to improve guideline-directed medical therapy in the month after its delivery while using an implementation design to also understand the reach, adoption, implementation, and maintenance of this approach within the context of real-world care delivery. Study enrollment was completed in January 2020, with a total 305 patients. Baseline data revealed significant opportunities, with <1% of patients on optimal HFrEF medical therapy. SUMMARY The EPIC-HF trial assesses the implementation, effectiveness, and safety of patient engagement in HFrEF prescribing decisions. If successful, the tool can be easily disseminated and may inform similar interventions for other chronic conditions.
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10
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Hirji SA, Halpern AL, Helmkamp LJ, Roberts SH, Houk AK, Osho A, Okoh AK, Meguid RA, Seese L, Weyant MJ, Rinewalt DE. Geographic and temporal patterns of growth in the utilization of donation after circulatory death donors for lung transplantation in the United States. J Heart Lung Transplant 2020; 39:1313-1315. [PMID: 32921583 DOI: 10.1016/j.healun.2020.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alison L Halpern
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Laura J Helmkamp
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado, Aurora, Colorado
| | - Sophia H Roberts
- Department of Surgery, Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, Missouri
| | - Anna K Houk
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Asishana Osho
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Alexis K Okoh
- Department of Medicine, Robert Wood Johnston Barnabas Health, Newark, New Jersey
| | - Robert A Meguid
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Laura Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburg, Pennsylvania
| | - Michael J Weyant
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Daniel E Rinewalt
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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11
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Wallace BC, Allen LA, Knoepke CE, Glasgow RE, Lewis CL, Fairclough DL, Helmkamp LJ, Fitzgerald MD, Tzou WS, Kramer DB, Varosy PD, Gupta SK, Mandrola JM, Brancato SC, Peterson PN, Matlock DD. A multicenter trial of a shared DECision Support Intervention for Patients offered implantable Cardioverter-DEfibrillators: DECIDE-ICD rationale, design, Medicare changes, and pilot data. Am Heart J 2020; 226:161-173. [PMID: 32599257 DOI: 10.1016/j.ahj.2020.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 04/15/2020] [Indexed: 01/15/2023]
Abstract
Shared decision making (SDM) facilitates delivery of medical therapies that are in alignment with patients' goals and values. Medicare national coverage decision for several interventions now includes SDM mandates, but few have been evaluated in nationwide studies. Based upon a detailed needs assessment with diverse stakeholders, we developed pamphlet and video patient decision aids (PtDAs) for implantable cardioverter/defibrillator (ICD) implantation, ICD replacement, and cardiac resynchronization therapy with defibrillation to help patients contemplate, forecast, and deliberate their options. These PtDAs are the foundation of the Multicenter Trial of a Shared Decision Support Intervention for Patients Offered Implantable Cardioverter-Defibrillators (DECIDE-ICD), a multicenter, randomized trial sponsored by the National Heart, Lung, and Blood Institute aimed at understanding the effectiveness and implementation of an SDM support intervention for patients considering ICDs. Finalization of a Medicare coverage decision mandating the inclusion of SDM for new ICD implantation occurred shortly after trial initiation, raising novel practical and statistical considerations for evaluating study end points. METHODS/DESIGN: A stepped-wedge randomized controlled trial was designed, guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) planning and evaluation framework using an effectiveness-implementation hybrid type II design. Six electrophysiology programs from across the United States will participate. The primary effectiveness outcome is decision quality (defined by knowledge and values-treatment concordance). Patients with heart failure who are clinically eligible for an ICD are eligible for the study. Target enrollment is 900 participants. DISCUSSION: Study findings will provide a foundation for implementing decision support interventions, including PtDAs, with patients who have chronic progressive illness and are facing decisions involving invasive, preference-sensitive therapy options.
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12
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Knupp KG, Rice JD, Helmkamp LJ, Galinkin J, Sempio C, Jost K, Chapman KE. Prospective evaluation of oral cannabis extracts in children with epilepsy. Seizure 2019; 72:23-27. [PMID: 31550641 DOI: 10.1016/j.seizure.2019.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 02/13/2019] [Revised: 09/10/2019] [Accepted: 09/14/2019] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Interest in the use of artisanal cannabinoids in pediatric epilepsy has increased but safety and utility data are lacking. Our aim was to prospectively characterize the use of oral cannabis extracts (OCE) in a refractory pediatric epilepsy population. METHODS Families considering the use of an OCE were enrolled in a prospective observational study. Baseline seizure frequency was assessed over a period of 4 weeks. Seizure frequency, CBD and THC-COOH levels were assessed every 4 weeks during a 12-week treatment period. Response was defined as at least a 50% reduction in seizure frequency over the final 8 weeks of the study relative to baseline. RESULTS Consent was obtained in 32 children; 11 were excluded from analysis (3 failed to complete baseline data, 3 started OCE before completing baseline period and 5 did not start OCE) leaving 21 to be included in subsequent analyses. Median age was 10.3 years (IQR 6.8-12.6), 13 (62%) were male and median seizure frequency was 2.7 seizures/day during the baseline period. The median of the high dose of CBD that was administered during the observation period was of 0.9 (0.6-2.2) mg/kg/day. Of the 21 subjects who were included in the analysis, 5 (24%) were responders. OCE was stopped early in 3 subjects (14%) due to a perceived increase in seizures. THC-COOH and CBD blood levels did not have a significant association with response status (p = 0.95 CBD, p = 0.53 THC-COOH, N = 14). CONCLUSION The observed response rate in this study is similar to placebo rates in prospective randomized trials of pharmaceutical grade products and the withdrawal rate is greater than rates obtained with retrospective methods. Doses of OCE administered were lower than doses used in randomized trials.
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Affiliation(s)
- Kelly G Knupp
- Department of Pediatrics and Neurology, University of Colorado, Anschutz Medical Campus, Aurora CO 80045, United States.
| | - John D Rice
- Department of Biostatistics and Informatics, University of Colorado, Anschutz Medical Campus, Aurora CO 80045, United States; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, 80045, United States
| | - Laura J Helmkamp
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, 80045, United States
| | - Jeffrey Galinkin
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora CO 80045, United States; Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora CO 80045, United States
| | - Cristina Sempio
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora CO 80045, United States
| | - Klawitter Jost
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora CO 80045, United States
| | - Kevin E Chapman
- Department of Pediatrics and Neurology, University of Colorado, Anschutz Medical Campus, Aurora CO 80045, United States
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13
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Moskowitz E, Campion EM, Burlew CC, Helmkamp LJ, Peltz ED, Gansar BL, McIntyre RC. Obstruction reduction: Use of water-soluble contrast challenge to differentiate between partial and complete small bowel obstruction. Am J Surg 2019; 218:913-917. [PMID: 30910130 DOI: 10.1016/j.amjsurg.2019.02.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/23/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
Differentiating SBO that will resolve conservatively from those requiring surgery remains challenging. Water-soluble contrast administration may be diagnostic and therapeutic. Our study evaluated use of a WSC challenge protocol. We hypothesize that protocol use discriminates between surgical SBO and obstructions which can be managed non-operatively. Demographics, prior surgeries, time to operation, complications, and LOS were analyzed. 108 patients were admitted with SBO. 13% underwent immediate laparotomy with concern for bowel compromise; these had a median LOS of 8.5 days. 91 received WSC protocol. Of these, 77% had contrast passage to the colon. Of the 48 in whom contrast passed between 0 and 12 h, LOS was 2 days. Of the 22 patients in whom contrast passed between 12 and 24 h, LOS was 4.5 days. 21 had failure of contrast passage; 18 of those underwent surgery after 24 h as a result. Of the 21 patients who failed WSC challenge, median LOS was 8 days. WSC protocol implementation facilitates early recognition of partial from complete obstruction and may decrease LOS. Our findings warrant further evaluation with a multicenter trial.
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Affiliation(s)
- Eliza Moskowitz
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, USA
| | - Eric M Campion
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, USA.
| | - Clay Cothren Burlew
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, USA
| | - Laura J Helmkamp
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, USA
| | - Erik D Peltz
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brittany L Gansar
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert C McIntyre
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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14
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Mitchell NS, Furniss AL, Helmkamp LJ, Van Pelt RE. Factors Associated with Achievement of Clinically Significant Weight Loss by Women in a National Nonprofit Weight Loss Program. J Womens Health (Larchmt) 2017; 26:911-917. [PMID: 28686527 DOI: 10.1089/jwh.2016.6264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Clinically significant weight loss (CSWL) is ≥5% of initial weight. The purpose of the study is to determine factors associated with women achieving CSWL in Take Off Pounds Sensibly (TOPS), a national, nonprofit weight loss program. METHODS This is a retrospective analysis of 48,674 females who joined TOPS from 2005 to 2011 and had a birth date in the database. Predictors of CSWL were evaluated using log-binomial regression and adjusted relative risks [99% CI] for participant age, initial weight, number of members per chapter, and chapter age. RESULTS Older women were more likely to achieve CSWL, with women ≥70 years 1.23 (1.18, 1.28) times more likely to achieve CSWL compared to women 18 to <45 years. Women who weighed 113 to <136 kg and ≥136 kg were 1.06 (1.02, 1.10) and 1.07 (1.02, 1.14) times more likely to achieve CSWL compared to women <80 kg, respectively. Women in chapters with 25 to <35 members and ≥35 members more were 1.09 (1.05, 1.13) and 1.14 (1.10, 1.18) times more likely to achieve CSWL than those in chapters with less than 15 members. Women in older chapters were less likely to achieve CSWL, with women in chapters 10 to 20 years old 0.95 (0.92, 0.99) times as likely to lose weight as those in chapters less than 10 years old. CONCLUSIONS Women in TOPS were more likely to achieve CSWL if older, ≥113 kg, and in larger, newer chapters. Future studies should address ways to modify the program to improve achievement of CSWL.
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Affiliation(s)
- Nia S Mitchell
- 1 Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus , Anschutz Health and Wellness Center, Aurora, Colorado
| | - Anna L Furniss
- 2 Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Laura J Helmkamp
- 2 Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Rachael E Van Pelt
- 3 Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus , Aurora, Colorado
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15
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Abstract
Among the methods currently available for inferring species trees from gene trees, the GLASS method of Mossel and Roch (2010), the Shallowest Divergence (SD) method of Maddison and Knowles (2006), the STEAC method of Liu et al. (2009), and a related method that we call Minimum Average Coalescence (MAC) are computationally efficient and provide branch length estimates. Further, GLASS and STEAC have been shown to be consistent estimators of tree topology under a multispecies coalescent model. However, divergence time estimates obtained with these methods are all systematically biased under the model because the pairwise interspecific gene divergence times on which they rely must be more ancient than the species divergence time. Jewett and Rosenberg (2012) derived an expression for the bias of GLASS and used it to propose an improved method that they termed iGLASS. Here, we derive the biases of SD, STEAC, and MAC, and we propose improved analogues of these methods that we call iSD, iSTEAC, and iMAC. We conduct simulations to compare the performance of these methods with their original counterparts and with GLASS and iGLASS, finding that each of them decreases the bias and mean squared error of pairwise divergence time estimates. The new methods can therefore contribute to improvements in the estimation of species trees from information on gene trees.
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Affiliation(s)
- Laura J Helmkamp
- Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109, USA.
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