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Carleton N, Abidi H, Puthanmadhom-Narayanan S, Marroquin OC, Oesterreich S, Diego EJ, Brufsky AM, Lee AV, McAuliffe PF. Omission of surgery, primary endocrine therapy adherence, and effect of comorbidity in older women with estrogen receptor positive breast cancer. J Geriatr Oncol 2024; 15:101679. [PMID: 38135542 PMCID: PMC10994773 DOI: 10.1016/j.jgo.2023.101679] [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] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/08/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023]
Affiliation(s)
- Neil Carleton
- Women's Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Hira Abidi
- Division of Breast Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, PA, USA
| | | | | | - Steffi Oesterreich
- Women's Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Emilia J Diego
- Division of Breast Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, PA, USA
| | - Adam M Brufsky
- Division of Medical Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Adrian V Lee
- Women's Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Priscilla F McAuliffe
- Women's Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA; Division of Breast Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, PA, USA.
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Kip KE, Diamond D, Mulukutla S, Marroquin OC. Is LDL cholesterol associated with long-term mortality among primary prevention adults? A retrospective cohort study from a large healthcare system. BMJ Open 2024; 14:e077949. [PMID: 38548371 PMCID: PMC10982736 DOI: 10.1136/bmjopen-2023-077949] [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: 07/20/2023] [Accepted: 03/18/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVES Among primary prevention-type adults not on lipid-lowering therapy, conflicting results exist on the relationship between low-density lipoprotein cholesterol (LDL-C) and long-term mortality. We evaluated this relationship in a real-world evidence population of adults. DESIGN Retrospective cohort study. SETTING Electronic medical record data for adults, from 4 January 2000 through 31 December 2022, were extracted from the University of Pittsburgh Medical Center healthcare system. PARTICIPANTS Adults without diabetes aged 50-89 years not on statin therapy at baseline or within 1 year and classified as primary prevention-type patients. To mitigate potential reverse causation, patients who died within 1 year or had baseline total cholesterol (T-C) ≤120 mg/dL or LDL-C <30 mg/dL were excluded. MAIN EXPOSURE MEASURE Baseline LDL-C categories of 30-79, 80-99, 100-129, 130-159, 160-189 or ≥190 mg/dL. MAIN OUTCOME MEASURE All-cause mortality with follow-up starting 365 days after baseline cholesterol measurement. RESULTS 177 860 patients with a mean (SD) age of 61.1 (8.8) years and mean (SD) LDL-C of 119 (31) mg/dL were evaluated over a mean of 6.1 years of follow-up. A U-shaped relationship was observed between the six LDL-C categories and mortality with crude 10-year mortality rates of 19.8%, 14.7%, 11.7%, 10.7%, 10.1% and 14.0%, respectively. Adjusted mortality HRs as compared with the referent group of LDL-C 80-99 mg/dL were: 30-79 mg/dL (HR 1.23, 95% CI 1.17 to 1.30), 100-129 mg/dL (0.87, 0.83-0.91), 130-159 mg/dL (0.88, 0.84-0.93), 160-189 mg/dL (0.91, 0.84-0.98) and ≥190 mg/dL (1.19, 1.06-1.34), respectively. Unlike LDL-C, both T-C/HDL cholesterol (high-density lipoprotein cholesterol) and triglycerides/HDL cholesterol ratios were independently associated with long-term mortality. CONCLUSIONS Among primary prevention-type patients aged 50-89 years without diabetes and not on statin therapy, the lowest risk for long-term mortality appears to exist in the wide LDL-C range of 100-189 mg/dL, which is much higher than current recommendations. For counselling these patients, minimal consideration should be given to LDL-C concentration.
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Affiliation(s)
- Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - David Diamond
- Department of Psychology, University of South Florida, Tampa, Florida, USA
| | - Suresh Mulukutla
- Clinical Analytics, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Oscar C Marroquin
- Physician Services Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Holder-Murray J, Esper SA, Althans AR, Knight J, Subramaniam K, Derenzo J, Ball R, Beaman S, Luke C, La Colla L, Schott N, Williams B, Lorenzi E, Berry LR, Viele K, Berry S, Masters M, Meister KA, Wilkinson T, Garrard W, Marroquin OC, Mahajan A. REMAP Periop: a randomised, embedded, multifactorial adaptive platform trial protocol for perioperative medicine to determine the optimal enhanced recovery pathway components in complex abdominal surgery patients within a US healthcare system. BMJ Open 2023; 13:e078711. [PMID: 38154902 PMCID: PMC10759097 DOI: 10.1136/bmjopen-2023-078711] [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: 08/09/2023] [Accepted: 11/23/2023] [Indexed: 12/30/2023] Open
Abstract
INTRODUCTION Implementation of enhanced recovery pathways (ERPs) has resulted in improved patient-centred outcomes and decreased costs. However, there is a lack of high-level evidence for many ERP elements. We have designed a randomised, embedded, multifactorial, adaptive platform perioperative medicine (REMAP Periop) trial to evaluate the effectiveness of several perioperative therapies for patients undergoing complex abdominal surgery as part of an ERP. This trial will begin with two domains: postoperative nausea/vomiting (PONV) prophylaxis and regional/neuraxial analgesia. Patients enrolled in the trial will be randomised to arms within both domains, with the possibility of adding additional domains in the future. METHODS AND ANALYSIS In the PONV domain, patients are randomised to optimal versus supraoptimal prophylactic regimens. In the regional/neuraxial domain, patients are randomised to one of five different single-injection techniques/combination of techniques. The primary study endpoint is hospital-free days at 30 days, with additional domain-specific secondary endpoints of PONV incidence and postoperative opioid consumption. The efficacy of an intervention arm within a given domain will be evaluated at regular interim analyses using Bayesian statistical analysis. At the beginning of the trial, participants will have an equal probability of being allocated to any given intervention within a domain (ie, simple 1:1 randomisation), with response adaptive randomisation guiding changes to allocation ratios after interim analyses when applicable based on prespecified statistical triggers. Triggers met at interim analysis may also result in intervention dropping. ETHICS AND DISSEMINATION The core protocol and domain-specific appendices were approved by the University of Pittsburgh Institutional Review Board. A waiver of informed consent was obtained for this trial. Trial results will be announced to the public and healthcare providers once prespecified statistical triggers of interest are reached as described in the core protocol, and the most favourable interventions will then be implemented as a standardised institutional protocol. TRIAL REGISTRATION NUMBER NCT04606264.
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Affiliation(s)
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alison R Althans
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joshua Knight
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph Derenzo
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ryan Ball
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shawn Beaman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Charles Luke
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Luca La Colla
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nicholas Schott
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian Williams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Kert Viele
- Berry Consultants Statistical Innovation, Austin, Texas, USA
| | - Scott Berry
- Berry Consultants Statistical Innovation, Austin, Texas, USA
| | - Miranda Masters
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Katie A Meister
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Todd Wilkinson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Oscar C Marroquin
- Clinical Analytics, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Schell JO, Schenker Y, Piscitello G, Belin SC, Chiu EJ, Zapf RL, Kip PL, Marroquin OC, Donahoe MP, Holder-Murray J, Arnold RM. Implementing a Serious Illness Risk Prediction Model: Impact on Goals of Care Documentation. J Pain Symptom Manage 2023; 66:603-610.e3. [PMID: 37532159 PMCID: PMC10828667 DOI: 10.1016/j.jpainsymman.2023.07.015] [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: 05/08/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/04/2023]
Abstract
CONTEXT Goals of care conversations can promote high value care for patients with serious illness, yet documented discussions infrequently occur in hospital settings. OBJECTIVES We sought to develop a quality improvement initiative to improve goals of care documentation for hospitalized patients. METHODS Implementation occurred at an academic medical center in Pittsburgh, Pennsylvania. Intervention included integration of a 90-day mortality prediction model grouping patients into low, intermediate, and high risk; a centralized goals of care note; and automated notifications and targeted palliative consults. We compared documented goals of care discussions by risk score before and after implementation. RESULTS Of the 12,571 patients hospitalized preimplementation and 10,761 postimplementation, 1% were designated high risk and 11% intermediate risk of mortality. Postimplementation, goals of care documentation increased for high (17.6%-70.8%, P< 0.0001) and intermediate risk patients (9.6%-28.0%, P < 0.0001). For intermediate risk patients, the percentage of goals of care documentation performed by palliative medicine specialists increased from pre- to postimplementation (52.3%-71.2%, P = 0.0002). For high-risk patients, the percentage of goals of care documentation completed by the primary service increased from pre-to postimplementation (36.8%-47.1%, P = 0.5898, with documentation performed by palliative medicine specialists slightly decreasing from pre- to postimplementation (63.2%-52.9%, P = 0.5898). CONCLUSIONS Implementation of a goals of care initiative using a mortality prediction model significantly increased goals of care documentation especially among high-risk patients. Further study to assess strategies to increase goals of care documentation for intermediate risk patients is needed especially by nonspecialty palliative care.
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Affiliation(s)
- Jane O Schell
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Renal-Electrolyte Division (J.O.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gina Piscitello
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shane C Belin
- Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eric J Chiu
- Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel L Zapf
- Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
| | - Paula L Kip
- Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
| | | | - Michael P Donahoe
- Division of Pulmonary, Allergy, and Critical Care Medicine (M.P.D.), Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Holder-Murray
- Departments of Surgery and Anesthesiology and Perioperative Medicine (J.H.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
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Lukanski A, Watters S, Bilderback AL, Buchanan D, Hodges JC, Burwell D, Triola A, Marroquin OC, Martin SC, Zapf RL, Kip PL, Minnier TE. Implementing a Discharge Follow-up Phone Call Program Reduces Readmission Rates in an Integrated Health System. J Healthc Qual 2023; 45:315-323. [PMID: 37788411 DOI: 10.1097/jhq.0000000000000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
ABSTRACT In this study, we sought to determine the effect of implementing a large-scale discharge follow-up phone call program on hospital readmission rates. Previous work has shown that patients with unaddressed concerns during discharge have significantly higher rates of care complications and hospital readmissions. This study is an observational quality improvement project completed from April 17, 2020 to January 31, 2022 at 22 hospitals in a large, integrated academic health system. A nurse-led scripted discharge follow-up phone call program was implemented to contact all patients discharged from inpatient care within 72 hours of discharge. Readmission rates were tracked before and after project implementation. Over a 21-month span, 137,515 phone calls were placed, and 57.92% of patients were successfully contacted within 7 days of discharge. The 7-day readmission rate for contacted patients was 2.91% compared with 4.73% for noncontacted patients. The 30-day readmission rate for contacted patients was 11.00% compared with 12.17% for noncontacted patients. We have found that discharge follow-up phone calls targeting patients decreases risk of readmission, which improves overall patient outcomes.
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Paez-Escamilla M, Caplash S, Kalra G, Odden J, Price D, Marroquin OC, Koscumb S, Commiskey P, Indermill C, Finkelstein J, Gushchin AG, Coca A, Friberg TR, Eller AW, Gallagher DS, Harwick JC, Waxman EL, Chhablani J, Bonhomme G, Prensky C, Anetakis AJ, Martel JN, Massicotte E, Ores R, Girmens JF, Pearce TM, Sahel JA, Dansingani K, Westcott M, Errera MH. Challenges in posterior uveitis-tips and tricks for the retina specialist. J Ophthalmic Inflamm Infect 2023; 13:35. [PMID: 37589912 PMCID: PMC10435440 DOI: 10.1186/s12348-023-00342-5] [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: 01/04/2023] [Accepted: 04/07/2023] [Indexed: 08/18/2023] Open
Abstract
PURPOSE Posterior uveitis is a common chorioretinal pathology affecting all ages worldwide and is a frequent reason for referral to the retina clinic. The spectrum of etiologies for uveitis is very broad and includes infectious and auto-immune diseases. Inflammation can be confined to the eye or may be a part of systemic disease. A useful outline is therefore proposed to aid in the correct diagnosis of these challenging entities. The situation is further complicated by the fact that many neoplastic conditions resemble features of posterior uveitis; they are known as "masqueraders of uveitis". Here, we summarize different posterior uveitides that present with rare findings, along with masqueraders that can be difficult to distinguish. These conditions pose a diagnostic dilemma resulting in delay in treatment because of diagnostic uncertainty. METHODS An extensive literature search was performed on the MEDLINE/PUBMED, EBSCO and Cochrane CENTRAL databases from January 1985 to January 2022 for original studies and reviews of predetermined diagnoses that include posterior uveitic entities, panuveitis and masquerade syndromes. RESULTS We described conditions that can present as mimickers of posterior uveitis (i.e., immune check-points inhibitors and Vogt-Koyanagi-Harada-like uveitis; leukemia and lymphoma associated posterior uveitis), inflammatory conditions that present as mimickers of retinal diseases (i.e., Purtscher-like retinopathy as a presentation of systemic lupus erythematosus; central serous chorioretinopathy masquerading inflammatory exudative retinal detachment), and uveitic conditions with rare and diagnostically challenging etiologies (i.e., paradoxical inflammatory effects of anti-TNF-α; post vaccination uveitis; ocular inflammation after intravitreal injection of antiangiogenic drugs). CONCLUSION This review of unique posterior uveitis cases highlights the overlapping features of posterior uveitis (paradoxical inflammatory effects of anti -TNF α and uveitis; Purtscher-like retinopathy as a presentation of systemic lupus erythematosus, …) and the nature of retinal conditions (ischemic ocular syndrome, or central retinal vein occlusion, amyloidosis, inherited conditions like retinitis pigmentosa, autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV), etc.…) that may mimic them is represented. Careful review of past uveitis history, current medications and recent vaccinations, detailed examination of signs of past or present inflammation, eventually genetic testing and/ or multimodal retinal imaging (like fluorescein angiography, EDI-OCT, OCT-angiography for lupus Purtscher-like retinopathy evaluation, or ICG for central serous retinopathy, or retinal amyloid angiopathy) may aid in correct diagnosis.
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Affiliation(s)
- Manuel Paez-Escamilla
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sonny Caplash
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Gagan Kalra
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jamie Odden
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Danielle Price
- Clinical Analytics, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Stephen Koscumb
- Clinical Analytics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick Commiskey
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chad Indermill
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jerome Finkelstein
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anna G Gushchin
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Andreea Coca
- Department of Rheumatology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Thomas R Friberg
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Andrew W Eller
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Denise S Gallagher
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jean C Harwick
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Evan L Waxman
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jay Chhablani
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Gabrielle Bonhomme
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Colin Prensky
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexander J Anetakis
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph N Martel
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Erika Massicotte
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Raphaelle Ores
- Department of Ophthalmology, McGill University Campus Outaouais, Gatineau, QC, Canada
| | | | - Thomas M Pearce
- Division of Neuropathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jose-Alain Sahel
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kunal Dansingani
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mark Westcott
- Department of Uveitis, Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - Marie-Helene Errera
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- UPMC Eye Center, University of Pittsburgh School of Medicine, 203 Lothrop Street, Pittsburgh, PA, 15213, USA.
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Mahajan A, Esper S, Oo TH, McKibben J, Garver M, Artman J, Klahre C, Ryan J, Sadhasivam S, Holder-Murray J, Marroquin OC. Development and Validation of a Machine Learning Model to Identify Patients Before Surgery at High Risk for Postoperative Adverse Events. JAMA Netw Open 2023; 6:e2322285. [PMID: 37418262 DOI: 10.1001/jamanetworkopen.2023.22285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
Importance Identifying patients at high risk of adverse outcomes prior to surgery may allow for interventions associated with improved postoperative outcomes; however, few tools exist for automated prediction. Objective To evaluate the accuracy of an automated machine-learning model in the identification of patients at high risk of adverse outcomes from surgery using only data in the electronic health record. Design, Setting, and Participants This prognostic study was conducted among 1 477 561 patients undergoing surgery at 20 community and tertiary care hospitals in the University of Pittsburgh Medical Center (UPMC) health network. The study included 3 phases: (1) building and validating a model on a retrospective population, (2) testing model accuracy on a retrospective population, and (3) validating the model prospectively in clinical care. A gradient-boosted decision tree machine learning method was used for developing a preoperative surgical risk prediction tool. The Shapley additive explanations method was used for model interpretability and further validation. Accuracy was compared between the UPMC model and National Surgical Quality Improvement Program (NSQIP) surgical risk calculator for predicting mortality. Data were analyzed from September through December 2021. Exposure Undergoing any type of surgical procedure. Main Outcomes and Measures Postoperative mortality and major adverse cardiac and cerebrovascular events (MACCEs) at 30 days were evaluated. Results Among 1 477 561 patients included in model development (806 148 females [54.5%; mean [SD] age, 56.8 [17.9] years), 1 016 966 patient encounters were used for training and 254 242 separate encounters were used for testing the model. After deployment in clinical use, another 206 353 patients were prospectively evaluated; an additional 902 patients were selected for comparing the accuracy of the UPMC model and NSQIP tool for predicting mortality. The area under the receiver operating characteristic curve (AUROC) for mortality was 0.972 (95% CI, 0.971-0.973) for the training set and 0.946 (95% CI, 0.943-0.948) for the test set. The AUROC for MACCE and mortality was 0.923 (95% CI, 0.922-0.924) on the training and 0.899 (95% CI, 0.896-0.902) on the test set. In prospective evaluation, the AUROC for mortality was 0.956 (95% CI, 0.953-0.959), sensitivity was 2148 of 2517 patients (85.3%), specificity was 186 286 of 203 836 patients (91.4%), and negative predictive value was 186 286 of 186 655 patients (99.8%). The model outperformed the NSQIP tool as measured by AUROC (0.945 [95% CI, 0.914-0.977] vs 0.897 [95% CI, 0.854-0.941], for a difference of 0.048), specificity (0.87 [95% CI, 0.83-0.89] vs 0.68 [95% CI, 0.65-0.69]), and accuracy (0.85 [95% CI, 0.82-0.87] vs 0.69 [95% CI, 0.66, 0.72]). Conclusions and Relevance This study found that an automated machine learning model was accurate in identifying patients undergoing surgery who were at high risk of adverse outcomes using only preoperative variables within the electronic health record, with superior performance compared with the NSQIP calculator. These findings suggest that using this model to identify patients at increased risk of adverse outcomes prior to surgery may allow for individualized perioperative care, which may be associated with improved outcomes.
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Affiliation(s)
- Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephen Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thien Htay Oo
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffery McKibben
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Garver
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jamie Artman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Cynthia Klahre
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John Ryan
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Holder-Murray
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Oscar C Marroquin
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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8
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Panza E, Kip KE, Venkatakrishnan K, Marroquin OC, Wing RR. Changes in body weight and glycemic control in association with COVID-19 Shutdown among 23,000 adults with type 2 diabetes. Acta Diabetol 2023; 60:787-795. [PMID: 36894712 PMCID: PMC9998005 DOI: 10.1007/s00592-023-02056-5] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/19/2023] [Indexed: 03/11/2023]
Abstract
AIMS To examine the association between COVID-19 Shutdown and within-subjects changes in body weight, body mass index (BMI), and glycemic parameters using electronic health record (EHR) data from 23,000 adults with type 2 diabetes (T2DM). METHODS Patients with T2DM with outpatient visit data on body weight, BMI, hemoglobin A1c (HbA1c), and blood glucose (≥ 2 measures before and after 3/16/2020) recorded in the EHR at the University of Pittsburgh Medical Center were included. A within-subjects analysis compared average and clinically significant changes in weight, BMI, HbA1c, and blood glucose during the year POST-Shutdown (Time 2-3) compared to the same interval during the PRE-Shutdown year (Time 0-1) using paired samples t-tests and the McNemar-Bowker test. RESULTS We studied 23,697 adults with T2DM (51% female; 89% White; mean age = 66 ± 13 years; mean BMI = 34 ± 7 kg/m2; mean HbA1c = 7 ± 2% [53 ± 21.9 mmol/mol]). Weight and BMI decreased during both the PRE- and POST-Shutdown intervals, but the changes were statistically smaller during the year POST-Shutdown relative to PRE (0.32 kg and 0.11 units, p < 0.0001). HbA1c showed statistically greater improvements during the POST-Shutdown interval compared to PRE (- 0.18% [-2 mmol/mol], p < 0.0001), but changes in glucose did not differ for the two intervals. CONCLUSIONS Despite widespread discussion of weight gain in association with the COVID-19 Shutdown, study data showed no evidence of adverse effects of Shutdown on body weight, BMI, HbA1C, or blood glucose in a large sample of adults with T2DM. This information may help to inform future public health decision-making.
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Affiliation(s)
- Emily Panza
- Weight Control and Diabetes Research Center, The Miriam Hospital, 196 Richmond Street, Providence, RI, 02903, USA.
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA.
| | - Kevin E Kip
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kripa Venkatakrishnan
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Oscar C Marroquin
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rena R Wing
- Weight Control and Diabetes Research Center, The Miriam Hospital, 196 Richmond Street, Providence, RI, 02903, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
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9
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Kip KE, McCreary EK, Collins K, Minnier TE, Snyder GM, Garrard W, McKibben JC, Yealy DM, Seymour CW, Huang DT, Bariola JR, Schmidhofer M, Wadas RJ, Angus DC, Kip PL, Marroquin OC. Evolving Real-World Effectiveness of Monoclonal Antibodies for Treatment of COVID-19 : A Cohort Study. Ann Intern Med 2023; 176:496-504. [PMID: 37011399 PMCID: PMC10074437 DOI: 10.7326/m22-1286] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Treatment guidelines and U.S. Food and Drug Administration emergency use authorizations (EUAs) of monoclonal antibodies (mAbs) for treatment of high-risk outpatients with mild to moderate COVID-19 changed frequently as different SARS-CoV-2 variants emerged. OBJECTIVE To evaluate whether early outpatient treatment with mAbs, overall and by mAb product, presumed SARS-CoV-2 variant, and immunocompromised status, is associated with reduced risk for hospitalization or death at 28 days. DESIGN Hypothetical pragmatic randomized trial from observational data comparing mAb-treated patients with a propensity score-matched, nontreated control group. SETTING Large U.S. health care system. PARTICIPANTS High-risk outpatients eligible for mAb treatment under any EUA with a positive SARS-CoV-2 test result from 8 December 2020 to 31 August 2022. INTERVENTION Single-dose intravenous mAb treatment with bamlanivimab, bamlanivimab-etesevimab, sotrovimab, bebtelovimab, or intravenous or subcutaneous casirivimab-imdevimab administered within 2 days of a positive SARS-CoV-2 test result. MEASUREMENTS The primary outcome was hospitalization or death at 28 days among treated patients versus a nontreated control group (no treatment or treatment ≥3 days after SARS-CoV-2 test date). RESULTS The risk for hospitalization or death at 28 days was 4.6% in 2571 treated patients and 7.6% in 5135 nontreated control patients (risk ratio [RR], 0.61 [95% CI, 0.50 to 0.74]). In sensitivity analyses, the corresponding RRs for 1- and 3-day treatment grace periods were 0.59 and 0.49, respectively. In subgroup analyses, those receiving mAbs when the Alpha and Delta variants were presumed to be predominant had estimated RRs of 0.55 and 0.53, respectively, compared with 0.71 for the Omicron variant period. Relative risk estimates for individual mAb products all suggested lower risk for hospitalization or death. Among immunocompromised patients, the RR was 0.45 (CI, 0.28 to 0.71). LIMITATIONS Observational study design, SARS-CoV-2 variant presumed by date rather than genotyping, no data on symptom severity, and partial data on vaccination status. CONCLUSION Early mAb treatment among outpatients with COVID-19 is associated with lower risk for hospitalization or death for various mAb products and SARS-CoV-2 variants. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (E.K.M., G.M.S., J.R.B.)
| | - Kevin Collins
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Tami E Minnier
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (T.E.M., P.L.K.)
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (E.K.M., G.M.S., J.R.B.)
| | - William Garrard
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Jeffrey C McKibben
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y., R.J.W.)
| | - Christopher W Seymour
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (C.W.S., D.C.A.)
| | - David T Huang
- Department of Emergency Medicine and Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.T.H.)
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (E.K.M., G.M.S., J.R.B.)
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (M.S.)
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y., R.J.W.)
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (C.W.S., D.C.A.)
| | - Paula L Kip
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (T.E.M., P.L.K.)
| | - Oscar C Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
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10
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Gilmer G, Jackson N, Koscumb S, Marroquin OC, Sowa G. A Retrospective Analysis of Clinical Utilization Between Patients Who Used Telemedicine and Office Visits in Outpatient Physical Medicine and Rehabilitation Clinics During the COVID-19 Pandemic. Am J Phys Med Rehabil 2023; 102:34-42. [PMID: 35302527 PMCID: PMC9464794 DOI: 10.1097/phm.0000000000002012] [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] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe the demographic characteristics of patients who used telemedicine and office visits in physical medicine and rehabilitation during the COVID-19 pandemic and to quantify differences in clinical utilization between groups. Clinical utilization was defined as emergency department, urgent care, and hospital visits. DESIGN This was a retrospective cohort study of 1096 patients who used telemedicine and 1171 patients who used office visits from April to June 2020 in the outpatient physical medicine and rehabilitation clinics at University of Pittsburgh Medical Center for musculoskeletal-related complaints. RESULTS The telemedicine groups contained proportionally more people of color and higher comorbidities than the office visit groups. Patients who were seen in the telemedicine groups were more likely to be prescribed opioids than the office visit group. There were no differences in clinical utilizations between the telemedicine and office visit groups. CONCLUSIONS The higher use of telemedicine in patients of color suggests a need for studying long-term outcomes to evaluate differences in care standards. There is an urgent need to understand how telemedicine affects opioid prescribing practices. Lastly, future studies are needed to understand why there were no differences in clinical utilization between the telemedicine and office visit groups.
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Affiliation(s)
- Gabrielle Gilmer
- Department of Physical Medicine and Rehabilitation, Ambrosio Laboratory, University of Pittsburgh, 450 Technology Drive, BSP II, Pittsburgh PA 15219 USA
- Department of Orthopedic Surgery, Ferguson Laboratory for Orthopedic and Spine Research, University of Pittsburgh, 200 Lothrop Street, E1644 Biomedical Science Tower, Pittsburgh, PA 15261 USA
| | - Natalie Jackson
- Department of Orthopedic Surgery, Ferguson Laboratory for Orthopedic and Spine Research, University of Pittsburgh, 200 Lothrop Street, E1644 Biomedical Science Tower, Pittsburgh, PA 15261 USA
| | | | | | - Gwendolyn Sowa
- Department of Orthopedic Surgery, Ferguson Laboratory for Orthopedic and Spine Research, University of Pittsburgh, 200 Lothrop Street, E1644 Biomedical Science Tower, Pittsburgh, PA 15261 USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219 USA
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11
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Pelletier JH, Au AK, Fuhrman DY, Marroquin OC, Suresh S, Clark RSB, Kochanek PM, Horvat CM. Healthcare Use in the Year Following Bronchiolitis Hospitalization. Hosp Pediatr 2022; 12:937-949. [PMID: 36281706 PMCID: PMC9946196 DOI: 10.1542/hpeds.2022-006657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
OBJECTIVES Healthcare utilization after bronchiolitis hospitalization is incompletely understood. We aimed to characterize readmissions and outpatient visits within 1 year after hospital discharge. METHODS Retrospective multicenter observational cohort study of children under 24-months old admitted with bronchiolitis between January 1, 2010 and December 12, 2019 to the Pediatric Health Information Systems database. A single-center nested subset using linked electronic health records allowed analysis of outpatient visits. RESULTS There were 308 306 admissions for bronchiolitis among 271 115 patients across 47 hospitals between 2010-2019. The percent of patients readmitted within 30 days after discharge was 6.0% (16 167 of 271 115), and 17.8% (48 332 of 271 115) of patients were readmitted within 1 year. 22.9% (16 919 of 74 001) of patients admitted to an ICU and 26.8% (7865 of 29 378) of patients undergoing mechanical ventilation were readmitted within 1 year. There were 1438 patients with outpatient healthcare data available. There were a median (interquartile range) of 9 (6-13) outpatient visits per patient within 1 year after discharge. Outpatient healthcare use increased for 4 months following bronchiolitis hospitalization compared with previously reported age-matched controls. Higher income, white race, commercial insurance, complex chronic conditions, ICU admission, and mechanical ventilation were associated with higher outpatient utilization. Higher quartiles of outpatient use were associated with readmission for bronchiolitis and all-cause readmissions. CONCLUSIONS Readmissions in the year after bronchiolitis hospitalization are common, and outpatient healthcare use is increased for 4 months following discharge. Prospective study is needed to track long-term outcomes of infants with bronchiolitis.
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Affiliation(s)
| | - Alicia K Au
- Departments of Critical Care Medicine
- Pediatrics
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Brain Care Institute
| | | | - Oscar C Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Srinivasan Suresh
- Division of Health Informatics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh; Pittsburgh, Pennsylvania
- Division Emergency Medicine, Department of Pediatrics, University of Pittsburgh and University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert S B Clark
- Departments of Critical Care Medicine
- Pediatrics
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Brain Care Institute
| | - Patrick M Kochanek
- Departments of Critical Care Medicine
- Pediatrics
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Brain Care Institute
| | - Christopher M Horvat
- Departments of Critical Care Medicine
- Pediatrics
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Brain Care Institute
- Division of Health Informatics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh; Pittsburgh, Pennsylvania
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12
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McCreary EK, Kip KE, Collins K, Minnier TE, Snyder GM, Steiner A, Meyers R, Borneman T, Adam M, Thurau L, Yealy DM, Huang DT, Bariola JR, Schmidhofer M, Wadas RJ, Angus DC, Kip PL, Marroquin OC. Evaluation of Bebtelovimab for Treatment of COVID-19 During the SARS-CoV-2 Omicron Variant Era. Open Forum Infect Dis 2022; 9:ofac517. [PMID: 36324319 PMCID: PMC9619560 DOI: 10.1093/ofid/ofac517] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/30/2022] [Indexed: 11/26/2022] Open
Abstract
Background Monoclonal antibody (mAb) treatment is associated with decreased risk of hospitalization and death in high-risk outpatients with mild to moderate coronavirus disease 2019 (COVID-19) caused by early severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants. Bebtelovimab exhibits in vitro activity against the Omicron variant and its sublineages; however, clinical data are lacking. Methods A retrospective cohort study was conducted comparing bebtelovimab-treated patients with propensity score–adjusted and matched nontreated control groups. Participants included high-risk outpatients eligible for bebtelovimab treatment under Emergency Use Authorization with a positive SARS-CoV-2 test from March 30 to May 28, 2022. Treated patients received single-dose intravenous treatment with bebtelovimab. The primary outcome was hospitalization or death over 28 days. Results Before matching/statistical adjustment, mAb-treated patients were, on average, 10 years older than nontreated patients (61.6 vs 51.3 years) and had higher prevalence of obstructive sleep apnea, hypertension, chronic kidney disease, cancer, organ or cell transplant, and immunocompromised status (standardized mean differences ≥0.20). The adjusted odds ratio (OR) of hospitalization or death comparing 1006 treated with 2023 nontreated patients was 0.50 (95% CI, 0.31–0.80). Among 930 treated and 930 propensity score–matched nontreated patients, the incidence of hospitalization or death was 3.1% vs 5.5%, respectively (conditional OR, 0.53; 95% CI, 0.32–0.86). The lower odds ratio of hospitalization or death associated with bebtelovimab treatment was most evident in older patients, those with immunocompromised status, and fully vaccinated patients. Conclusions Monoclonal antibody treatment with bebtelovimab among COVID-19 outpatients is associated with lower odds of hospitalization or death, particularly among immunocompromised and older patients.
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA , USA
| | - Kevin E Kip
- Clinical Analytics , UPMC, Pittsburgh, PA , USA
| | | | | | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA , USA
| | - Ashley Steiner
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Tina Borneman
- UPMC Corporate Pharmacy Service Center , Pittsburgh, PA , USA
| | - Michelle Adam
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Lauren Thurau
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA , USA
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
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13
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Zhu L, Marsh JW, Griffith MP, Collins K, Srinivasa V, Waggle K, Van Tyne D, Snyder GM, Phan T, Wells A, Marroquin OC, Harrison LH. Predictive model for severe COVID-19 using SARS-CoV-2 whole-genome sequencing and electronic health record data, March 2020-May 2021. PLoS One 2022; 17:e0271381. [PMID: 35819967 PMCID: PMC9275682 DOI: 10.1371/journal.pone.0271381] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/30/2022] [Indexed: 01/08/2023] Open
Abstract
Objective We used SARS-CoV-2 whole-genome sequencing (WGS) and electronic health record (EHR) data to investigate the associations between viral genomes and clinical characteristics and severe outcomes among hospitalized COVID-19 patients. Methods We conducted a case-control study of severe COVID-19 infection among patients hospitalized at a large academic referral hospital between March 2020 and May 2021. SARS-CoV-2 WGS was performed, and demographic and clinical characteristics were obtained from the EHR. Severe COVID-19 (case patients) was defined as having one or more of the following: requirement for supplemental oxygen, mechanical ventilation, or death during hospital admission. Controls were hospitalized patients diagnosed with COVID-19 who did not meet the criteria for severe infection. We constructed predictive models incorporating clinical and demographic variables as well as WGS data including lineage, clade, and SARS-CoV-2 SNP/GWAS data for severe COVID-19 using multiple logistic regression. Results Of 1,802 hospitalized SARS-CoV-2-positive patients, we performed WGS on samples collected from 590 patients, of whom 396 were case patients and 194 were controls. Age (p = 0.001), BMI (p = 0.032), test positive time period (p = 0.001), Charlson comorbidity index (p = 0.001), history of chronic heart failure (p = 0.003), atrial fibrillation (p = 0.002), or diabetes (p = 0.007) were significantly associated with case-control status. SARS-CoV-2 WGS data did not appreciably change the results of the above risk factor analysis, though infection with clade 20A was associated with a higher risk of severe disease, after adjusting for confounder variables (p = 0.024, OR = 3.25; 95%CI: 1.31–8.06). Conclusions Among people hospitalized with COVID-19, older age, higher BMI, earlier test positive period, history of chronic heart failure, atrial fibrillation, or diabetes, and infection with clade 20A SARS-CoV-2 strains can predict severe COVID-19.
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Affiliation(s)
- Lei Zhu
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Jane W. Marsh
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Marissa P. Griffith
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Kevin Collins
- Healthcare Data and Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Vatsala Srinivasa
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Kady Waggle
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Daria Van Tyne
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Graham M. Snyder
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Department of Infection Prevention and Control, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Tung Phan
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Alan Wells
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Oscar C. Marroquin
- Healthcare Data and Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Lee H. Harrison
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
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14
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Huang DT, McCreary EK, Bariola JR, Minnier TE, Wadas RJ, Shovel JA, Albin D, Marroquin OC, Kip KE, Collins K, Schmidhofer M, Wisniewski MK, Nace DA, Sullivan C, Axe M, Meyers R, Weissman A, Garrard W, Peck-Palmer OM, Wells A, Bart RD, Yang A, Berry LR, Berry S, Crawford AM, McGlothlin A, Khadem T, Linstrum K, Montgomery SK, Ricketts D, Kennedy JN, Pidro CJ, Nakayama A, Zapf RL, Kip PL, Haidar G, Snyder GM, McVerry BJ, Yealy DM, Angus DC, Seymour CW. Effectiveness of Casirivimab-Imdevimab and Sotrovimab During a SARS-CoV-2 Delta Variant Surge: A Cohort Study and Randomized Comparative Effectiveness Trial. JAMA Netw Open 2022; 5:e2220957. [PMID: 35834252 PMCID: PMC10881222 DOI: 10.1001/jamanetworkopen.2022.20957] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [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: 02/21/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
Importance The effectiveness of monoclonal antibodies (mAbs), casirivimab-imdevimab and sotrovimab, is unknown in patients with mild to moderate COVID-19 caused by the SARS-CoV-2 Delta variant. Objective To evaluate the effectiveness of mAb against the Delta variant compared with no mAb treatment and to ascertain the comparative effectiveness of casirivimab-imdevimab and sotrovimab. Design, Setting, and Participants This study comprised 2 parallel studies: (1) a propensity score-matched cohort study of mAb treatment vs no mAb treatment and (2) a randomized comparative effectiveness trial of casirivimab-imdevimab and sotrovimab. The cohort consisted of patients who received mAb treatment at the University of Pittsburgh Medical Center outpatient infusion centers and emergency departments from July 14 to September 29, 2021. Participants were patients with a positive SARS-CoV-2 test result who were eligible to receive mAbs according to emergency use authorization criteria. Exposure For the trial, patients were randomized to either intravenous casirivimab-imdevimab or sotrovimab according to a system therapeutic interchange policy. Main Outcomes and Measures For the cohort study, risk ratio (RR) estimates for the primary outcome of hospitalization or death by 28 days were compared between mAb treatment and no mAb treatment using propensity score-matched models. For the comparative effectiveness trial, the primary outcome was hospital-free days (days alive and free of hospitalization) within 28 days after mAb treatment, where patients who died were assigned -1 day in a bayesian cumulative logistic model adjusted for treatment location, age, sex, and time. Inferiority was defined as a 99% posterior probability of an odds ratio (OR) less than 1. Equivalence was defined as a 95% posterior probability that the OR was within a given bound. Results A total of 3069 patients (1023 received mAb treatment: mean [SD] age, 53.2 [16.4] years; 569 women [56%]; 2046 had no mAb treatment: mean [SD] age, 52.8 [19.5] years; 1157 women [57%]) were included in the prospective cohort study, and 3558 patients (mean [SD] age, 54 [18] years; 1919 women [54%]) were included in the randomized comparative effectiveness trial. In propensity score-matched models, mAb treatment was associated with reduced risk of hospitalization or death (RR, 0.40; 95% CI, 0.28-0.57) compared with no treatment. Both casirivimab-imdevimab (RR, 0.31; 95% CI, 0.20-0.50) and sotrovimab (RR, 0.60; 95% CI, 0.37-1.00) were associated with reduced hospitalization or death compared with no mAb treatment. In the clinical trial, 2454 patients were randomized to receive casirivimab-imdevimab and 1104 patients were randomized to receive sotrovimab. The median (IQR) hospital-free days were 28 (28-28) for both mAb treatments, the 28-day mortality rate was less than 1% (n = 12) for casirivimab-imdevimab and less than 1% (n = 7) for sotrovimab, and the hospitalization rate by day 28 was 12% (n = 291) for casirivimab-imdevimab and 13% (n = 140) for sotrovimab. Compared with patients who received casirivimab-imdevimab, those who received sotrovimab had a median adjusted OR for hospital-free days of 0.88 (95% credible interval, 0.70-1.11). This OR yielded 86% probability of inferiority for sotrovimab vs casirivimab-imdevimab and 79% probability of equivalence. Conclusions and Relevance In this propensity score-matched cohort study and randomized comparative effectiveness trial, the effectiveness of casirivimab-imdevimab and sotrovimab against the Delta variant was similar, although the prespecified criteria for statistical inferiority or equivalence were not met. Both mAb treatments were associated with a reduced risk of hospitalization or death in nonhospitalized patients with mild to moderate COVID-19 caused by the Delta variant. Trial Registration ClinicalTrials.gov Identifier: NCT04790786.
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Affiliation(s)
- David T. Huang
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Tami E. Minnier
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Richard J. Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Judith A. Shovel
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Debbie Albin
- Supply Chain Management/HC Pharmacy, UPMC, Pittsburgh, Pennsylvania
| | | | - Kevin E. Kip
- Clinical Analytics, UPMC, Pittsburgh, Pennsylvania
| | | | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - David A. Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Colleen Sullivan
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Octavia M. Peck-Palmer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alan Wells
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert D. Bart
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health Services Division, UPMC, Pittsburgh, Pennsylvania
| | - Anne Yang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | | | - Tina Khadem
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Stephanie K. Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Daniel Ricketts
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jason N. Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Caroline J. Pidro
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anna Nakayama
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Rachel L. Zapf
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Paula L. Kip
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Graham M. Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bryan J. McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Donald M. Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
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15
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Carleton N, Oesterreich S, Marroquin OC, Diego EJ, Tseng GC, Lee AV, McAuliffe PF. Is the Choosing Wisely Recommendation for Omission of Sentinel Lymph Node Biopsy Applicable for Invasive Lobular Carcinoma? Ann Surg Oncol 2022; 29:5379-5382. [PMID: 35697956 DOI: 10.1245/s10434-022-12003-3] [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: 04/15/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Neil Carleton
- Women's Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Steffi Oesterreich
- Women's Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Oscar C Marroquin
- Clinical Analytics, UPMC Health Services Division, Pittsburgh, PA, USA
| | - Emilia J Diego
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - George C Tseng
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adrian V Lee
- Women's Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Priscilla F McAuliffe
- Women's Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA. .,Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Division of Breast Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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16
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McCreary EK, Bariola JR, Minnier TE, Wadas RJ, Shovel JA, Albin D, Marroquin OC, Kip KE, Collins K, Schmidhofer M, Wisniewski MK, Nace DA, Sullivan C, Axe M, Meyers R, Weissman A, Garrard W, Peck-Palmer OM, Wells A, Bart RD, Yang A, Berry LR, Berry S, Crawford AM, McGlothlin A, Khadem T, Linstrum K, Montgomery SK, Ricketts D, Kennedy JN, Pidro CJ, Haidar G, Snyder GM, McVerry BJ, Yealy DM, Angus DC, Nakayama A, Zapf RL, Kip PL, Seymour CW, Huang DT. The comparative effectiveness of COVID-19 monoclonal antibodies: A learning health system randomized clinical trial. Contemp Clin Trials 2022; 119:106822. [PMID: 35697146 PMCID: PMC9187853 DOI: 10.1016/j.cct.2022.106822] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/09/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022]
Abstract
Background Monoclonal antibodies (mAb) that neutralize SARS-CoV-2 decrease hospitalization and death compared to placebo in patients with mild to moderate COVID-19; however, comparative effectiveness is unknown. We report the comparative effectiveness of bamlanivimab, bamlanivimab-etesevimab, and casirivimab-imdevimab. Methods A learning health system platform trial in a U.S. health system enrolled patients meeting mAb Emergency Use Authorization criteria. An electronic health record-embedded application linked local mAb inventory to patient encounters and provided random mAb allocation. Primary outcome was hospital-free days to day 28. Primary analysis was a Bayesian model adjusting for treatment location, age, sex, and time. Inferiority was defined as 99% posterior probability of an odds ratio < 1. Equivalence was defined as 95% posterior probability the odds ratio is within a given bound. Findings Between March 10 and June 25, 2021, 1935 patients received treatment. Median hospital-free days were 28 (IQR 28, 28) for each mAb. Mortality was 0.8% (1/128), 0.8% (7/885), and 0.7% (6/922) for bamlanivimab, bamlanivimab-etesevimab, and casirivimab-imdevimab, respectively. Relative to casirivimab-imdevimab (n = 922), median adjusted odds ratios were 0.58 (95% credible interval [CI] 0.30–1.16) and 0.94 (95% CI 0.72–1.24) for bamlanivimab (n = 128) and bamlanivimab-etesevimab (n = 885), respectively. These odds ratios yielded 91% and 94% probabilities of inferiority of bamlanivimab versus bamlanivimab-etesevimab and casirivimab-imdevimab, and an 86% probability of equivalence between bamlanivimab-etesevimab and casirivimab-imdevimab. Interpretation Among patients with mild to moderate COVID-19, bamlanivimab-etesevimab or casirivimab-imdevimab treatment resulted in 86% probability of equivalence. No treatment met prespecified criteria for statistical equivalence. Median hospital-free days to day 28 were 28 (IQR 28, 28) for each mAb. Funding and registration This work received no external funding. The U.S. government provided the reported mAb. This trial is registered at ClinicalTrials.gov, NCT04790786.
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tami E Minnier
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Judith A Shovel
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Debbie Albin
- Supply Chain Management/HC Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Oscar C Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin Collins
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Colleen Sullivan
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - William Garrard
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Octavia M Peck-Palmer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alan Wells
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert D Bart
- Health Services Division, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anne Yang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | | | | | - Tina Khadem
- Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephanie K Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel Ricketts
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jason N Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Caroline J Pidro
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Derek C Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anna Nakayama
- Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rachel L Zapf
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paula L Kip
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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17
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Wing RR, Venkatakrishnan K, Panza E, Marroquin OC, Kip KE. Association of COVID-19 Stay-at-Home Orders With 1-Year Weight Changes. JAMA Netw Open 2022; 5:e2217313. [PMID: 35708692 PMCID: PMC9204539 DOI: 10.1001/jamanetworkopen.2022.17313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Rena R. Wing
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kripa Venkatakrishnan
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Emily Panza
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Oscar C. Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kevin E. Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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18
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McCreary EK, Bariola JR, Wadas RJ, Shovel JA, Wisniewski MK, Adam M, Albin D, Minnier T, Schmidhofer M, Meyers R, Marroquin OC, Collins K, Garrard W, Berry LR, Berry S, Crawford AM, McGlothlin A, Linstrum K, Nakayama A, Montgomery SK, Snyder GM, Yealy DM, Angus DC, Kip PL, Seymour CW, Huang DT, Kip KE. Association of Subcutaneous or Intravenous Administration of Casirivimab and Imdevimab Monoclonal Antibodies With Clinical Outcomes in Adults With COVID-19. JAMA Netw Open 2022; 5:e226920. [PMID: 35412625 PMCID: PMC9006104 DOI: 10.1001/jamanetworkopen.2022.6920] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Monoclonal antibody (mAb) treatment decreases hospitalization and death in high-risk outpatients with mild to moderate COVID-19; however, only intravenous administration has been evaluated in randomized clinical trials of treatment. Subcutaneous administration may expand outpatient treatment capacity and qualified staff available to administer treatment, but the association with patient outcomes is understudied. OBJECTIVES To evaluate whether subcutaneous casirivimab and imdevimab treatment is associated with reduced 28-day hospitalization and death compared with nontreatment among mAb-eligible patients and whether subcutaneous casirivimab and imdevimab treatment is clinically and statistically similar to intravenous casirivimab and imdevimab treatment. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study evaluated high-risk outpatients in a learning health system in the US with mild to moderate COVID-19 symptoms from July 14 to October 26, 2021, who were eligible for mAb treatment under emergency use authorization. A nontreated control group of eligible patients was also studied. EXPOSURES Subcutaneous injection or intravenous administration of the combined single dose of 600 mg of casirivimab and 600 mg of imdevimab. MAIN OUTCOMES AND MEASURES The primary outcome was the 28-day adjusted risk ratio or adjusted risk difference for hospitalization or death. Secondary outcomes included 28-day adjusted risk ratios and differences in hospitalization, death, a composite end point of emergency department admission and hospitalization, and rates of adverse events. Among 1959 matched adults with mild to moderate COVID-19, 969 patients (mean [SD] age, 53.8 [16.7] years; 547 women [56.4%]) who received casirivimab and imdevimab subcutaneously had a 28-day rate of hospitalization or death of 3.4% (22 of 653 patients) compared with 7.0% (92 of 1306 patients) in nontreated controls (risk ratio, 0.48; 95% CI, 0.30-0.80; P = .002). Among 2185 patients treated with subcutaneous (n = 969) or intravenous (n = 1216; mean [SD] age, 54.3 [16.6] years; 672 women [54.4%]) casirivimab and imdevimab, the 28-day rate of hospitalization or death was 2.8% vs 1.7%, which resulted in an adjusted risk difference of 1.5% (95% CI, -0.6% to 3.5%; P = .16). Among all infusion patients, there was no difference in intensive care unit admission (adjusted risk difference, 0.7%; 95% CI, -3.5% to 5.0%) or need for mechanical ventilation (adjusted risk difference, 0.2%; 95% CI, -5.8% to 5.5%). CONCLUSIONS AND RELEVANCE In this cohort study of high-risk outpatients with mild to moderate COVID-19 symptoms, subcutaneously administered casirivimab and imdevimab was associated with reduced hospitalization and death when compared with no treatment. These results provide preliminary evidence of potential expanded use of subcutaneous mAb treatment, particularly in areas that are facing treatment capacity and/or staffing shortages.
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Affiliation(s)
- Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard J. Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Judith A. Shovel
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Michelle Adam
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Debbie Albin
- Supply Chain Management/HC Pharmacy, UPMC, Pittsburgh, Pennsylvania
| | - Tami Minnier
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | - Kelsey Linstrum
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Anna Nakayama
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | | | - Graham M. Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Donald M. Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula L. Kip
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David T. Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kevin E. Kip
- Clinical Analytics, UPMC, Pittsburgh, Pennsylvania
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19
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Nasrazadani A, Marti JLG, Kip KE, Marroquin OC, Lemon L, Shapiro SD, Brufsky AM. Breast cancer mortality as a function of age. Aging (Albany NY) 2022; 14:1186-1199. [PMID: 35134749 PMCID: PMC8876898 DOI: 10.18632/aging.203881] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/28/2022] [Indexed: 11/25/2022]
Abstract
Background: Incidence of breast cancer (BC) in US women continues to increase with age as the strongest risk factor. We aimed to compare clinical, pathological and sociological variables associated to BC diagnosis, as well as the relative mortality rates of BC patients compared to the general US population. Methods: We performed a retrospective, single-institution study evaluating 52,509 patients diagnosed with unilateral BC at the University of Pittsburgh Medical Center (UPMC) between 1990–2020. Primary outcome was death from any cause with cancer recurrence as a secondary outcome, evaluated for 4 age groups: 20–44, 45–55, 56–69, and 70–90. A dataset of expected mortality for women in the general population over a 10-year period was constructed using the Surveillance, Epidemiology, and End Results (SEER) Program. Observed vs. expected mortality and standardized mortality ratios (SMR) for each age group were calculated. Results: Youngest patients with BC demonstrated the highest SMR at 10-year follow-up from time of diagnosis compared to the general US population (SMR 9.68, 95% CI: 8.99to 10.42), and remained highest compared to other age groups when analysis was limited to Stage 0/1 disease (10-year SMR 3.11, 95% CI: 2.54 to 3.76). SMRs decreased with increasing age at diagnosis with an SMR <1.0 in patients diagnosed with stage 0/1 at ages 70–90 at 5-year follow-up. Conclusions: Younger BC patients have the highest SMR which declines gradually with age. In the elderly, lower stage 0/1 SMR’s are found compared to the general population, suggesting the possibility of an associated protective effect.
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Affiliation(s)
- Azadeh Nasrazadani
- Division of Medical Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Juan Luis Gomez Marti
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Kevin E. Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Oscar C. Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Lara Lemon
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Steve D. Shapiro
- Keck Medicine of USC, University of Southern California, Los Angeles, CA 90007, USA
| | - Adam M. Brufsky
- Division of Medical Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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20
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McCreary EK, Kip KE, Bariola JR, Schmidhofer M, Minnier T, Mayak K, Albin D, Daley J, Linstrum K, Hernandez E, Sackrowitz R, Hughes K, Horvat C, Snyder GM, McVerry BJ, Yealy DM, Huang DT, Angus DC, Marroquin OC. A learning health system approach to the
COVID
‐19 pandemic:
System‐wide
changes in clinical practice and
30‐day
mortality among hospitalized patients. Learn Health Syst 2022; 6:e10304. [PMID: 35860323 PMCID: PMC9284933 DOI: 10.1002/lrh2.10304] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Rapid, continuous implementation of credible scientific findings and regulatory approvals is often slow in large, diverse health systems. The coronavirus disease 2019 (COVID‐19) pandemic created a new threat to this common “slow to learn and adapt” model in healthcare. We describe how the University of Pittsburgh Medical Center (UPMC) committed to a rapid learning health system (LHS) model to respond to the COVID‐19 pandemic. Methods A treatment cohort study was conducted among 11 429 hospitalized patients (pediatric/adult) from 22 hospitals (PA, NY) with a primary diagnosis of COVID‐19 infection (March 19, 2020 ‐ June 6, 2021). Sociodemographic and clinical data were captured from UPMC electronic medical record (EMR) systems. Patients were grouped into four time‐defined patient “waves” based on nadir of daily hospital admissions, with wave 3 (September 20, 2020 ‐ March 10, 2021) split at its zenith due to high volume with steep acceleration and deceleration. Outcomes included changes in clinical practice (eg, use of corticosteroids, antivirals, and other therapies) in relation to timing of internal system analyses, scientific publications, and regulatory approvals, along with 30‐day rate of mortality over time. Results The mean (SD) daily number of admissions across hospitals was 26 (29) with a maximum 7‐day moving average of 107 patients. System‐wide implementation of the use of dexamethasone, remdesivir, and tocilizumab occurred within days of release of corresponding seminal publications and regulatory actions. After adjustment for differences in patient clinical profiles over time, each month of hospital admission was associated with an estimated 5% lower odds of 30‐day mortality (adjusted odds ratio [OR] = 0.95, 95% confidence interval: 0.93‐0.97, P < .001). Conclusions In our large LHS, near real‐time changes in clinical management of COVID‐19 patients happened promptly as scientific publications and regulatory approvals occurred throughout the pandemic. Alongside these changes, patients with COVID‐19 experienced lower adjusted 30‐day mortality following hospital admission over time.
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Affiliation(s)
- Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Kevin E. Kip
- Health Services Division Clinical Analytics, UPMC Pittsburgh Pennsylvania USA
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Mark Schmidhofer
- Division of Cardiology, Dept of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Tami Minnier
- Health Services Division UPMC Wolff Center and Quality Offices, UPMC Pittsburgh Pennsylvania USA
| | - Katelyn Mayak
- Media Relations Department UPMC Communications, UPMC Pittsburgh Pennsylvania USA
| | - Debbie Albin
- UPMC Enterprises UPMC Supply Chain Management/HC Pharmacy, UPMC Pittsburgh Pennsylvania USA
| | - Jessica Daley
- UPMC Enterprises UPMC Supply Chain Management/HC Pharmacy, UPMC Pittsburgh Pennsylvania USA
| | - Kelsey Linstrum
- UPMC Health System UPMC Office of Healthcare Innovation Pittsburgh Pennsylvania USA
| | - Erik Hernandez
- Department of Pharmacy UPMC Pinnacle, UPMC Pittsburgh Pennsylvania USA
| | - Rachel Sackrowitz
- Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Kailey Hughes
- Division of Infectious Diseases, Department of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Christopher Horvat
- Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
- Department of Critical Care Medicine UPMC Children’s Hospital of Pittsburgh Pittsburgh Pennsylvania USA
| | - Graham M. Snyder
- Division of Infectious Diseases, Department of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Bryan J. McVerry
- Department of Medicine, Division of Pulmonary Allergy, and Critical Care Medicine Pittsburgh Pennsylvania USA
| | - Donald M. Yealy
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - David T. Huang
- Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Derek C. Angus
- UPMC Health System UPMC Office of Healthcare Innovation Pittsburgh Pennsylvania USA
- Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Oscar C. Marroquin
- Health Services Division Clinical Analytics, UPMC Pittsburgh Pennsylvania USA
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21
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Carleton N, Nasrazadani A, Gade K, Beriwal S, Barry PN, Brufsky AM, Bhargava R, Berg WA, Zuley ML, van Londen GJ, Marroquin OC, Thull DL, Mai PL, Diego EJ, Lotze MT, Oesterreich S, McAuliffe PF, Lee AV. Personalising therapy for early-stage oestrogen receptor-positive breast cancer in older women. Lancet Healthy Longev 2022; 3:e54-e66. [PMID: 35047868 PMCID: PMC8765742 DOI: 10.1016/s2666-7568(21)00280-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Indexed: 12/15/2022] Open
Abstract
Age is one of the most important risk factors for the development of breast cancer. Nearly a third of all breast cancer cases occur in older women (aged ≥70 years), with most cases being oestrogen receptor-positive (ER+). Such tumours are often indolent and unlikely to be the ultimate cause of death for older women, particularly when considering other comorbidities. This Review focuses on unique clinical considerations for screening, detection, and treatment regimens for older women who develop ER+ breast cancers-specifically, we focus on recent trends for de-implementation of screening, staging, surgery, and adjuvant therapies along the continuum of care. Additionally, we also review emerging basic and translational research that will further uncover the unique underlying biology of these tumours, which develop in the context of systemic age-related inflammation and changing hormone profiles. With prevailing trends of clinical de-implementation, new insights into mechanistic biology might provide an opportunity for precision medicine approaches to treat patients with well tolerated, low-toxicity agents to extend patients' lives with a higher quality of life, prevent tumour recurrences, and reduce cancer-related burdens.
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Affiliation(s)
- Neil Carleton
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Azadeh Nasrazadani
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Kristine Gade
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Sushil Beriwal
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Parul N Barry
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Adam M Brufsky
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Rohit Bhargava
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Wendie A Berg
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Margarita L Zuley
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - G J van Londen
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Oscar C Marroquin
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Darcy L Thull
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Phuong L Mai
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Emilia J Diego
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Michael T Lotze
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Steffi Oesterreich
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Priscilla F McAuliffe
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
| | - Adrian V Lee
- (N Carleton BS, Prof S Oesterreich PhD, P F McAuliffe MD, Prof A V Lee PhD) (S Beriwal MD, P N Barry MD), (N Carleton, Prof S Oesterreich, P F McAuliffe, Prof A V Lee); (A Nasrazadani MD, K Gade MD, Prof A M Brufksy MD, G J van Londen MD), (Prof R Bhargava MD), (D L Thull MS, P L Mai MD), (E J Diego MD, Prof M T Lotze MD, P F McAuliffe), (Prof M T Lotze), (Prof M T Lotze), (Prof S Oesterreich, Prof A V Lee), (Prof W A Berg MD, Prof M L Zuley MD); (O C Marroquin MD)
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22
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McCreary EK, Bariola JR, Minnier T, Wadas RJ, Shovel JA, Albin D, Marroquin OC, Schmidhofer M, Wisniewski MK, Nace DA, Sullivan C, Axe M, Meyers R, Khadem T, Garrard W, Collins K, Wells A, Bart RD, Linstrum K, Montgomery SK, Haidar G, Snyder GM, McVerry BJ, Seymour CW, Yealy DM, Huang DT, Angus DC. Launching a comparative effectiveness adaptive platform trial of monoclonal antibodies for COVID-19 in 21 days. Contemp Clin Trials 2021; 113:106652. [PMID: 34896293 PMCID: PMC8654455 DOI: 10.1016/j.cct.2021.106652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/04/2021] [Accepted: 12/05/2021] [Indexed: 12/05/2022]
Abstract
Outpatient treatments that limit progression to severe coronavirus disease 2019 (COVID-19) are of vital importance to optimise patient outcomes and public health. Monoclonal antibodies (mAb) demonstrated ability to decrease hospitalizations in randomized, clinical trials. However, there are many barriers to mAb treatment such as patient access and clinician education. There are no data comparing efficacy or safety of available mAbs. We sought to rapidly launch an adaptive platform trial with the goals of enhancing access to treatment, regardless of geography and socioeconomic status, and evaluating comparative efficacy and safety of available mAbs. Within 21 days from idea genesis, we allocated mAb treatment to all patients within the context of this clinical trial. Within 2 months, we closed the gap of the likelihood of receiving mAb, conditional on background positivity rate, between Black and White patients (Black patients 0.238; White patients 0.241). We describe trial infrastructure, lessons learned, and future directions for a culture of learning while doing.
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Debbie Albin
- UPMC Supply Chain Management/HC Pharmacy, UPMC, Pittsburgh, PA, USA
| | | | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Colleen Sullivan
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tina Khadem
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - Alan Wells
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert D Bart
- UPMC Health Services Division, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
| | - Stephanie K Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bryan J McVerry
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, UPMC, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Derek C Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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23
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Asif A, Sezer A, Thoma F, Toma C, Schindler J, Fowler J, Smith C, Marroquin OC, Mulukutla SR. Relationship between predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score and mortality among patients with atrial fibrillation undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 98:838-845. [PMID: 33300267 DOI: 10.1002/ccd.29399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 10/11/2020] [Accepted: 11/09/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy, PRECISE-DAPT (P-DAPT) score has been validated in large cohorts as an effective tool in predicting bleeding complication after dual antiplatelet therapy (DAPT) as well as in predicting in-hospital mortality. The implication of using this score to predict outcomes, including mortality in patients with atrial fibrillation (AF) undergoing PCI is unknown. OBJECTIVE Role of P-DAPT score to study clinical outcomes, including mortality, hospitalization, and major bleeding, particularly among patients with AF. METHODS This is a retrospective observational study of 18,850 consecutive patients who underwent percutaneous coronary intervention (PCI) across a large multihospital healthcare system from 2010 to 2019. Patients were stratified into four groups depending on the presence or absence of AF and P-DAPT score, with score ≥ 25 defined as high risk. The primary outcome was all-cause mortality. The secondary outcomes evaluated were hospitalization and major bleeding. RESULTS In the unadjusted analyses, a P-DAPT score ≥ 25, in both AF and non-AF population, was associated with increased mortality, hospitalization, and bleeding. After adjusting for baseline covariates, no significant differences in major bleeding risk were found across the four groups. However, a P-DAPT score of ≥25 in AF patients was associated with a higher risk for hospitalizations related to cardiovascular causes (HR: 2.15 95% CI 2.00-2.3, p < .0001). Among AF patients, P-DAPT score ≥ 25 was found to be strongly associated with mortality (HR 3.5; 95% CI 2.95-4.25, p < .0001) as compared with AF patients with score < 25 (HR 1.18, 95% CI 0.88-1.54, p = .26). CONCLUSION In this large cohort of patients undergoing PCI, the P-DAPT score can help to identify patients at high risk for long-term mortality, particularly among those with atrial fibrillation.
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Affiliation(s)
- Anum Asif
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ahmet Sezer
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John Schindler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jeffrey Fowler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Conrad Smith
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Oscar C Marroquin
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Suresh R Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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24
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Woltemate TJ, Wadas RJ, McCreary EK, Bariola R, Minnier T, Marroquin OC, Schmidhofer M, Albin D, Angus DC, Yealy DM. Emergency department implementation of monoclonal antibody infusion for the treatment of coronavirus disease 2019: A template for rapid deployment. J Am Coll Emerg Physicians Open 2021; 2:e12550. [PMID: 34568870 PMCID: PMC8448483 DOI: 10.1002/emp2.12550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 11/19/2022] Open
Abstract
Monoclonal antibody (mAb) therapy can improve coronavirus disease 2019 outcomes when infused early in select patients. We sought to rapidly create and implement a program for emergency department (ED) mAb infusion to aid care. Using multiple strategies and actions-education, selection criteria, screening tools, rapid testing, compounding, and delivery-we infused 832 ED patients with a mAb. The screening tool identified 94.5% of these patients as potential candidates. Length of stay was nearly identical for patients who tested positive for coronavirus disease 2019 versus those requiring testing. Mild adverse reactions occurred in 2.3% of mAb infusions, and severe reactions occurred in 0.5% of infusions. We highlight a strategic approach for using the ED as a key coronavirus disease 2019 therapeutic site for this intervention and with high utility and low disruption.
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Affiliation(s)
- Thomas J. Woltemate
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Richard J. Wadas
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Erin K. McCreary
- Division of Infectious Diseases, Department of Internal MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Ryan Bariola
- Division of Infectious Diseases, Department of Internal MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Tami Minnier
- Wolff Center, University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Oscar C. Marroquin
- Clinical Analytics, University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Mark Schmidhofer
- Division of Cardiology, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Debbie Albin
- University of Pittsburgh Medical Center Supply Chain Management/HC PharmacyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Derek C. Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- University of Pittsburgh Medical Center Health System Office of Healthcare InnovationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Donald M. Yealy
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
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25
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Bailes AH, Navlani R, Koscumb S, Malecky A, Marroquin OC, Wasan AD, Gutstein HB, Delitto A, Zigler C, Vo N, Sowa GA. Use of healthcare resources in patients with low back pain and comorbid depression or anxiety. Spine J 2021; 21:1440-1449. [PMID: 33785473 DOI: 10.1016/j.spinee.2021.03.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/03/2021] [Accepted: 03/23/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Psychological comorbidities are important prognostic factors for low back pain (LBP). To develop improved treatment paradigms, it is first necessary to characterize and determine current patterns of treatment in this population. PURPOSE Identify how comorbid depression or anxiety in patients with LBP is related to use of healthcare resources. STUDY DESIGN/SETTING Retrospective cohort study using electronic health records from outpatient offices at a large multisite academic medical center. PATIENT SAMPLE Data from 513,088 unique patients seen between January 2010 and July 2020 (58.0% female, 52.6±19.5 years) with a diagnosis of LBP, indicated by predetermined ICD-9 and ICD-10 codes. OUTCOME MEASURES Average self-reported pain scores, absolute differences and unadjusted risk ratios to compare opioid use, emergency department visits, hospitalizations, advanced imaging orders, spinal injections, and back surgeries between cohorts. METHODS Clinical characteristics and data regarding use of healthcare resources were extracted from the electronic health record. Clinical features and patterns in healthcare utilization were determined for patients with depression or anxiety compared to those without. RESULTS Depression or anxiety was coded for 21.4% of patients at first LBP visit. Those with depression or anxiety were more likely to be on opioids (unadjusted risk ratio: 1.22, CI: [1.22,1.23]), go to the emergency department (1.31 [1.30-1.33]), be hospitalized (1.15 [1.13, 1.17]), receive advanced imaging (1.09 [1.08, 1.11]), receive an epidural steroid injection (1.16 [1.15, 1.18]), and less likely to have back surgery (0.74 [0.72, 0.77]). Differences in pain scores for those with depression/anxiety compared to those without were not clinically significant. CONCLUSIONS Depression/anxiety is associated with increased use of healthcare resources, and is not associated with clinically meaningful elevated pain scores. Limitations come from use of an aggregate data set and reliance on administrative coding.
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Affiliation(s)
- Anna H Bailes
- Bioengineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, PA, 15213, USA; Physical Therapy, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219 USA.
| | - Rohit Navlani
- Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, 3471 Fifth Avenue, Pittsburgh, PA, 15213 USA
| | - Stephen Koscumb
- Clinical Analytics, UPMC Health Services Division, 200 Lothrop Street, Pittsburgh, PA, 15213 USA
| | - Amanda Malecky
- Clinical Analytics, UPMC Health Services Division, 200 Lothrop Street, Pittsburgh, PA, 15213 USA
| | - Oscar C Marroquin
- Clinical Analytics, UPMC Health Services Division, 200 Lothrop Street, Pittsburgh, PA, 15213 USA; Heart and Vascular Institute, UPMC, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Ajay D Wasan
- Anesthesiology and Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15213, USA
| | - Howard B Gutstein
- Anesthesiology Institute, Allegheny Health Network, 230 E. North Avernue, Pittsburgh, PA, 15212, USA
| | - Anthony Delitto
- Physical Therapy, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219 USA
| | - Christina Zigler
- Population Health Sciences, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Nam Vo
- Orthopaedic Surgery, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15213, USA
| | - Gwendolyn A Sowa
- Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, 3471 Fifth Avenue, Pittsburgh, PA, 15213 USA
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Goldberger JJ, Subačius H, Marroquin OC, Beau SL, Simonson J. One-Year Landmark Analysis of the Effect of Beta-Blocker Dose on Survival After Acute Myocardial Infarction. J Am Heart Assoc 2021; 10:e019017. [PMID: 34227397 PMCID: PMC8483468 DOI: 10.1161/jaha.120.019017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Although beta-blockers are recommended following myocardial infarction (MI), the benefits of long-term treatment have not been established. The study's aim was to evaluate beta-blocker efficacy by dose in 1-year post-MI survivors. Methods and Results The OBTAIN (Outcomes of Beta-Blocker Therapy After Myocardial Infarction) registry included 7057 patients with acute MI, with 6077 one-year survivors. For this landmark analysis, beta-blocker dose status was available in 3004 patients and analyzed by use (binary) and dose at 1 year after MI. Doses were classified as no beta-blocker and >0% to 12.5%, >12.5% to 25%, >25% to 50%, and >50% of target doses used in randomized clinical trials. Age was 63 to 64 years, and approximately two thirds were men. Median follow-up duration was 1.05 years (interquartile range, 0.98-1.22). When analyzed dichotomously, beta-blocker therapy was not associated with improved survival. When analyzed by dose, propensity score analysis showed significantly increased mortality in the no-beta-blocker group (hazard ratio,1.997; 95% CI, 1.118-3.568; P<0.02), the >0% to 12.5% group (hazard ratio, 1.817; 95% CI, 1.094-3.016; P<0.02), and the >25% to 50% group (hazard ratio, 1.764; 95% CI, 1.105-2.815; P<0.02), compared with the >12.5% to 25% dose group. The mortality in the full-dose group was not significantly higher (hazard ratio, 1.196; 95% CI, 0.687-2.083). In subgroup analyses, only history of congestive heart failure demonstrated significant interaction with beta-blocker effects on survival. Conclusions This analysis suggests that patients treated with >12.5% to 25% of the target dose used in prior randomized clinical trials beyond 1 year after MI may have enhanced survival compared with no beta-blocker and other beta-blocker doses. A new paradigm for post-MI beta-blocker therapy is needed that addresses which patients should be treated, for how long, and at what dose.
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Affiliation(s)
| | - Haris Subačius
- Division of Research and Optimal Patient Care American College of Surgeons Chicago IL
| | - Oscar C Marroquin
- UPMC Heart and Vascular Institute and Division of Cardiology University of Pittsburgh PA
| | | | - Jay Simonson
- Park Nicollet Methodist Hospital St. Louis Park MN
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27
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Bariola JR, McCreary EK, Wadas RJ, Kip KE, Marroquin OC, Minnier T, Koscumb S, Collins K, Schmidhofer M, Shovel JA, Wisniewski MK, Sullivan C, Yealy DM, Nace DA, Huang DT, Haidar G, Khadem T, Linstrum K, Seymour CW, Montgomery SK, Angus DC, Snyder GM. Impact of Bamlanivimab Monoclonal Antibody Treatment on Hospitalization and Mortality Among Nonhospitalized Adults With Severe Acute Respiratory Syndrome Coronavirus 2 Infection. Open Forum Infect Dis 2021; 8:ofab254. [PMID: 34250192 PMCID: PMC8241472 DOI: 10.1093/ofid/ofab254] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [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: 04/30/2021] [Accepted: 05/12/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Monoclonal antibody treatment may prevent complications of coronavirus disease 2019 (COVID-19). We sought to quantify the impact of bamlanivimab monoclonal antibody monotherapy on hospitalization and mortality among outpatients at high risk of COVID-19 complications. METHODS In this observational study we compared outpatients who received bamlanivimab monoclonal antibody from December 9, 2020 to March 3, 2021 to nontreated patients with a positive polymerase chain reaction or antigen test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the same period who were eligible for monoclonal antibody treatment. The primary outcome was 28-day hospitalization or all-cause mortality, and the secondary outcome was hospitalization or emergency department visit without hospitalization. The risk-adjusted odds of study outcomes comparing bamlanivimab treated and untreated patients was determined using 1:5 propensity matching and multivariable logistic regression. RESULTS Among 232 patients receiving bamlanivimab matched with 1160 comparator patients, the mean age was 67 years, 56% were female, and 196 (14%) of patients experienced hospitalization or mortality. After adjustment for propensity to receive treatment, bamlanivimab treatment was associated with a significantly reduced risk-adjusted odds of hospitalization or mortality within 28 days (odds ratio [OR], 0.40; 95% confidence interval [95% CI], 0.24-0.69; P < .001). Bamlanivimab treatment was also associated with a significantly lower risk adjusted odds of hospitalization or emergency department visit without hospitalization (OR, 0.54; 95% CI, 0.35-0.82; P = .004). The results were most strongly associated with patients age 65 years and older. CONCLUSIONS Bamlanivimab monoclonal antibody monotherapy was associated with reduced hospitalizations and mortality within 28 days among outpatients with mild to moderate COVID-19.Use of bamlanivimab monotherapy for outpatients with mild to moderate COVID-19 infection was associated with reductions in hospitalizations and mortality within 28 days. Benefit was strongest in those age 65 years or older.
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Affiliation(s)
- J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Oscar C Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tami Minnier
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stephen Koscumb
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kevin Collins
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mark Schmidhofer
- Division of Cardiology, Dept of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Judith A Shovel
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Colleen Sullivan
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tina Khadem
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kelsey Linstrum
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania, USA
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christopher W Seymour
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania, USA
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Stephanie K Montgomery
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania, USA
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Derek C Angus
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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28
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Huang DT, McCreary EK, Bariola JR, Wadas RJ, Kip KE, Marroquin OC, Koscumb S, Collins K, Shovel JA, Schmidhofer M, Wisniewski MK, Sullivan C, Yealy DM, Axe M, Nace DA, Haidar G, Khadem T, Linstrum K, Snyder GM, Seymour CW, Montgomery SK, McVerry BJ, Berry L, Berry S, Meyers R, Weissman A, Peck-Palmer OM, Wells A, Bart R, Albin DL, Minnier T, Angus DC. The UPMC OPTIMISE-C19 (OPtimizing Treatment and Impact of Monoclonal antIbodieS through Evaluation for COVID-19) trial: a structured summary of a study protocol for an open-label, pragmatic, comparative effectiveness platform trial with response-adaptive randomization. Trials 2021; 22:363. [PMID: 34034784 PMCID: PMC8144687 DOI: 10.1186/s13063-021-05316-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022] Open
Abstract
Objectives The primary objective is to evaluate the comparative effectiveness of COVID-19 specific monoclonal antibodies (mABs) with US Food and Drug Administration (FDA) Emergency Use Authorization (EUA), alongside UPMC Health System efforts to increase patient access to these mABs. Trial design Open-label, pragmatic, comparative effectiveness platform trial with response-adaptive randomization Participants We will evaluate patients who meet the eligibility criteria stipulated by the COVID-19 mAB EUAs who receive mABs within the UPMC Health System, including infusion centers and emergency departments. EUA eligibility criteria include patients with mild to moderate COVID-19, <10 days of symptoms, and who are at high risk for progressing to severe COVID-19 and/or hospitalization (elderly, obese, and/or with specific comorbidities). The EUA criteria exclude patients who require oxygen for the treatment of COVID-19 and patients already hospitalized for the treatment of COVID-19. We will use data collected for routine clinical care, including data entered into the electronic medical record and from follow-up calls. Intervention and comparator The interventions are the COVID-19 specific mABs authorized by the EUAs. All aspects of mAB treatment, including eligibility criteria, dosing, and post-infusion monitoring, are as per the EUAs. As a comparative effectiveness trial, all patients receive mAB treatment, and the interventions are compared against each other. When U.S. government mAB policies change (e.g., FDA grants or revokes EUAs), UPMC Health System policies and the evaluated mAB interventions will accordingly change. From November 2020 to February 2021, FDA issued EUAs for three mAB treatments (bamlanivimab; bamlanivimab and etesevimab; and casirivimab and imdevimab), and at trial launch on March 10, 2021 we evaluated all three. Due to a sustained increase in SARS-CoV-2 variants in the United States resistant to bamlanivimab administered alone, on March 24, 2021 the U.S. Government halted distribution of bamlanivimab alone, and UPMC accordingly halted bamlanivimab monotherapy on March 31, 2021. On April 16, 2021, FDA revoked the EUA for bamlanivimab monotherapy. At the time of manuscript submission, we are therefore evaluating the two mAB treatments authorized by EUAs (bamlanivimab and etesevimab; and casirivimab and imdevimab). Main outcomes The primary outcome is total hospital free days (HFD) at 28 days after mAB administration, calculated as 28 minus the number of days during the index stay (if applicable – e.g., for patients admitted to hospital after mAB administration in the emergency department) minus the number of days readmitted during the 28 days after treatment. This composite endpoint captures the number of days from the day of mAB administration to the 28 days thereafter, during which the patient is alive and free of hospitalization. Death within 28 days is recorded as -1 HFD, as the worst outcome. Randomisation We will start with equal allocation. Due to uncertainty in sample size, we will use a Bayesian adaptive design and response adaptive randomization to ensure ability to provide statistical inference despite variable sample size. When mABs are ordered by UPMC physicians as a generic referral order, the order is filled by UPMC pharmacy via therapeutic interchange. OPTIMISE-C19 provides the therapeutic interchange via random allocation. Infusion center operations teams and pharmacists use a mAB assignment application embedded in the electronic medical record to determine the random allocation. Blinding (masking) This trial is open-label. However, outcome assessors conducting follow-up calls at day 28 are blinded to mAB assignment, and investigators are blinded to by-mAB aggregate outcome data until a statistical platform trial conclusion is reached. Numbers to be randomised (sample size) Sample size will be determined by case volume throughout the course of the pandemic, supply of FDA authorized mABs, and by that needed to reach a platform trial conclusion of inferiority, superiority, or futility of a given mAB. The trial will continue as long as more than one mAB type is available under EUA, and their comparative effectiveness is uncertain. Trial Status Protocol Version 1.0, February 24, 2021. Recruitment began March 10, 2021 and is ongoing at the time of manuscript submission. The estimated recruitment end date is February 22, 2022, though the final end date is dependent on how the pandemic evolves, mAB availability, and when final platform trial conclusions are reached. As noted above, due to U.S. Government decisions, UPMC Health System halted bamlanivimab monotherapy on March 31, 2021. Trial registration ClinicalTrials.gov Identifier: NCT04790786. Registered March 10, 2021 Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05316-3.
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Affiliation(s)
- David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA. .,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA
| | - Kevin E Kip
- Clinical Analytics, UPMC, Pittsburgh, PA, USA
| | | | | | | | | | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Colleen Sullivan
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA
| | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tina Khadem
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kelsey Linstrum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
| | - Stephanie K Montgomery
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA
| | - Octavia M Peck-Palmer
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alan Wells
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert Bart
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Health Services Division, Pittsburgh, PA, USA
| | - Debbie L Albin
- UPMC Supply Chain Management/HC Pharmacy, Pittsburgh, PA, USA
| | | | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
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Carleton N, Zou J, Fang Y, Koscumb SE, Shah OS, Chen F, Beriwal S, Diego EJ, Brufsky AM, Oesterreich S, Shapiro SD, Ferris R, Emens LA, Tseng G, Marroquin OC, Lee AV, McAuliffe PF. Outcomes After Sentinel Lymph Node Biopsy and Radiotherapy in Older Women With Early-Stage, Estrogen Receptor-Positive Breast Cancer. JAMA Netw Open 2021; 4:e216322. [PMID: 33856473 PMCID: PMC8050744 DOI: 10.1001/jamanetworkopen.2021.6322] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Overtreatment of early-stage breast cancer with favorable tumor biology in older patients may be harmful without affecting recurrence and survival. Guidelines that recommend deimplementation of sentinel lymph node biopsy (SLNB) (Choosing Wisely) and radiotherapy (RT) (National Comprehensive Cancer Network) have been published. OBJECTIVE To describe the use rates and association with disease recurrence of SLNB and RT in older women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained patient and clinical data from an integrated cancer registry and electronic health record of a single health care system in Pennsylvania. The cohort was composed of consecutive female patients 70 years or older who were diagnosed with early-stage, estrogen receptor-positive, ERBB2 (formerly HER2)-negative, clinically node-negative breast cancer from January 1, 2010, to December 31, 2018, who were treated at 15 community and academic hospitals within the health system. EXPOSURES Sentinel lymph node biopsy and adjuvant RT. MAIN OUTCOMES AND MEASURES Primary outcomes were 5-year locoregional recurrence-free survival (LRFS) rate and disease-free survival (DFS) rate after SLNB and after RT. Secondary outcomes included recurrence rate, subgroups that may benefit from SLNB or RT, and use rate of SLNB and RT over time. Propensity scores were used to create 2 cohorts to separately evaluate the association of SLNB and RT with recurrence outcomes. Cox proportional hazards regression model was used to estimate hazard ratios (HRs). RESULTS From 2010 to 2018, a total of 3361 women 70 years or older (median [interquartile range {IQR}] age, 77.0 [73.0-82.0] years) with estrogen receptor-positive, ERBB2-negative, clinically node-negative breast cancer were included in the study. Of these women, 2195 (65.3%) received SLNB and 1828 (54.4%) received adjuvant RT. Rates of SLNB steadily increased (1.0% per year), a trend that persisted after the 2016 adoption of the Choosing Wisely guideline. Rates of RT decreased slightly (3.4% per year). To examine patient outcomes and maximize follow-up time, the analysis was limited to cases from 2010 to 2014, identifying 2109 patients with a median (IQR) follow-up time of 4.1 (2.5-5.7) years. In the propensity score-matched cohorts, no association was found between SLNB and either LRFS (HR, 1.26; 95% CI, 0.37-4.30; P = .71) or DFS (HR, 1.92; 95% CI, 0.86-4.32; P = .11). In addition, RT was not associated with LRFS (HR, 0.33; 95% CI, 0.09-1.24; P = .10) or DFS (HR, 0.99; 95% CI, 0.46-2.10; P = .97). Subgroup analysis showed that stratification by tumor grade or comorbidity was not associated with LRFS or DFS. Low absolute rates of recurrence were observed when comparing the groups that received SLNB (3.5%) and those that did not (4.5%) as well as the groups that received RT (2.7%) and those that did not (5.5%). CONCLUSIONS AND RELEVANCE This study found that receipt of SLNB or RT was not associated with improved LRFS or DFS in older patients with ER-positive, clinically node-negative breast cancer. Despite limited follow-up time and wide 95% CIs, this study supports the continued deimplementation of both SLNB and RT in accordance with the Choosing Wisely and National Comprehensive Cancer Network guidelines.
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Affiliation(s)
- Neil Carleton
- Women’s Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
- Medical Scientist Training Program, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jian Zou
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yusi Fang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stephen E. Koscumb
- Clinical Analytics, UPMC Health Services Division, Pittsburgh, Pennsylvania
| | - Osama Shiraz Shah
- Women’s Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Fangyuan Chen
- Women’s Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
- School of Medicine, Tsinghua University, Beijing, China
| | - Sushil Beriwal
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Emilia J. Diego
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam M. Brufsky
- Women’s Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
- Division of Medical Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Steffi Oesterreich
- Women’s Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Steven D. Shapiro
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert Ferris
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Leisha A. Emens
- Women’s Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
- Division of Medical Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - George Tseng
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Oscar C. Marroquin
- Clinical Analytics, UPMC Health Services Division, Pittsburgh, Pennsylvania
| | - Adrian V. Lee
- Women’s Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Priscilla F. McAuliffe
- Women’s Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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30
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Lemon LS, Bodnar LM, Garrard W, Venkataramanan R, Platt RW, Marroquin OC, Caritis SN. Ondansetron use in the first trimester of pregnancy and the risk of neonatal ventricular septal defect. Int J Epidemiol 2021; 49:648-656. [PMID: 31860078 DOI: 10.1093/ije/dyz255] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Literature is divided regarding the risk of neonatal ventricular septal defect (VSD) associated with first trimester ondansetron use in pregnancy. METHODS We evaluated the risk of VSD associated with first trimester exposure to intravenous or oral ondansetron in 33 677 deliveries at Magee-Womens Hospital in Pittsburgh, PA (2006-2014). Using log-binomial regression, we evaluated the risk: (1) in the full cohort, (2) using propensity score designs with both matching and inverse probability weighting and (3) utilizing clustered trajectory analysis evaluating the role of dose. Sensitivity analyses assessed the association between ondansetron and all recorded birth defects in aggregate. RESULTS A total of 3733 (11%) pregnancies were exposed to ondansetron in the first trimester (dose range: 2.4-1008 mg). Ondansetron was associated with increased risk of VSD with risk ratios ranging from 1.7 [95% confidence interval (CI) 1.0-2.9] to 2.1 (95% CI 1.1-4.0) across methods. Risks correspond to one additional VSD for approximately every 330 pregnancies exposed in the first trimester. The association was dose-dependent with increased risk in women receiving highest cumulative doses compared with lowest doses [adjusted risk ratio: 3.2 (95% CI 1.0-9.9)]. The association between ondansetron and congenital malformations was diluted as the outcome included additional birth defects. CONCLUSIONS First trimester ondansetron use is associated with an increased risk of neonatal VSD potentially driven by higher doses. This risk should be viewed in the context of risks attributable to severe untreated nausea and vomiting of pregnancy.
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Affiliation(s)
- Lara S Lemon
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, PA, USA.,Department of Clinical Analytics, University of Pittsburgh Medical Centers, PA, USA
| | - Lisa M Bodnar
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, PA, USA.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA, USA
| | - William Garrard
- Department of Clinical Analytics, University of Pittsburgh Medical Centers, PA, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Science, School of Pharmacy, University of Pittsburgh, PA, USA.,Department of Pathology, University of Pittsburgh, PA, USA
| | - Robert W Platt
- Departments of Pediatrics and Epidemiology, Biostatistics and Occupational Health, McGill University, Quebec, Canada
| | - Oscar C Marroquin
- Department of Clinical Analytics, University of Pittsburgh Medical Centers, PA, USA.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA, USA
| | - Steve N Caritis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, PA, USA
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31
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McAuliffe PF, Carleton NM, Zou J, Fang Y, Koscumb SE, Shah O, Chen F, Beriwal S, Diego EJ, Brufsky AM, Oesterreich S, Shapiro SD, Ferris R, Emens LA, Tseng G, Marroquin OC, Lee AV. Abstract PS1-10: Outcomes after sentinel lymph node biopsy and radiation therapy in women over 70 years old with ER+, HER2-, clinically node negative breast cancer. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps1-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Overtreatment of early-stage breast cancer with favorable tumor biology in elderly patients can result in higher rates of complications and morbidities without impacting survival. Guidelines directed towards deimplementation of sentinel lymph node biopsy (SLNB) (Choosing Wisely) and radiation therapy (RT) (National Comprehensive Cancer Network) have been recommended. We sought to describe rates and impact on disease recurrence and survival of SLNB and RT in elderly patients with early breast cancer. Patient data were obtained from the cancer registry and electronic health record from University of Pittsburgh Medical Center, multicenter, single health care system. Consecutive female patients aged ≥ 70 with ER+, HER2- clinically node-negative breast cancer within a health care system from 2010 to 2018 were identified. Rates and patient characteristics associated with receipt of SLNB and RT, as well as local recurrence free survival (LRFS) and disease-free survival (DFS) were compared for patients that were diagnosed between 2010 and 2014 to allow for adequate follow up time. Cox proportional hazards regression was used to estimate hazard ratios (HRs) of mortality. Among 3,361 identified women, 2,195 (65.3%) received SLNB and 1,828 (54.4%) received RT. Rates of SLNB steadily increased (1.0% per year); this trend persisted in 2017 and 2018, even after the Society of Surgical Oncology adopted the Choosing Wisely Guidelines in 2016. During the same time period, rates of RT declined (3.4% per year). To examine outcomes, we limited the analysis to 2109 cases from 2010-2014; median (IQR) follow up time was 4.1 (2.5-5.7) years. Median (IQR) age was 77 (73-82) years. 1373 (65.1%) received SLNB and 1,219 (57.8%) received RT. Patients receiving SLNB were younger (P < 0.001) with smaller (P < 0.0001) and lower stage (P < 0.0001) tumors. They had fewer comorbidities (P < 0.001), longer follow-up times (P < 0.001), were less likely on Medicaid/Medicare (P = 0.0091), and were more often seen at an academic center (P < 0.0001). There was no difference in grade between those that did and did not receive SLNB (P = 0.31) and those that did and did not receive RT (P = 0.13). Multivariate cox proportional hazard analysis showed no effect of SLNB on LRFS (HR = 1.17, 95% CI 0.29-4.75, P = 0.83) or DFS (HR = 0.90, 95% CI 0.44-1.83, P = 0.77). Log rank test showed no difference in 5-year LRFS (P = 0.78) between patients who received (98.5%, 95% CI 97.7%-99.7%) and did not receive (98.1%, 95% CI 96.7%-99.5%) SLNB, but an increase was seen with 5-year DFS (P = 0.023), with 96.2% (95% CI 95.0%-97.4%) of patients disease-free among those who did receive SLNB vs. 93.0% (95% CI 90.6%-95.4%) with no SLNB. Multivariate cox proportional hazard analysis showed that RT was associated with improved LRFS (HR = 0.13, 95% CI 0.03-0.51, P < 0.01) and DFS (HR = 0.32, 95% CI 0.15-0.68, P < 0.01). Log rank test showed a difference in 5-year LRFS (P < 0.0001) for those who received RT (99.4%, 95% CI 98.8%-100%) against those who did not (96.5%, 95% CI 95.0%-98.1%), and a similar difference in 5-year DFS (P < 0.0001) in patients who did (97.0%, 95% CI 95.8%-98.1%) and did not (92.4%, 95% CI 90.2%-94.7%) receive RT. Lower age (OR = 0.89, 95% CI 0.87-0.92) and comorbidities (OR = 0.79, 95% CI 0.66-0.94) were associated with receipt of SLNB, while only age (OR = 0.91, 95% CI 0.88-0.94) was associated with receipt of RT.
We conclude that receipt of SLNB has no impact upon DFS or LRFS. This data supports deimplementation of SLNB for this patient population. Receipt of RT is important for controlling locoregional recurrence, supporting use of RT in this patient cohort.
Citation Format: Priscilla F McAuliffe, Neil M Carleton, Jian Zou, Yusi Fang, Stephen E Koscumb, Osama Shah, Fangyuan Chen, Sushil Beriwal, Emilia J Diego, Adam M Brufsky, Steffi Oesterreich, Steve D Shapiro, Robert Ferris, Leisha A Emens, George Tseng, Oscar C Marroquin, Adrian V Lee. Outcomes after sentinel lymph node biopsy and radiation therapy in women over 70 years old with ER+, HER2-, clinically node negative breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-10.
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Affiliation(s)
| | | | - Jian Zou
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yusi Fang
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Osama Shah
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Fangyuan Chen
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | | | | | | | - Robert Ferris
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - George Tseng
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Adrian V Lee
- University of Pittsburgh Medical Center, Pittsburgh, PA
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Reitz KM, Seymour CW, Vates J, Quintana M, Viele K, Detry M, Morowitz M, Morris A, Methe B, Kennedy J, Zuckerbraun B, Girard TD, Marroquin OC, Esper S, Holder-Murray J, Newman AB, Berry S, Angus DC, Neal M. Strategies to Promote ResiliencY (SPRY): a randomised embedded multifactorial adaptative platform (REMAP) clinical trial protocol to study interventions to improve recovery after surgery in high-risk patients. BMJ Open 2020; 10:e037690. [PMID: 32994242 PMCID: PMC7526307 DOI: 10.1136/bmjopen-2020-037690] [Citation(s) in RCA: 8] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION As the population ages, there is interest in strategies to promote resiliency, especially for frail patients at risk of its complications. The physiological stress of surgery in high-risk individuals has been proposed both as an important cause of accelerated age-related decline in health and as a model testing the effectiveness of strategies to improve resiliency to age-related health decline. We describe a randomised, embedded, multifactorial, adaptative platform (REMAP) trial to investigate multiple perioperative interventions, the first of which is metformin and selected for its anti-inflammatory and anti-ageing properties beyond its traditional blood glucose control features. METHODS AND ANALYSIS Within a multihospital, single healthcare system, the Core Protocol for Strategies to Promote ResiliencY (SPRY) will be embedded within both the electronic health record (EHR) and the healthcare culture generating a continuously self-learning healthcare system. Embedding reduces the administrative burden of a traditional trial while accessing and rapidly analysing routine patient care EHR data. SPRY-Metformin is a placebo-controlled trial and is the first SPRY domain evaluating the effectiveness of three metformin dosages across three preoperative durations within a heterogeneous set of major surgical procedures. The primary outcome is 90-day hospital-free days. Bayesian posterior probabilities guide interim decision-making with predefined rules to determine stopping for futility or superior dosing selection. Using response adaptative randomisation, a maximum of 2500 patients allows 77%-92% power, detecting >15% primary outcome improvement. Secondary outcomes include mortality, readmission and postoperative complications. A subset of patients will be selected for substudies evaluating the microbiome, cognition, postoperative delirium and strength. ETHICS AND DISSEMINATION The Core Protocol of SPRY REMAP and associated SPRY-Metformin Domain-Specific Appendix have been ethically approved by the Institutional Review Board and are publicly registered. Results will be publicly available to healthcare providers, patients and trial participants following achieving predetermined platform conclusions. TRIAL REGISTRATION NUMBER NCT03861767.
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Affiliation(s)
| | | | - Jennifer Vates
- Department of Critical Care Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Kert Viele
- Berry Consultants Statistical Innovation, Austin, Texas, USA
| | - Michelle Detry
- Berry Consultants Statistical Innovation, Austin, Texas, USA
| | - Michael Morowitz
- Department of Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | - Alison Morris
- Department of Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Barbara Methe
- Department of Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Jason Kennedy
- Department of Critical Care Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Brian Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Timothy D Girard
- Department of Critical Care Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Oscar C Marroquin
- Clinical Analytics, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Stephen Esper
- Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Anne B Newman
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Scott Berry
- Berry Consultants Statistical Innovation, Austin, Texas, USA
| | - Derek C Angus
- Department of Critical Care Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Matthew Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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33
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Reitz KM, Marroquin OC, Zenati MS, Kennedy J, Korytkowski M, Tzeng E, Koscum S, Newhouse D, Garcia RM, Vates J, Billiar TR, Zuckerbraun BS, Simmons RL, Shapiro S, Seymour CW, Angus DC, Rosengart MR, Neal MD. Association Between Preoperative Metformin Exposure and Postoperative Outcomes in Adults With Type 2 Diabetes. JAMA Surg 2020; 155:e200416. [PMID: 32267474 DOI: 10.1001/jamasurg.2020.0416] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Adults with comorbidity have less physiological reserve and an increased rate of postoperative mortality and readmission after the stress of a major surgical intervention. Objective To assess postoperative mortality and readmission among individuals with diabetes with or without preoperative prescriptions for metformin. Design, Setting, and Participants This cohort study obtained data from the electronic health record of a multicenter, single health care system in Pennsylvania. Included were adults with diabetes who underwent a major operation with hospital admission from January 1, 2010, to January 1, 2016, at 15 community and academic hospitals within the system. Individuals without a clinical indication for metformin therapy were excluded. Follow-up continued until December 18, 2018. Exposures Preoperative metformin exposure was defined as 1 or more prescriptions for metformin in the 180 days before the surgical procedure. Main Outcomes and Measures All-cause postoperative mortality, hospital readmission within 90 days of discharge, and preoperative inflammation measured by the neutrophil to leukocyte ratio were compared between those with and without preoperative prescriptions for metformin. The corresponding absolute risk reduction (ARR) and adjusted hazard ratio (HR) with 95% CI were calculated in a propensity score-matched cohort. Results Among the 10 088 individuals with diabetes who underwent a major surgical intervention, 5962 (59%) had preoperative metformin prescriptions. A total of 5460 patients were propensity score-matched, among whom the mean (SD) age was 67.7 (12.2) years, and 2866 (53%) were women. In the propensity score-matched cohort, preoperative metformin prescriptions were associated with a reduced hazard for 90-day mortality (adjusted HR, 0.72 [95% CI, 0.55-0.95]; ARR, 1.28% [95% CI, 0.26-2.31]) and hazard of readmission, with mortality as a competing risk at both 30 days (ARR, 2.09% [95% CI, 0.35-3.82]; sub-HR, 0.84 [95% CI, 0.72-0.98]) and 90 days (ARR, 2.78% [95% CI, 0.62-4.95]; sub-HR, 0.86 [95% CI, 0.77-0.97]). Preoperative inflammation was reduced in those with metformin prescriptions compared with those without (mean neutrophil to leukocyte ratio, 4.5 [95% CI, 4.3-4.6] vs 5.0 [95% CI, 4.8-5.3]; P < .001). E-value analysis suggested robustness to unmeasured confounding. Conclusions and Relevance This study found an association between metformin prescriptions provided to individuals with type 2 diabetes before a major surgical procedure and reduced risk-adjusted mortality and readmission after the operation. This association warrants further investigation.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania
| | - Oscar C Marroquin
- Clinical Analytics, UPMC Health Services Division, Pittsburgh, Pennsylvania
| | - Mazen S Zenati
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Jason Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mary Korytkowski
- Department of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Stephen Koscum
- Clinical Analytics, UPMC Health Services Division, Pittsburgh, Pennsylvania
| | - David Newhouse
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ricardo Martinez Garcia
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Vates
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Richard L Simmons
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephen Shapiro
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christopher W Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Makani A, Saba S, Jain SK, Bhonsale A, Sharbaugh MS, Thoma F, Wang Y, Marroquin OC, Lee JS, Estes NM, Mulukutla SR. Safety and Efficacy of Direct Oral Anticoagulants Versus Warfarin in Patients With Chronic Kidney Disease and Atrial Fibrillation. Am J Cardiol 2020; 125:210-214. [PMID: 31780073 DOI: 10.1016/j.amjcard.2019.10.033] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Abstract
Patients with atrial fibrillation (AF) commonly have impaired renal function. The safety and efficacy of direct oral anticoagulants (DOACs) in patients with chronic kidney disease (CKD) and end-stage renal disease has not been fully elucidated. This study evaluated and compared the safety outcomes of DOACs versus warfarin in patients with nonvalvular AF and concomitant CKD. Patients in our health system with AF prescribed oral anticoagulants during 2010 to 2017 were identified. All-cause mortality, bleeding and hemorrhagic, and ischemic stroke were evaluated based on degree of renal impairment and method of anticoagulation. There were 21,733 patients with a CHA2DS2-VASc score of ≥2 included in this analysis. Compared with warfarin, DOAC use in patients with impaired renal function was associated with lower risk of mortality with a hazard ratio (HR): 0.76 (95% confidence interval [CI] 0.70 to 0.84, p value <0.001) in patients with eGFR >60, HR 0.74 (95% CI 0.68 to 0.81, p value <0.001) in patients with eGFR >30 to 60, and HR 0.76 (95% CI 0.63 to 0.92, p value <0.001) in patients with eGFR ≤30 or on dialysis. Bleeding requiring hospitalization was also less in the DOAC group with a HR 0.93 (95% CI 0.82 to 1.04, p value 0.209) in patients with eGFR >60, HR 0.83 (95% CI 0.74 to 0.94, p value 0.003) in patients with eGFR >30 to 60, and HR 0.69 (95% CI 0.50 to 0.93, p value 0.017) in patients with eGFR ≤30 or on dialysis. In conclusion, in comparison to warfarin, DOACs appear to be safe and effective with a lower risk of all-cause mortality and lower bleeding across all levels of CKD.
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Kilic A, Sultan I, Gleason TG, Wang Y, Smith C, Marroquin OC, Thoma F, Toma C, Lee JS, Mulukutla SR. Surgical versus percutaneous multivessel coronary revascularization in patients with chronic kidney disease. Eur J Cardiothorac Surg 2019; 57:994-1000. [DOI: 10.1093/ejcts/ezz336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022] Open
Abstract
Abstract
OBJECTIVES
This study compared contemporary outcomes following surgical versus percutaneous coronary revascularization for multivessel coronary artery disease (MVCAD) in patients with chronic kidney disease.
METHODS
Patients with MVCAD and a reduced glomerular filtration rate (<60 ml/min) undergoing coronary bypass surgery (CABG) or percutaneous coronary intervention (PCI) at a single institution between 2010 and 2017 were included. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) defined as a composite outcome of death, stroke, myocardial infarction or repeat revascularization. Multivariable Cox regression models were used for risk-adjustment and propensity matching was also performed.
RESULTS
A total of 1853 patients were included in the study (1269 CABG, 584 PCI). CABG was associated with greater 5-year freedom from MACCE (70.1% vs 47.3%, P < 0.0001), a finding that persisted after risk-adjustment. The rates of early and late mortality and readmission were also lower with CABG as were individual rates of myocardial infarction and repeat revascularization. A propensity-matched analysis generated 704 well-matched patients (352 in each arm) with similar results, including greater 5-year freedom from MACCE (72.8% vs 45.8%, P < 0.0001), improved 5-year survival (73.9% vs 52.3%, P < 0.0001), lower readmission (cause-specific hazard ratio 0.68, 95% confidence interval 0.58–0.80; P < 0.0001), lower individual rates of myocardial infarction (2.6% vs 9.7%, P < 0.0001) and repeat revascularization (1.1% vs 7.4%, P < 0.0001).
CONCLUSIONS
CABG is associated with a lower MACCE rate than that of PCI in patients with MVCAD and chronic kidney disease. Multidisciplinary discussions regarding the optimal revascularization strategy are important in MVCAD, particularly in more complex scenarios such as chronic kidney disease.
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Affiliation(s)
- Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Conrad Smith
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Oscar C Marroquin
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joon S Lee
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Suresh R Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Cilia L, Sharbaugh M, Marroquin OC, Toma C, Smith C, Thoma F, Lee J, Mulukutla SR. Impact of Chronic Kidney Disease and Anemia on Outcomes After Percutaneous Coronary Revascularization. Am J Cardiol 2019; 124:851-856. [PMID: 31375241 DOI: 10.1016/j.amjcard.2019.06.001] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/20/2019] [Accepted: 06/10/2019] [Indexed: 12/14/2022]
Abstract
Few studies have evaluated outcomes after percutaneous coronary intervention (PCI) in patients with both anemia (hemoglobin < 12 g/dl in women; <13 in men) and chronic kidney disease (CKD, estimated glomerular filtration rate < 60 ml/min/1.73 m2). Patients with coronary artery disease who underwent PCI in our health system from 2010 to 2018 were included (n = 10,756), excluding those with ST-elevation myocardial infarction or shock. We evaluated the individual and combined effects of anemia and CKD on outcomes. Five-year mortality was highest in the cohort with both anemia and CKD and lowest in those with neither. After multivariate analysis, with the group with neither anemia nor CKD as a reference, the adjusted hazard ratio for mortality was 1.68 (95% confidence interval [CI] 1.45 to 1.95, p <0.001) for those with anemia alone, 1.33 (95% CI 1.15 to 1.53, p <0.001) for those with CKD alone, and 2.83 (95% CI 2.49 to 3.22, p <0.001) for those with both anemia and CKD. With respect to readmission and reintervention, similar tends were observed, with patients with both CKD and anemia having the highest risk for these outcomes. In conclusion, the combined effects of anemia and CKD on outcomes post-PCI appear to be worse than either of their effects individually.
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Affiliation(s)
- Lindsey Cilia
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Catalin Toma
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Conrad Smith
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joon Lee
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Donohue JM, Kennedy JN, Seymour CW, Girard TD, Lo-Ciganic WH, Kim CH, Marroquin OC, Moyo P, Chang CCH, Angus DC. Patterns of Opioid Administration Among Opioid-Naive Inpatients and Associations With Postdischarge Opioid Use: A Cohort Study. Ann Intern Med 2019; 171:81-90. [PMID: 31207646 PMCID: PMC6815349 DOI: 10.7326/m18-2864] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patterns of inpatient opioid use and their associations with postdischarge opioid use are poorly understood. OBJECTIVE To measure patterns in timing, duration, and setting of opioid administration in opioid-naive hospitalized patients and to examine associations with postdischarge use. DESIGN Retrospective cohort study using electronic health record data from 2010 to 2014. SETTING 12 community and academic hospitals in Pennsylvania. PATIENTS 148 068 opioid-naive patients (191 249 admissions) with at least 1 outpatient encounter within 12 months before and after admission. MEASUREMENTS Number of days and patterns of inpatient opioid use; any outpatient use (self-report and/or prescription orders) 90 and 365 days after discharge. RESULTS Opioids were administered in 48% of admissions. Patients were given opioids for a mean of 67.9% (SD, 25.0%) of their stay. Location of administration of first opioid on admission, timing of last opioid before discharge, and receipt of nonopioid analgesics varied substantially. After adjustment for potential confounders, 5.9% of inpatients receiving opioids had outpatient use at 90 days compared with 3.0% of those without inpatient use (difference, 3.0 percentage points [95% CI, 2.8 to 3.2 percentage points]). Opioid use at 90 days was higher in inpatients receiving opioids less than 12 hours before discharge than in those with at least 24 opioid-free hours before discharge (7.5% vs. 3.9%; difference, 3.6 percentage points [CI, 3.3 to 3.9 percentage points]). Differences based on proportion of the stay with opioid use were modest (opioid use at 90 days was 6.4% and 5.4%, respectively, for patients with opioid use for ≥75% vs. ≤25% of their stay; difference, 1.0 percentage point [CI, 0.4 to 1.5 percentage points]). Associations were similar for opioid use 365 days after discharge. LIMITATION Potential unmeasured confounders related to opioid use. CONCLUSION This study found high rates of opioid administration to opioid-naive inpatients and associations between specific patterns of inpatient use and risk for long-term use after discharge. PRIMARY FUNDING SOURCE UPMC Health System and University of Pittsburgh.
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Affiliation(s)
- Julie M Donohue
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (J.M.D.)
| | - Jason N Kennedy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (J.N.K., C.W.S., T.D.G., O.C.M., D.C.A.)
| | - Christopher W Seymour
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (J.N.K., C.W.S., T.D.G., O.C.M., D.C.A.)
| | - Timothy D Girard
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (J.N.K., C.W.S., T.D.G., O.C.M., D.C.A.)
| | | | - Catherine H Kim
- UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania (C.H.K.)
| | - Oscar C Marroquin
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (J.N.K., C.W.S., T.D.G., O.C.M., D.C.A.)
| | - Patience Moyo
- Brown University School of Public Health, Providence, Rhode Island (P.M.)
| | - Chung-Chou H Chang
- University of Pittsburgh School of Medicine and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (C.H.C.)
| | - Derek C Angus
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (J.N.K., C.W.S., T.D.G., O.C.M., D.C.A.)
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Mulukutla SR, Gleason TG, Sharbaugh M, Sultan I, Marroquin OC, Thoma F, Smith C, Toma C, Lee JS, Kilic A. Coronary Bypass Versus Percutaneous Revascularization in Multivessel Coronary Artery Disease. Ann Thorac Surg 2019; 108:474-480. [PMID: 31056197 DOI: 10.1016/j.athoracsur.2019.02.064] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [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: 09/21/2018] [Revised: 12/21/2018] [Accepted: 02/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study focused on contemporary outcomes after coronary artery bypass graft (CABG) surgery versus percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (MVCAD). METHODS This was a propensity-matched retrospective, observational analysis. Patients with MVCAD who underwent CABG or PCI between 2010 and 2018 and for whom data were available through the National Cardiovascular Data Registry or The Society of Thoracic Surgeons Adult Cardiac Surgery Database were included. The primary outcome was overall survival. Secondary outcomes included freedom from inpatient readmission and freedom from repeat revascularization. RESULTS Of the initial 6,163 patients with MVCAD, the propensity-matched cohort included 844 in each group. The estimated 1-year mortality was 11.5% and 7.2% (p < 0.001) in the PCI and CABG groups, respectively, with an overall hazard ratio for mortality of PCI versus CABG of 1.64 (95% confidence interval [CI], 1.29 to 2.10; p < 0.001). The overall hazard ratio for readmission for PCI versus CABG was 1.42 (95% CI, 1.23 to 1.64; p < 0.001). The overall hazard ratio for repeat revascularization for PCI versus CABG was 4.06 (95% CI, 2.39 to 6.91; p < 0.001). Overall major adverse cardiovascular events and individual outcomes of mortality, readmission, and repeat revascularization all favored CABG across virtually all major clinical subgroups. CONCLUSIONS This contemporary propensity-matched analysis of patients undergoing coronary revascularization for MVCAD demonstrates a significant mortality benefit with CABG over PCI, and this benefit is consistent across virtually all major patient subgroups. Futures studies are needed reflecting routine practice to assess how best to approach shared decision making and informed consent when it comes to revascularization decisions in any patient with MVCAD.
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Affiliation(s)
- Suresh R Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Thomas G Gleason
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Sharbaugh
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Oscar C Marroquin
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Conrad Smith
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joon S Lee
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Kenkre TS, Malhotra P, Johnson BD, Handberg EM, Thompson DV, Marroquin OC, Rogers WJ, Pepine CJ, Bairey Merz CN, Kelsey SF. Ten-Year Mortality in the WISE Study (Women's Ischemia Syndrome Evaluation). Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.116.003863. [PMID: 29217675 DOI: 10.1161/circoutcomes.116.003863] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 09/18/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The WISE study (Women's Ischemia Syndrome Evaluation) was a prospective cohort study of 936 clinically stable symptomatic women who underwent coronary angiography to evaluate symptoms and signs of ischemia. Long-term mortality data for such women are limited. METHODS AND RESULTS Obstructive coronary artery disease (CAD) was defined as ≥50% stenosis on angiography by core laboratory. We conducted a National Death Index search to assess the mortality of women who were alive at their final WISE contact date. Death certificates were obtained. All deaths were adjudicated as cardiovascular or noncardiovascular by a panel of WISE cardiologists masked to angiographic data. Multivariate Cox proportional hazards regression was used to identify significant independent predictors of mortality. At baseline, mean age was 58±12 years; 176 (19%) were non-white, primarily black; 25% had a history of diabetes mellitus, 59% hypertension, 55% dyslipidemia, and 59% had a body mass index ≥30. During a median follow-up of 9.5 years (range, 0.2-11.5 years), a total of 184 (20%) died. Of these, 115 (62%) were cardiovascular deaths; 31% of all cardiovascular deaths occurred in women without obstructive CAD (<50% stenosis). Independent predictors of mortality were obstructive CAD, age, baseline systolic blood pressure, history of diabetes mellitus, history of smoking, elevated triglycerides, and estimated glomerular filtration rate. CONCLUSIONS Among women referred for coronary angiography for signs and symptoms of ischemia, 1 in 5 died from predominantly cardiac pathogeneses within 9 years of angiographic evaluation. A majority of the factors contributing to the risk of death seem to be modifiable by existing therapies. Of note, 1 in 3 of the deaths in this cohort occurred in women without obstructive CAD, a condition often considered benign and without guideline-recommended treatments. Clinical trials are needed to provide treatment guidance for the group without obstructive CAD.
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Affiliation(s)
- Tanya S Kenkre
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.).
| | - Pankaj Malhotra
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - B Delia Johnson
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Eileen M Handberg
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Diane V Thompson
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Oscar C Marroquin
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - William J Rogers
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Carl J Pepine
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - C Noel Bairey Merz
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Sheryl F Kelsey
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
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Johnson AE, Adhikari S, Althouse AD, Thoma F, Marroquin OC, Koscumb S, Hausmann LRM, Myaskovsky L, Saba SF. Persistent sex disparities in implantable cardioverter-defibrillator therapy. Pacing Clin Electrophysiol 2018; 41:1150-1157. [PMID: 29959781 DOI: 10.1111/pace.13435] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/17/2018] [Accepted: 06/10/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical guidelines recommend cardioverter defibrillator implantation for patients with heart failure and reduced ejection fraction. Despite this, women and minorities have been less likely to receive implantable cardioverter-defibrillator (ICD) therapy than white men. We examined race and sex differences in ICD implantation in a recent cohort. METHODS Using cross-sectional, retrospective analyses, we mined our health system's outpatient electronic medical records to assess age, race, sex, medications, and comorbidities for patients aged ≥18 years with ejection fraction ≤ 35% during 2014. While adjusting for confounding variables such as medications, age, and comorbidities, we conducted a multivariable logistic regression assessing whether racial and sex differences in ICD therapy persist. RESULTS Among 5,156 outpatients with ejection fraction ≤35%, 1,681 (32.6%) patients had an ICD present at the time of their index outpatient visit in 2014. Women were less likely to have an ICD than men (25.0% vs 36.3%, P < 0.01), and black patients were less likely to have an ICD than white patients (28.0% vs 33.2%, P = 0.02). In adjusted multivariable analyses, women were less like to have ICDs (adjusted odds ratio [OR] = 0.68, 95% confidence interval [CI], 0.58-0.79, P < 0.01) but the race difference dissipated (adjusted OR for black race = 0.86, 95% CI, 0.68-1.08, P = 0.18). CONCLUSIONS In this large, outpatient cohort, we have shown that sex differences in ICD therapy continue to exist, but the difference in ICD prevalence by race was attenuated. Dedicated studies are required to fully understand the causes of persistent sex differences in ICD therapy.
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Affiliation(s)
- Amber E Johnson
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Floyd Thoma
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Oscar C Marroquin
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,UPMC's Department of Clinical Analytics, Pittsburgh, PA, USA
| | - Stephen Koscumb
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,UPMC's Department of Clinical Analytics, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- University of Pittsburgh Department of Medicine, Pittsburgh, PA, USA.,Veterans Affairs Pittsburgh Healthcare System Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease and Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Samir F Saba
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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41
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Agarwal N, Agarwal P, Querry A, Mazurkiewicz A, Whiteside B, Marroquin OC, Koscumb SF, Wecht DA, Friedlander RM. Reducing Surgical Infections and Implant Costs via a Novel Paradigm of Enhanced Physician Awareness. Neurosurgery 2017; 82:661-669. [DOI: 10.1093/neuros/nyx273] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 05/16/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Studies have demonstrated that physicians are often unaware of prescription drug, laboratory, diagnostic, and surgical supply costs.
OBJECTIVE
To investigate the effects of increased physician awareness on infection incidence and surgical device cost containment.
METHODS
Within our institution, physicians were informed of individual, independently adjudicated, craniotomy and ventricular shunt infection incidence and rankings among peers, after which a protocol aimed at reducing skin bacterial burden was implemented for craniotomies. Physicians were also made aware of the costs for shunts and dural substitutes as well as available alternatives.
RESULTS
The combined craniotomy and ventricular shunt infection incidence significantly decreased by 37.5% from 3.2% over May 2011 to April 2015 (132 infections/4137 procedures) to 2.1% over May 2015 to April 2016 (26 infections/1250 procedures; P = .041). The average annual cost savings was $234 175 from preventing postoperative craniotomy infections and $121 125 from preventing postoperative ventricular shunt infections. Total supply costs of ventricular shunts significantly decreased by 26% from $2345 per procedure in fiscal year 2015 to $1747 per procedure in fiscal year 2016 (P < .001). Total supply cost of dural grafts significantly decreased by 54% from $191 per procedure in fiscal year 2015 to $88 per procedure in fiscal year 2016 (P < .001). In total, all initiatives in this study resulted in an estimated annual savings of $567 062.
CONCLUSION
Physician awareness of outcomes and costs resulted in increasing the quality of care, while at the same time reducing the cost.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Prateek Agarwal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashley Querry
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anna Mazurkiewicz
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brittany Whiteside
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Oscar C Marroquin
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephen F Koscumb
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Daniel A Wecht
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Roberts JK, Rao SV, Shaw LK, Gallup DS, Marroquin OC, Patel UD. Comparative Efficacy of Coronary Revascularization Procedures for Multivessel Coronary Artery Disease in Patients With Chronic Kidney Disease. Am J Cardiol 2017; 119:1344-1351. [PMID: 28318510 DOI: 10.1016/j.amjcard.2017.01.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/18/2017] [Accepted: 01/18/2017] [Indexed: 12/18/2022]
Abstract
Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular disease and death, yet little data exist regarding the comparative efficacy of coronary revascularization procedures in CKD patients with multivessel disease. We created a cohort of 4,687 adults who underwent cardiac catheterization, had a serum creatinine value measured within 30 days, and had more than one vessel with ≥50% stenosis. We used Cox proportional hazard regression modeling weighted by the inverse probability of treatment to examine the association between 4 treatment strategies (medical management, percutaneous coronary intervention [PCI] with bare metal stent, PCI with drug-eluting stent, and coronary artery bypass grafting [CABG]) and mortality among patients across categories of estimated glomerular filtration rate; secondary outcome was a composite of mortality, myocardial infarction, or revascularization. Compared with medical management, CABG was associated with a reduced risk of death for patients of any nondialysis CKD severity (hazard ratio [HR] range 0.43 to 0.59). There were no significant mortality differences between CABG and PCI, except a decreased death risk in CABG-treated CKD patients (HR range 0.54 to 0.55). Compared with medical management and PCI, CABG was associated with a lower risk of death, myocardial infarction, or revascularization in nondialysis CKD patients (HR range 0.41 to 0.64). There were similar associations between decreased estimated glomerular filtration rate and increased mortality across all multivessel coronary artery disease patient treatment groups. When accounting for treatment propensity, surgical revascularization was associated with improved outcomes in patients of all CKD severities. A prospective randomized trial in CKD patients is required to confirm our findings.
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Epps KC, Holper EM, Selzer F, Vlachos HA, Gualano SK, Abbott JD, Jacobs AK, Marroquin OC, Naidu SS, Groeneveld PW, Wilensky RL. Sex Differences in Outcomes Following Percutaneous Coronary Intervention According to Age. Circ Cardiovasc Qual Outcomes 2016; 9:S16-25. [PMID: 26908855 DOI: 10.1161/circoutcomes.115.002482] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Women <50 years of age with coronary artery disease may represent a group at higher risk for recurrent ischemic events after percutaneous coronary intervention (PCI); however, no long-term, multicenter outcomes assessment exists in this population. METHODS AND RESULTS Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated the association of sex and age on cardiovascular-related outcomes in 10,963 patients (3797 women, 394 <50 years) undergoing PCI and followed for 5 years. Death, myocardial infarction, coronary artery bypass graft surgery, and repeat PCI were primary outcomes comprising major adverse cardiovascular events. Although procedural success rates were similar by sex, the cumulative rate of major adverse cardiovascular events at 1 year was higher in young women (27.8 versus 19.9%; P=0.003), driven largely by higher rates of repeat revascularizations for target vessel or target lesion failure (coronary artery bypass graft surgery: 8.9% versus 3.9%, P<0.001, adjusted hazard ratio 2.4, 95% confidence interval 1.5-4.0; PCI: 19.0% versus 13.0%, P=0.005, adjusted hazard ratio 1.6, 95% confidence interval 1.2-2.2). At 5 years, young women remained at higher risk for repeat procedures (coronary artery bypass graft surgery: 10.7% versus 6.8%, P=0.04, adjusted hazard ratio 1.71, 95% confidence interval 1.01-2.88; repeat PCI [target vessel]: 19.7% versus 11.8%, P=0.002, adjusted hazard ratio 1.8, 95% confidence interval 1.24-2.82). Compared with older women, younger women remained at increased risk of major adverse cardiovascular events, whereas all outcome rates were similar in older women and men. CONCLUSIONS Young women, despite having less severe angiographic coronary artery disease, have an increased risk of target vessel and target lesion failure. The causes of this difference deserve further investigation. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00005677.
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Affiliation(s)
- Kelly C Epps
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Elizabeth M Holper
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Faith Selzer
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Helen A Vlachos
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Sarah K Gualano
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - J Dawn Abbott
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Alice K Jacobs
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Oscar C Marroquin
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Srihari S Naidu
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Peter W Groeneveld
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Robert L Wilensky
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
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Kudaravalli M, Althouse AD, Marroquin OC, Khandhar SJ, Sharbaugh MS, Toma C, Conrad Smith A, Schindler JT, Lee JS, Mulukutla SR. Assessment of P2Y12 inhibitor usage and switching in acute coronary syndrome patients undergoing percutaneous coronary revascularization. Int J Cardiol 2016; 223:854-859. [DOI: 10.1016/j.ijcard.2016.08.144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/05/2016] [Accepted: 08/06/2016] [Indexed: 10/21/2022]
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Rijal S, Wolfe J, Rattan R, Durrani A, Althouse AD, Marroquin OC, Jain S, Mulukutla S, Saba S. Lead related complications in quadripolar versus bipolar left ventricular leads. Indian Pacing Electrophysiol J 2016; 17:3-7. [PMID: 28401860 PMCID: PMC5357860 DOI: 10.1016/j.ipej.2016.10.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 08/19/2016] [Accepted: 10/21/2016] [Indexed: 11/29/2022] Open
Abstract
Background Quadripolar left ventricular (LV) leads are capable of pacing from four different electrodes which allows for easier and more stable intra-operative lead positioning with optimal pacing parameters. We therefore investigated the rate of combined intra-operative and post-operative LV lead related events in quadripolar vs. bipolar LV lead cardiac resynchronization therapy (CRT) recipients in the real world setting. Methods We retrospectively collected data for N = 1441 patients at our institution implanted with quadripolar (n = 292) or bipolar (n = 1149) LV leads from 2012 to 2014 and followed them to the primary end-point of composite lead outcome defined as intra-operative lead implant failure or post-operative lead dislodgement or deactivations. Results Patients implanted with a quadripolar lead were younger (70.6 ± 11.4 vs 72.5 ± 11.6, p = 0.014) and had higher incidence of diabetes (41.8% vs 32.8%, p = 0.004) compared to those with bipolar leads. All other baseline characteristics were comparable. Patients implanted with a quadripolar were significantly less likely to reach the primary endpoint in the first 12 months after LV lead implantation (Hazard Ratio 0.22, 95% Confidence Interval 0.08–0.60, p = 0.001). There were no differences between the two groups in rates of hospitalization for any cause or in mortality. Conclusion In this real world study, quadripolar LV leads have significantly lower rates of implantation failure and post-operative lead dislodgement or deactivation. These results have important clinical implications to CRT recipients.
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Affiliation(s)
- Shasank Rijal
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jonathan Wolfe
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Rohit Rattan
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Asad Durrani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Andrew D Althouse
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Oscar C Marroquin
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Sandeep Jain
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Suresh Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Samir Saba
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
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Sanchez CE, Dota A, Badhwar V, Kliner D, Smith AJC, Chu D, Toma C, Wei L, Marroquin OC, Schindler J, Lee JS, Mulukutla SR. Revascularization heart team recommendations as an adjunct to appropriate use criteria for coronary revascularization in patients with complex coronary artery disease. Catheter Cardiovasc Interv 2015; 88:E103-E112. [PMID: 26527352 DOI: 10.1002/ccd.26276] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 10/03/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To evaluate how a comprehensive evidence-based clinical review by a multidisciplinary revascularization heart team on treatment decisions for revascularization in patients with complex coronary artery disease using SYNTAX scores combined with Society of Thoracic Surgeons-derived clinical variables can be additive to the utilization of Appropriate Use Criteria for coronary revascularization. BACKGROUND Decision-making regarding the use of revascularization for coronary artery disease has come under major scrutiny due to inappropriate overuse of revascularization. There is little data in routine clinical practice evaluating how a structured, multidisciplinary heart team approach may be used in combination with the Appropriate Use Criteria for revascularization. METHODS From May 1, 2012 to January 1, 2015, multidisciplinary revascularization heart team meetings were convened to discuss evidence-based management of 301 patients with complex coronary artery disease. Heart team recommendations were adjudicated with the Appropriate Use Criteria for coronary revascularization for each clinical scenario using the Society for Cardiovascular Angiography and Interventions' Quality Improvement Toolkit (SCAI-QIT) Appropriate Use Criteria App. RESULTS Concordance of the Heart Team to Appropriate Use Criteria had a 99.3% appropriate primary indication for coronary revascularization. Among patients who underwent percutaneous revascularization, 34.9% had an inappropriate or uncertain indication as recommended by the Heart Team. Patients with uncertain or inappropriate percutaneous coronary interventions had significantly higher SYNTAX score (27.3 ± 6.6; 28.5 ± 5.5; 19.2 ± 6; P < 0.0001) and Society of Thoracic Surgeons-Predicted Risk of Mortality (6.1% ± 4.7%; 8.1% ± 6.3%; 3.7% ± 4.1%; P < 0.0081) compared to appropriate indications, frequently had concomitant forms of advanced comorbidities and frailty in the setting of symptomatic coronary artery disease. CONCLUSIONS A formal, multidisciplinary revascularization heart team can provide proper validation for clinical decisions and should be considered in combination with the Appropriate Use Criteria for coronary revascularization to formulate revascularization strategies for individuals in a patient-centered fashion. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Carlos E Sanchez
- Department of Internal Medicine, Division of Cardiology, Riverside Methodist Hospital, Columbus, Ohio
| | - Anthony Dota
- Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vinay Badhwar
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Dustin Kliner
- Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - A J Conrad Smith
- Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Catalin Toma
- Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Lawrence Wei
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Oscar C Marroquin
- Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John Schindler
- Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joon S Lee
- Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh R Mulukutla
- Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. .,Department of Internal Medicine, Division of Cardiology, VA Medical Center, Pittsburgh, Pennsylvania.
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Jones CR, Khandhar SJ, Ramratnam M, Mulukutla SR, Marroquin OC, Althouse AD, Rao A, Kato K, Jang IK, Toma C. Identification of Intrastent Pathology Associated With Late Stent Thrombosis Using Optical Coherence Tomography. J Interv Cardiol 2015; 28:439-48. [DOI: 10.1111/joic.12220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Christopher R. Jones
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Sameer J. Khandhar
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Mohun Ramratnam
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Suresh R. Mulukutla
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Oscar C. Marroquin
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Andrew D. Althouse
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Anjali Rao
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Koji Kato
- Cardiology Division; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Ik-Kyung Jang
- Cardiology Division; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Catalin Toma
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
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Perin EC, Borow KM, Silva GV, DeMaria AN, Marroquin OC, Huang PP, Traverse JH, Krum H, Skerrett D, Zheng Y, Willerson JT, Itescu S, Henry TD. A Phase II Dose-Escalation Study of Allogeneic Mesenchymal Precursor Cells in Patients With Ischemic or Nonischemic Heart Failure. Circ Res 2015; 117:576-84. [PMID: 26148930 DOI: 10.1161/circresaha.115.306332] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [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: 02/24/2015] [Accepted: 07/06/2015] [Indexed: 12/18/2022]
Abstract
RATIONALE Allogeneic mesenchymal precursor cells (MPCs) have been effective in large animal models of ischemic and nonischemic heart failure (HF). OBJECTIVE To evaluate the feasibility and safety of 3 doses (25, 75, or 150 million cells) of immunoselected allogeneic MPCs in chronic HF patients in a phase 2 trial. METHODS AND RESULTS We sequentially allocated 60 patients to a dosing cohort (20 per dose group) and randomized them to transendocardial MPC injections (n=15) or mock procedures (n=5). The primary objective was safety, including antibody testing. Secondary efficacy end points included major adverse cardiac events (MACE; cardiac death, myocardial infarction, or revascularization), left ventricular imaging, and other clinical-event surrogates. Safety and MACE were evaluated for up to 3 years. MPC injections were feasible and safe. Adverse events were similar across groups. No clinically symptomatic immune responses were noted. MACE was seen in 15 patients: 10 of 45 (22%) MPC-treated and 5 of 15 (33%) control patients. We found no differences between MPC-treated and control patients in survival probability, MACE-free probability, and all-cause mortality. We conducted a post hoc analysis of HF-related MACE (HF hospitalization, successfully resuscitated cardiac death, or cardiac death) and events were significantly reduced in the 150 million MPC group (0/15) versus control (5/15; 33%), 25 million MPC group (3/15; 20%), and 75 million MPC group (6/15; 40%); the 150 million MPC group differed significantly from all groups according to Kaplan-Meier statistics >3 years (P=0.025 for 150 million MPC group versus control). CONCLUSIONS Transendocardial injections of allogeneic MPCs were feasible and safe in chronic HF patients. High-dose allogeneic MPCs may provide benefits in this population.
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Affiliation(s)
- Emerson C Perin
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.).
| | - Kenneth M Borow
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - Guilherme V Silva
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - Anthony N DeMaria
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - Oscar C Marroquin
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - Paul P Huang
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - Jay H Traverse
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - Henry Krum
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - Donna Skerrett
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - Yi Zheng
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - James T Willerson
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - Silviu Itescu
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - Timothy D Henry
- From the Stem Cell Center (E.C.P., G.V.S., Y.Z., J.T.W.), Adult Cardiology (E.C.P., G.V.S., J.T.W.), Texas Heart Institute, Houston; Borow Consulting Group, LLC, Bryn Mawr, PA (K.M.B.); Division of Cardiology, School of Medicine, University of California San Diego (A.N.D.M.); Heart and Vascular Institute, Center for Heart and Vascular Quality, Outcomes, and Clinical Research, University of Pittsburgh Medical Center, PA (O.C.M.); Heart and Vascular Institute, Swedish Medical Center, Seattle, WA (P.P.H.); Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (J.H.T.); Monash University, Melbourne, Australia (H.K.); Mesoblast, Inc, New York (D.S.); Mesoblast, Inc, Melbourne, Victoria, Australia (S.I.); and Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
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49
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Chu D, Anastacio MM, Mulukutla SR, Lee JS, Smith AJC, Marroquin OC, Sanchez CE, Morell VO, Cook CC, Lico SC, Wei LM, Badhwar V. Safety and efficacy of implementing a multidisciplinary heart team approach for revascularization in patients with complex coronary artery disease: an observational cohort pilot study. JAMA Surg 2015; 149:1109-12. [PMID: 25207883 DOI: 10.1001/jamasurg.2014.2059] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Since the advent of transcatheter aortic valve replacement, the multidisciplinary heart team (MHT) approach has rapidly become the standard of care for patients undergoing the procedure. However, little is known about the potential effect of MHT on patients with coronary artery disease (CAD). OBJECTIVE To determine the safety and efficacy of implementing the MHT approach for patients with complex CAD. DESIGN, SETTING, AND PARTICIPANTS Observational cohort pilot study of 180 patients with CAD involving more than 1 vessel in a single major academic tertiary/quaternary medical center. From May 1, 2012, through May 31, 2013, MHT meetings were convened to discuss evidence-based management of CAD. All cases were reviewed by a team of interventional cardiologists and cardiac surgeons within 72 hours of angiography. All clinical data were reviewed by the team to adjudicate optimal treatment strategies. Final recommendations were based on a consensus decision. Outcome measures were tracked for all patients to determine the safety and efficacy profile of this pilot program. EXPOSURES Multidisciplinary heart team meeting. MAIN OUTCOMES AND MEASURES Thirty-day periprocedural mortality and rate of major adverse cardiac events. RESULTS Most of the patients underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG); a small percentage of patients underwent a hybrid procedure or medical management. Incidence of 30-day periprocedural mortality was low across all groups of patients (PCI group, 5 of 64 [8%]; CABG group, 1 of 87 [1%]). The rate of major adverse cardiac events during a median follow-up of 12.1 months ranged from 12 of 87 patients (14%) in the CABG group to 15 of 64 (23%) in the PCI group. CONCLUSIONS AND RELEVANCE Outcomes of patients with complex CAD undergoing the optimal treatment strategy recommended by the MHT were similar to those of published national standards. Implementation of the MHT approach for patients with complex CAD is safe and efficacious.
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Affiliation(s)
- Danny Chu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania2Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Melissa M Anastacio
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania2Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Suresh R Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania3Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joon S Lee
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania3Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - A J Conrad Smith
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania3Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Oscar C Marroquin
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania3Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carlos E Sanchez
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania3Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Victor O Morell
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania2Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Chris C Cook
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania2Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Serrie C Lico
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania2Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lawrence M Wei
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania2Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Vinay Badhwar
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania2Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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50
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Olafiranye O, Vlachos H, Mulukutla SR, Marroquin OC, Selzer F, Kelsey SF, Williams DO, Strollo PJ, Reis SE, Lee JS, Smith AJC. Comparison of long-term safety and efficacy outcomes after drug-eluting and bare-metal stent use across racial groups: Insights from NHLBI Dynamic Registry. Int J Cardiol 2015; 184:79-85. [PMID: 25697874 DOI: 10.1016/j.ijcard.2015.01.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 12/07/2014] [Accepted: 01/26/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Long-term data on outcomes after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) and bare-metal stent (BMS) across racial groups are limited, and minorities are under-represented in existing clinical trials. Whether DES has better long-term clinical outcomes compared to BMS across racial groups remains to be established. Accordingly, we assessed whether longer-term clinical outcomes are better with DES compared to BMS across racial groups. METHODS Using the multicenter National Heart, Lung, and Blood Institute (NHLBI)-sponsored Dynamic Registry, 2-year safety (death, MI) and efficacy (repeat revascularization) outcomes of 3326 patients who underwent PCI with DES versus BMS were evaluated. RESULTS With propensity-score adjusted analysis, the use of DES, compared to BMS, was associated with a lower risk for death or MI at 2 years for both blacks (adjusted Hazard Ratio (aHR)=0.41, 95% CI 0.25-0.69, p<0.001) and whites (aHR=0.67, 95% CI 0.51-0.90, p=0.007). DES use was associated with a significant 24% lower risk of repeat revascularization in whites (aHR=0.76, 95% CI 0.60-0.97, p=0.03) and with nominal 34% lower risk in blacks (aHR=0.66, 95% CI 0.39-1.13, p=0.13). CONCLUSION The use of DES in PCI was associated with better long-term safety outcomes across racial groups. Compared to BMS, DES was more effective in reducing repeat revascularization in whites and blacks, but this benefit was attenuated after statistical adjustment in blacks. These findings indicate that DES is superior to BMS in all patients regardless of race. Further studies are needed to determine long-term outcomes across racial groups with newer generation stents.
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Affiliation(s)
- Oladipupo Olafiranye
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Helen Vlachos
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Suresh R Mulukutla
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Oscar C Marroquin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Faith Selzer
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sheryl F Kelsey
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, United States
| | - David O Williams
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, United States
| | - Patrick J Strollo
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Steven E Reis
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Joon S Lee
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - A J Conrad Smith
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States
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