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Bolden DM, Wogu AF, Peterson PN, Ross EG, Hogan SE, Matsushita K, Criqui MH, Allison M. Association between Statin use and Incident Peripheral Artery Disease According to Race, Age, and Presence of Depression in the Multi-Ethnic Study of Atherosclerosis. Ann Vasc Surg 2024; 102:160-171. [PMID: 38309426 PMCID: PMC10997470 DOI: 10.1016/j.avsg.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 02/05/2024]
Abstract
BACKGROUND Peripheral artery disease (PAD) is associated with high morbidity and mortality and has been commonly described as a coronary heart disease equivalent. Statin medications are recommended for primary prevention of atherosclerotic cardiovascular disease (CVD) among other indications. Therefore, understanding the longitudinal relationship of incident PAD is necessary to inform future research on how to prevent the disease. Depression complicates CVD patients' ability to properly adhere to their medications, yet the effect of depression on the relationship between statin use and incident PAD is understudied. People with PAD have a higher incidence of depressive symptoms than people without PAD. Black American and Hispanic populations are disproportionately affected by both PAD and depression yet research on the modifying effect of either race or depression on the relationship between statin use and onset of PAD is minimal. While statin utilization is highest for ages 75-84 years, there is minimal evidence of favorable risk-benefit balance. Consequently, in this project, we examined the relationship between statin use and incident PAD and whether this relationship is modified by race/ethnicity, depressive symptoms, or age. METHODS We used data on participants from the Multi-Ethnic Study of Atherosclerosis from visit 1 (2000) through study visit 6 (2020) who had three separate measurements of the ankle-brachial index (ABI) taken at visit 1, visit 3, and visit 5. Incident PAD was defined as 1) incident lower extremity amputation or revascularization or 2) ABI less than 0.90 coupled with ABI decrease greater than 0.15 over the follow-up period. Statin use was noted on the study visit prior to incident PAD diagnosis while depressive symptoms were measured at exam 1, visit 3, and visit 5. Propensity score matching was implemented to create balance between the participants in the two treatment groups, that is, statin-treated and statin-untreated groups, to reduce the problem of confounding by indication. Propensity scores were calculated using multivariate logistic regression model to estimate the probability of receiving statin treatment. We used Cox proportional hazards regression to investigate the relationship between time-dependent statin use as well as other risk factors with incident PAD, overall and stratified by 1) race, 2) depression status, and 3) age. RESULTS A total of 4,210 participants were included in the final matched analytic cohort. There were 810 incident cases (19.3%) of PAD that occurred over an average (mean) of 11.3 years (SD = 5.7) of follow-up time. In the statin-treated group, and with an average follow-up time of 12.5 years (SD = 5.6), there were 281 cases (13.4%) of incident PAD with the average follow-up time of 10.1 years (SD = 5.5), whereas in the statin-untreated group, there were 531 cases (25.2%) (P < 0.001). Results demonstrate a lower risk of PAD event in the statin-treated group compared to the untreated group (hazard ratio [HR] = 0.45, 95% confidence interval [CI]: 0.33-0.62) over the span of 18.5 years. The interactions between 1) depression and 2) race with statin use for incident PAD were not significant. However, other risk factors which were significant included Black American race that had approximately 30% lower hazard of PAD compared to non-Hispanic White (HR = 0.70, 95% CI: 0.58-0.84); age-stratified models were also fitted, and stain use was still a significant treatment factor for ages 45-54 (HR = 0.45, 95% CI: 0.33-0.63), 55-64 (HR = 0.61, 95% CI: 0.46-0.79), and 65-74 years (HR = 0.61, 95% CI: 0.48-0.78) but not for ages 75-84 years. CONCLUSIONS Statin use was associated with a decreased risk of incident PAD for those under the age of 75 years. Neither race nor depression significantly modified the relationship between statin use and incident PAD; however, the risk of incident PAD was lower among Black Americans. These findings highlight that the benefit of statin may wane for those over the age of 75 years. Findings also suggest that statin use may not be compromised in those living with depression.
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Affiliation(s)
- Demetria M Bolden
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Adane F Wogu
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Pamela N Peterson
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; Division of Cardiology, Denver Health Medical Center, Denver, CO
| | - Elsie G Ross
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Shea E Hogan
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; Division of Cardiology, Denver Health Medical Center, Denver, CO
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael H Criqui
- Department of Family Medicine, School of Medicine, University of California San Diego, San Diego, CA
| | - Matthew Allison
- Department of Family Medicine, School of Medicine, University of California San Diego, San Diego, CA
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Demedis J, Reedy J, Chow EJ, Dorsey Holliman B, Peterson PN, Studts CR. Provider perspectives and recommendations on standardized sexual function screening intervention in adolescent/young adult oncology patients. Pediatr Blood Cancer 2024; 71:e30872. [PMID: 38233999 DOI: 10.1002/pbc.30872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/13/2023] [Accepted: 01/03/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND Sexual function (SF) concerns are common among adolescent and young adult (AYA) cancer survivors, are underrecognized and undertreated. This study sought AYA oncology provider input on the implementation of an SF screening tool to address this unmet need. PROCEDURE Semi-structured interviews were completed with oncology providers (n = 25) who care for AYAs at a single institution. Interviews sought to understand barriers to addressing SF, elicit perspectives on use of an established screening tool, and obtain recommendations for SF screening intervention development and implementation. Interviews were developed using the Consolidated Framework for Implementation Research (CFIR); thematic analysis-guided interpretation. RESULTS AYA oncology providers were in favor of using an SF screening tool, but confirmed previously identified barriers and implementation considerations within multiple CFIR domains, including concerns about privacy, patient comfort, provider buy-in, provider knowledge, resource needs, and workflow/capacity constraints. They identified numerous strategies to address barriers through screening intervention design and implementation approaches. For example, provider buy-in could be optimized through education, availability of clinical resources, creation of a dedicated sexual healthcare team, provider engagement in intervention development, and leadership involvement. CONCLUSIONS Development and implementation of an effective SF screening intervention is necessary to improve diagnosis and treatment of sexual dysfunction, with the ultimate goal of improving sexual health-related quality of life in AYA cancer survivors. AYA oncology providers identified numerous intervention and implementation design strategies for the development and implementation of an SF screening intervention, which must be integrated with patient recommendations.
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Affiliation(s)
- Jenna Demedis
- Adult & Child Center for Health Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julia Reedy
- Center for Cancer and Blood Disorders at Children's Hospital Colorado, Aurora, Colorado, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Washington, USA
| | - Brooke Dorsey Holliman
- Center for Cancer and Blood Disorders at Children's Hospital Colorado, Aurora, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Pamela N Peterson
- Center for Cancer and Blood Disorders at Children's Hospital Colorado, Aurora, Colorado, USA
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Denver Health Medical Center, Denver, Colorado, USA
| | - Christina R Studts
- Adult & Child Center for Health Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado, USA
- Center for Cancer and Blood Disorders at Children's Hospital Colorado, Aurora, Colorado, USA
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Mujahid MS, Peterson PN. JAHA Go Red for Women Spotlight on Women and Cardiovascular Disease and Stroke. J Am Heart Assoc 2024; 13:e035104. [PMID: 38410949 PMCID: PMC10944069 DOI: 10.1161/jaha.124.035104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 02/28/2024]
Affiliation(s)
| | - Pamela N. Peterson
- Department of MedicineDenver Health Medical CenterDenverCOUSA
- Department of MedicineUniversity of Colorado Anschutz Medical CenterAuroraCOUSA
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Bhatt AS, Fonarow GC, Greene SJ, Holmes DN, Alhanti B, Devore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Linganathan K, Joyntmaddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Vaduganathan M. Medical Therapy Before, During and After Hospitalization in Medicare Beneficiaries With Heart Failure and Diabetes: Get With The Guidelines - Heart Failure Registry. J Card Fail 2024; 30:319-328. [PMID: 37757995 DOI: 10.1016/j.cardfail.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/23/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Patients hospitalized with heart failure (HF) and diabetes mellitus (DM) are at risk for worsening clinical status. Little is known about the frequency of therapeutic changes during hospitalization. We characterized the use of medical therapies before, during and after hospitalization in patients with HF and DM. METHODS We identified Medicare beneficiaries in Get With The Guidelines-Heart Failure (GWTG-HF) hospitalized between July 2014 and September 2019 with Part D prescription coverage. We evaluated trends in the use of 7 classes of antihyperglycemic therapies (metformin, sulfonylureas, GLP-1RA, SGLT2-inhibitors, DPP-4 inhibitors, thiazolidinediones, and insulins) and 4 classes of HF therapies (evidence-based β-blockers, ACEi or ARB, MRA, and ARNI). Medication fills were assessed at 6 and 3 months before hospitalization, at hospital discharge and at 3 months post-discharge. RESULTS Among 35,165 Medicare beneficiaries, the median age was 77 years, 54% were women, and 76% were white; 11,660 (33%) had HFrEF (LVEF ≤ 40%), 3700 (11%) had HFmrEF (LVEF 41%-49%), and 19,805 (56%) had HFpEF (LVEF ≥ 50%). Overall, insulin was the most commonly prescribed antihyperglycemic after HF hospitalization (n = 12,919, 37%), followed by metformin (n = 7460, 21%) and sulfonylureas (n = 7030, 20%). GLP-1RA (n = 700, 2.0%) and SGLT2i (n = 287, 1.0%) use was low and did not improve over time. In patients with HFrEF, evidence-based beta-blocker, RASi, MRA, and ARNI fills during the 6 months preceding HF hospitalization were 63%, 62%, 19%, and 4%, respectively. Fills initially declined prior to hospitalization, but then rose from 3 months before hospitalization to discharge (beta-blocker: 56%-82%; RASi: 51%-57%, MRA: 15%-28%, ARNI: 3%-6%, triple therapy: 8%-20%; P < 0.01 for all). Prescription rates 3 months after hospitalization were similar to those at hospital discharge. CONCLUSIONS In-hospital optimization of medical therapy in patients with HF and DM is common in participating hospitals of a large US quality improvement registry.
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Affiliation(s)
- Ankeet S Bhatt
- Kaiser Permanente San Francisco Medical Center and Division of Research, Oakland, CA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles, CA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | | | - Adam D Devore
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | | | | | | | - Karen E Joyntmaddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, CO; Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, University of Minnesota, Minneapolis, MN
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Grimshaw C, Keteyian SJ, Benzo R, Finkelstein J, Forman DE, Gaalema DE, Peterson PN, Einhorn PT, Punturieri A, Shero S, Fleg JL. Baseline Characteristics and Barriers to Recruitment in Cardiac and Pulmonary Rehabilitation NIH-Funded Trials. J Cardiopulm Rehabil Prev 2023; 43:407-411. [PMID: 37643249 PMCID: PMC10615858 DOI: 10.1097/hcr.0000000000000824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
| | | | | | | | - Daniel E. Forman
- Department of Medicine (Cardiology and Geriatrics), University of Pittsburgh, and the Geriatrics, Research, Education, and Clinical Center (GRECC), VA Pittsburgh Healthcare System, Pittsburgh, PA
| | | | - Pamela N. Peterson
- Denver Health Medical Center and University of Colorado Anschutz Medical Center, Denver and Aurora CO
| | | | | | - Susan Shero
- National Heart, Lung, and Blood Institute, Bethesda MD
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Pierce JB, Blumer V, Choi S, Hardy NC, Greiner MA, Carnicelli AP, Shen X, Lippmann SJ, Peterson PN, Allen LA, Fonarow GC, Mentz RJ, Greene SJ, O'Brien EC. Comparative Outcomes of Sacubitril/Valsartan Use After Hospitalization for Heart Failure Among Medicare Beneficiaries Naïve to Renin-Angiotensin System Inhibitors. Am J Cardiol 2023; 204:151-158. [PMID: 37544137 DOI: 10.1016/j.amjcard.2023.07.099] [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: 05/28/2023] [Accepted: 07/14/2023] [Indexed: 08/08/2023]
Abstract
Sacubitril/valsartan improves outcomes in patients with heart failure with reduced ejection fraction (HFrEF) compared with angiotensin-converting enzyme inhibitors (ACEis). However, data on postdischarge outcomes in renin-angiotensin system inhibitor (RASi)-naïve patients are limited. We included Medicare beneficiaries aged ≥65 years who were hospitalized for HFrEF in the Get With The Guidelines-Heart Failure registry between October 2015 and June 2019, had part D prescription coverage, and were not on RASi therapy during the 6 months before hospital admission. We examined the associations between sacubitril/valsartan prescription at hospital discharge and outcomes at 30 days and 1 year after discharge using overlap-weighted median regression and Cox proportional hazards models. The end points included "home time" (defined as days alive and out of any health care institution), mortality, and rehospitalization. Among 3,572 patients with HFrEF and who are naïve to RASi therapy, at discharge, 290 (8.1%) were prescribed sacubitril/valsartan and 1,390 (38.9%) were prescribed ACEis and angiotensin receptor blockers. After adjusting for baseline characteristics, patients prescribed sacubitril/valsartan had a longer median home time (parameter estimate 27.0 days, 95% confidence interval [CI] 12.40 to 41.6, p <0.001) and lower all-cause mortality (hazard ratio [HR] 0.74, 95% CI 0.61 to 0.91, p = 0.004) at 1 year than patients not prescribed sacubitril/valsartan. The prescription of sacubitril/valsartan was not significantly associated with all-cause rehospitalization (HR 0.87, 95% CI 0.74 to 1.03, p = 0.10) or heart failure rehospitalization (HR 0.87, 95% CI 0.70 to 1.07, p = 0.19). In a restricted comparison of patients discharged on sacubitril/valsartan versus ACEis and angiotensin receptor blockers, there were no significant differences in the outcomes. In conclusion, in this contemporary population of RASi-naïve patients with HFrEF from routine clinical practice, compared with not initiating, the initiation of sacubitril/valsartan at discharge was associated with longer home time and improvements in overall survival.
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Affiliation(s)
- Jacob B Pierce
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | | | - Sujung Choi
- Duke Department of Population Health Sciences, Durham, North Carolina
| | - N Chantelle Hardy
- Duke Department of Population Health Sciences, Durham, North Carolina
| | - Melissa A Greiner
- Duke Department of Population Health Sciences, Durham, North Carolina
| | - Anthony P Carnicelli
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Xian Shen
- Novartis Pharmaceutical Corporation, East Hanover, New Jersey
| | - Steven J Lippmann
- Duke Department of Population Health Sciences, Durham, North Carolina
| | - Pamela N Peterson
- Denver Health Medical Center, Denver, Colorado; University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Larry A Allen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
| | - Emily C O'Brien
- Duke Department of Population Health Sciences, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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Swat SA, Xu H, Allen LA, Greene SJ, DeVore AD, Matsouaka RA, Goyal P, Peterson PN, Hernandez AF, Krumholz HM, Yancy CW, Fonarow GC, Hess PL. Opportunities and Achievement of Medication Initiation Among Inpatients With Heart Failure With Reduced Ejection Fraction. JACC Heart Fail 2023; 11:918-929. [PMID: 37318420 DOI: 10.1016/j.jchf.2023.04.015] [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] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Initiation of evidence-based medications for patients with heart failure with reduced ejection fraction (HFrEF) during hospitalization in contemporary practice is unknown. OBJECTIVES This study characterized opportunities for and achievement of heart failure (HF) medication initiation. METHODS Using the GWTG-HF (Get With The Guidelines-Heart Failure) Registry 2017-2020, which collected data on contraindications and prescribing for 7 evidence-based HF-related medications, we assessed the number of medications for which each patient with HFrEF was eligible, use before admission, and prescribed at discharge. Multivariable logistic regression identified factors associated with medication initiation. RESULTS Among 50,170 patients from 160 sites, patients were eligible for mean number of 3.9 ± 1.1 evidence-based medications with 2.1 ± 1.3 used before admission and 3.0 ± 1.0 prescribed on discharge. The number of patients receiving all indicated medications increased from admission (14.9%) to discharge (32.8%), a mean net gain of 0.9 ± 1.3 medications over a mean of 5.6 ± 5.3 days. In multivariable analysis, factors associated with lower odds of HF medication initiation included older age, female sex, medical pre-existing conditions (stroke, peripheral arterial disease, pulmonary disease, and renal insufficiency), and rural location. Odds of medication initiation increased during the study period (adjusted OR: 1.08; 95% CI: 1.06-1.10). CONCLUSIONS Nearly 1 in 6 patients received all indicated HF-related medications on admission, increasing to 1 in 3 on discharge with an average of 1 new medication initiation. Opportunities to initiate evidence-based medications persist, particularly among women, those with comorbidities, and those receiving care at rural hospitals.
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Affiliation(s)
- Stanley A Swat
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Haolin Xu
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Larry A Allen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Parag Goyal
- Weill Cornell Medicine Division of Cardiology, New York, New York, USA
| | - Pamela N Peterson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Gregg C Fonarow
- Ronald Reagan-University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Paul L Hess
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.
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Waughtal J, Glorioso TJ, Sandy LM, Peterson PN, Chavez C, Bull S, Ho PM, Allen LA. Patient engagement with prescription refill text reminders across time and major societal events. Cardiovasc Digit Health J 2023; 4:133-136. [PMID: 37600444 PMCID: PMC10290239 DOI: 10.1016/j.cvdhj.2023.06.002] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023] Open
Affiliation(s)
- Joy Waughtal
- Colorado School of Public Health, Aurora, Colorado
| | | | - Lisa M. Sandy
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Catia Chavez
- Colorado School of Public Health, Aurora, Colorado
| | - Sheana Bull
- Colorado School of Public Health, Aurora, Colorado
| | - P. Michael Ho
- Veteran Affairs Eastern Colorado Health Care System, Aurora, Colorado
| | - Larry A. Allen
- University of Colorado School of Medicine, Aurora, Colorado
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Pierce JB, Vaduganathan M, Fonarow GC, Ikeaba U, Chiswell K, Butler J, DeVore AD, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, Linganathan KK, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Greene SJ. Contemporary Use of Sodium-Glucose Cotransporter-2 Inhibitor Therapy Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction in the US: The Get With The Guidelines-Heart Failure Registry. JAMA Cardiol 2023; 8:652-661. [PMID: 37212192 PMCID: PMC10203967 DOI: 10.1001/jamacardio.2023.1266] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [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: 03/09/2023] [Accepted: 04/11/2023] [Indexed: 05/23/2023]
Abstract
Importance Clinical guidelines for patients with heart failure with reduced ejection fraction (HFrEF) strongly recommend treatment with a sodium-glucose cotransporter-2 inhibitor (SGLT2i) to reduce cardiovascular mortality or HF hospitalization. Nationwide adoption of SGLT2i for HFrEF in the US is unknown. Objective To characterize patterns of SGLT2i use among eligible US patients hospitalized for HFrEF. Design, Setting, and Participants This retrospective cohort study analyzed 49 399 patients hospitalized for HFrEF across 489 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry between July 1, 2021, and June 30, 2022. Patients with an estimated glomerular filtration rate less than 20 mL/min/1.73 m2, type 1 diabetes, and previous intolerance to SGLT2i were excluded. Main Outcomes and Measures Patient-level and hospital-level prescription of SGLT2i at hospital discharge. Results Of 49 399 included patients, 16 548 (33.5%) were female, and the median (IQR) age was 67 (56-78) years. Overall, 9988 patients (20.2%) were prescribed an SGLT2i. SGLT2i prescription was less likely among patients with chronic kidney disease (CKD; 4550 of 24 437 [18.6%] vs 5438 of 24 962 [21.8%]; P < .001) but more likely among patients with type 2 diabetes (T2D; 5721 of 21 830 [26.2%] vs 4262 of 27 545 [15.5%]; P < .001) and those with both T2D and CKD (2905 of 12 236 [23.7%] vs 7078 vs 37 139 [19.1%]; P < .001). Patients prescribed SGLT2i therapy were more likely to be prescribed background triple therapy with an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, β-blocker, and mineralocorticoid receptor antagonist (4624 of 9988 [46.3%] vs 10 880 of 39 411 [27.6%]; P < .001), and 4624 of 49 399 total study patients (9.4%) were discharged with prescriptions for quadruple medical therapy including SGLT2i. Among 461 hospitals with 10 or more eligible discharges, 19 hospitals (4.1%) discharged 50% or more of patients with prescriptions for SGLT2i, whereas 344 hospitals (74.6%) discharged less than 25% of patients with prescriptions for SGLT2i (including 29 [6.3%] that discharged zero patients with SGLT2i prescriptions). There was high between-hospital variance in the rate of SGLT2i prescription in unadjusted models (median odds ratio, 2.53; 95% CI, 2.36-2.74) and after adjustment for patient and hospital characteristics (median odds ratio, 2.51; 95% CI, 2.34-2.71). Conclusions and Relevance In this study, prescription of SGLT2i at hospital discharge among eligible patients with HFrEF was low, including among patients with comorbid CKD and T2D who have multiple indications for therapy, with substantial variation among US hospitals. Further efforts are needed to overcome implementation barriers and improve use of SGLT2i among patients with HFrEF.
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Affiliation(s)
- Jacob B. Pierce
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles
- Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
| | | | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
- Baylor Scott and White Research Institute, Dallas, Texas
| | - Adam D. DeVore
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Paul A. Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, California
| | - Karen E. Joynt Maddox
- Cardiology Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | | | | | - Anjali Tiku Owens
- Division of Cardiology, Department of Medicine University of Pennsylvania, Philadelphia
| | - Pamela N. Peterson
- Department of Medicine, Denver Health Medical Center, Denver, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Center. Aurora
| | - Scott D. Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, University of Minnesota, Minneapolis
| | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Deputy Editor, JAMA Cardiology
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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10
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Gupta P, Sandy LC, Glorioso TJ, Khanna A, Khazanie P, Allen LA, Peterson PN, Bull S, Ho PJM. Secondary analysis of electronic opt-out consent in pragmatic research: A study design method to diversify clinical trials? Am Heart J 2023; 261:104-108. [PMID: 36966921 DOI: 10.1016/j.ahj.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/06/2023] [Accepted: 03/22/2023] [Indexed: 05/26/2023]
Abstract
We conducted a multi-center pragmatic trial of a low-risk intervention focused on medication adherence using an opt-out consent approach, where patients could opt out by letter and then electronically. We focus on the cohort after opt-out by mail. Here, we describe that 8% of patients opted out electronically, resulting in a 92% participation rate. Patients who self-identify as Black or Hispanic were less likely to opt out in the study, and half the study cohort was female. This demographic data is useful for planning future trials employing this approach.
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Affiliation(s)
- Prerna Gupta
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO.
| | - Lisa C Sandy
- Anschutz Medical Center, Division of General Internal Medicine, University of Colorado, Aurora, CO
| | - Thomas J Glorioso
- Rocky Mountain Regional Veteran Affairs Medical Center, Cardiology Section, Aurora, CO
| | - Amber Khanna
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO
| | - Prateeti Khazanie
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO
| | - Larry A Allen
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO
| | - Pamela N Peterson
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO; Department of Cardiology, Denver Health, Denver, CO
| | - Sheana Bull
- Colorado School of Public Health, Aurora, CO
| | - Pei Jai Michael Ho
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO; Rocky Mountain Regional Veteran Affairs Medical Center, Cardiology Section, Aurora, CO
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11
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Shah KS, Reyes-Miranda AE, Bradley SM, Breathett K, Das SR, Gluckman TJ, Gupta D, Leung DT, Mutharasan RK, Peterson PN, Spivak ES, Shah RU. Clinical Trial Participation and COVID-19: a Descriptive Analysis from the American Heart Association's Get With The Guidelines Registry. J Racial Ethn Health Disparities 2023; 10:892-898. [PMID: 35380371 PMCID: PMC8982302 DOI: 10.1007/s40615-022-01277-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/13/2022] [Accepted: 02/28/2022] [Indexed: 10/31/2022]
Abstract
As COVID-19 cases begin to decrease in the USA, learning from the pandemic experience will provide insights regarding disparities of care delivery. We sought to determine if specific populations hospitalized with COVID-19 are equally likely to be enrolled in clinical trials. We examined patients hospitalized with COVID-19 at centers participating in the American Heart Association's COVID-19 CVD Registry. The primary outcome was odds of enrollment in a clinical trial, according to sex, race, and ethnicity. Among 14,397 adults hospitalized with COVID-19, 9.5% (n = 1,377) were enrolled in a clinical trial. The proportion of enrolled patients was the lowest for Black patients (8%); in multivariable analysis, female and Black patients were less likely to be enrolled in a clinical trial related to COVID-19 compared to men and other racial groups, respectively. Determination of specific reasons for the disparities in trial participation related to COVID-19 in these populations should be further investigated.
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Affiliation(s)
- Kevin S Shah
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. 1900 E, Room 4A100, UT, 84132, Salt Lake City, USA.
| | - Adriana E Reyes-Miranda
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. 1900 E, Room 4A100, UT, 84132, Salt Lake City, USA
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ, USA
| | - Sandeep R Das
- Department of Internal Medicine, Cardiology Division, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Portland, OR, USA
| | - Divya Gupta
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel T Leung
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - R Kannan Mutharasan
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pamela N Peterson
- Denver Health Medical Center, Denver, CO, USA
- University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Emily S Spivak
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. 1900 E, Room 4A100, UT, 84132, Salt Lake City, USA
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12
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Hogan SE, Holland M, Burke J, Johnson P, McNeal D, Cicutto L, Nehler M, Peterson PN. Retrospective Review of Directional Atherectomy and Drug-Coated Balloon Use in a PAD Safety-Net Population. J Invasive Cardiol 2023; 35:E205-E216. [PMID: 37029994] [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] [Subscribe] [Scholar Register] [Indexed: 04/10/2023]
Abstract
BACKGROUND Peripheral artery disease (PAD) is associated with high morbidity and mortality, particularly once patients develop critical limb threatening ischemia (CLTI). Minorities and vulnerable populations often present with CLTI and experience worse outcomes. The use of directional atherectomy (DA) and drug-coated balloon (DCB) during lower-extremity revascularization (LER) has not been previously described in a safety-net population. OBJECTIVE To review demographic and clinical characteristics, and short- intermediate term outcomes of patients presenting to a safety-net hospital with PAD treated with DA and DCB during LER. METHODS In this retrospective, observational cohort study, chart review was performed of all patients who underwent DA and DCB during LER for PAD from April 2016 to January 2020 in a safety-net hospital. RESULTS The analysis included 58 patients, with 41% female, 24% Black/African American, and 31% Hispanic. From this group, 17% spoke a non-English primary language and 10% reported current or previous housing insecurity. Most (65%) presented with CLTI and had undergone a previous index leg LER (58%). The combination of DA and DCB was efficacious, resulting in low rates of bail-out stenting (16%) and target-vessel revascularization (26%) at 2 years. Low complication rates (tibial embolism in 12% and vessel perforation in 2% of cases) were also observed. Most patients (67%) with Rutherford category 5 experienced wound healing by 2 years. CONCLUSION In this safety-net population, the majority presented with CLTI and a previous LER of the index leg. The combination of DA and DCB resulted in low complication rates, and good short-intermediate outcomes in this frequently undertreated population.
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Affiliation(s)
| | - Pamela N. Peterson
- Division of Cardiology, Department of MedicineUniversity of Colorado Anschutz Medical Campus, Aurora and Denver Health Medical CenterDenverCOUSA
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14
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Acker SN, Kaar JL, Prendergast C, Inge TH, Diaz-Miron J, Peterson PN. Variation in cost of disposable operating room supplies at a children's hospital. J Pediatr Surg 2023; 58:518-523. [PMID: 35973858 DOI: 10.1016/j.jpedsurg.2022.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/13/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Operating room (OR) costs account for 40% of hospital costs. Disposable supplies make up a portion of OR costs and are the only cost that is under control of the surgeon. There are little data to explain how surgeons select surgical supplies and what factors predict supply selection. Our goal with the current work was to assess variation in cost of disposable OR supplies at the surgeon level, hypothesizing high variability would be observed. STUDY DESIGN Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For each procedure, the average disposable OR costs for each surgeon were tabulated and compared to the median supply cost for a given procedure at the group level. RESULTS For each procedure, the variation ranged from 149% (gastrostomy tube placement) to 758% (tonsillectomy and adenoidectomy). The median supply cost for an individual surgeon was not always above or below the median supply cost for that procedure for the group. No relationship was observed between whether the supply cost was above or below the median for a given case and a surgeon's case volume, years in practice, or operative length. There was also no relationship between surgeon volume and median cost, surgery length, and years of experience. CONCLUSION These data demonstrate variation in the cost of disposable OR supplies at the individual surgeon level at a single institution. This variation is not explained by case volume, years in practice, or operative length.
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Affiliation(s)
- Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States; Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States.
| | - Jill L Kaar
- Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States; Section of Endocrinology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
| | - Connor Prendergast
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States; Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Thomas H Inge
- Division of Pediatric Surgery, Lurie Children's Hospital, Northwestern University School of Medicine, Chicago, IL, United States
| | - Jose Diaz-Miron
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States; Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Pamela N Peterson
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States
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15
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Pierce JB, Li Z, Greiner MA, Lippmann SJ, Hardy NC, Shen X, Stampehl M, Mentz RJ, Allen LA, Peterson PN, Fonarow GC, O'Brien EC, Greene SJ. Adoption of Sacubitril/Valsartan Among Patients With Heart Failure With Mildly Reduced or Preserved Ejection Fraction: The Get With The Guidelines-Heart Failure Registry. Circ Heart Fail 2023; 16:e010176. [PMID: 36314141 DOI: 10.1161/circheartfailure.122.010176] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Jacob B Pierce
- Department of Medicine (J.B.P., R.J.M., E.C.O., S.J.G.), Duke University School of Medicine, Durham, NC
| | - Zhen Li
- Department of Population Health Sciences (Z.L., M.A.G., S.J.L., N.C.H.), Duke University School of Medicine, Durham, NC
| | - Melissa A Greiner
- Department of Population Health Sciences (Z.L., M.A.G., S.J.L., N.C.H.), Duke University School of Medicine, Durham, NC
| | - Steven J Lippmann
- Department of Population Health Sciences (Z.L., M.A.G., S.J.L., N.C.H.), Duke University School of Medicine, Durham, NC
| | - N Chantelle Hardy
- Department of Population Health Sciences (Z.L., M.A.G., S.J.L., N.C.H.), Duke University School of Medicine, Durham, NC
| | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (X.S., M.S.)
| | - Mark Stampehl
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (X.S., M.S.)
| | - Robert J Mentz
- Department of Medicine (J.B.P., R.J.M., E.C.O., S.J.G.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute, Durham, NC (R.J.M., E.C.O., S.J.G.)
| | - Larry A Allen
- Palliative and Advanced Illness Research, Center and Department of Medicine, Pennsylvania Perelman School of Medicine, Philadelphia (L.A.A.)
| | - Pamela N Peterson
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (P.N.P.).,Division of Cardiology, Denver Health Hospital, CO (P.N.P.)
| | - Gregg C Fonarow
- Department of Medicine, University of California Los Angeles (G.C.F.)
| | - Emily C O'Brien
- Department of Medicine (J.B.P., R.J.M., E.C.O., S.J.G.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute, Durham, NC (R.J.M., E.C.O., S.J.G.)
| | - Stephen J Greene
- Department of Medicine (J.B.P., R.J.M., E.C.O., S.J.G.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute, Durham, NC (R.J.M., E.C.O., S.J.G.)
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16
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Acker SN, Ogle S, Cooper E, Meier M, Peterson PN, Kulungowski AM. Current approaches to the management of pneumatosis intestinalis: an American Pediatric Surgical Association membership survey. Pediatr Surg Int 2022; 38:1965-1970. [PMID: 36242600 DOI: 10.1007/s00383-022-05249-1] [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] [Accepted: 09/15/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Pneumatosis intestinalis (PI) remains difficult to treat as it can lead to a broad range of clinical sequalae and there are little published data available to guide management. Our aim was to evaluate how pediatric surgeons currently manage children with PI, how treatment varies based on etiology, and to identify opportunities to optimize current PI management strategies. METHODS We administered a web-based survey of practicing pediatric surgeons in the United States and Canada. The survey was distributed to all members of the American Pediatric Surgical Association. RESULTS Of 1508 distributed surveys, 333 responses were received (22% response rate); 174 were complete and included in analysis (12% analyzed). For all scenarios, respondents recommended treatment for PI include a median 7 days of bowel rest and 7 days antibiotics. Only 41% reported their approach to PI management was optimal. Ways to optimize care include treatment based on etiology (83%), decreased number of repeat images (64%), shorter NPO course (49%), and shorter antibiotic course (47%). CONCLUSION Pediatric surgeons manage PI similarly regardless of etiology but most report this is suboptimal. Future work is needed to prospectively evaluate management protocols that consider etiology.
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Affiliation(s)
- Shannon N Acker
- Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Box 323, Aurora, CO, 80045, USA.
| | - Sarah Ogle
- Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Box 323, Aurora, CO, 80045, USA
| | - Emily Cooper
- Research Outcomes in Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Maxene Meier
- Research Outcomes in Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Pamela N Peterson
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, CO, USA
- Division of Cardiology, Department of Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Ann M Kulungowski
- Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Box 323, Aurora, CO, 80045, USA
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17
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Knoepke CE, Wallace BC, Allen LA, Lewis CL, Gupta SK, Peterson PN, Kramer DB, Brancato SC, Varosy PD, Mandrola JM, Tzou WS, Matlock DD. Experiences Implementing a Suite of Decision Aids for Implantable Cardioverter Defibrillators: Qualitative Insights From the DECIDE-ICD Trial. Circ Cardiovasc Qual Outcomes 2022; 15:e009352. [PMID: 36378770 PMCID: PMC9680003 DOI: 10.1161/circoutcomes.122.009352] [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: 05/31/2022] [Accepted: 10/05/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Shared decision making (SDM) is gaining importance in cardiology, including Centers for Medicare & Medicaid Services (CMS) reimbursement policies requiring documented SDM for patients considering primary prevention implantable cardioverter defibrillators. The DECIDE-ICD Trial (Decision Support Intervention for Patients offered implantable Cardioverter-Defibrillators) assessed the implementation and effectiveness of patient decision aids (DAs) using a stepped-wedge design at 7 sites. The purpose of this subanalysis was to qualitatively describe electrophysiology clinicians' experience implementing and using the DAs. METHODS This included semi-structured individual interviews with electrophysiology clinicians at participating sites across the US, at least 6 months following conversion into the implementation phase of the trial (from June 2020 through February 2022). The interview guide was structured according to the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance [implementation evaluation model]) framework, assessing clinician experiences, which can impact implementation domains, and was qualitatively assessed using a mixed inductive/deductive method. RESULTS We completed 22 interviews post-implementation across all 7 sites. Participants included both physicians (n=16) and other clinicians who counsel patients regarding treatment options (n=6). While perception of SDM and the DA were positive, participants highlighted reasons for uneven delivery of DAs to appropriate patients. The CMS mandate for SDM was not universally viewed as associating with patients receiving DA's, but rather (1) logistics of DA delivery, (2) perceived effectiveness in improving patient decision-making, and (3) match of DA content to current patient populations. Remaining tensions include the specific trial data used in DAs and reconciling timing of delivery with when patients are actively making decisions. CONCLUSIONS Clinicians charged with delivering DAs to patients considering primary prevention implantable cardioverter defibrillators were generally supportive of the tenets of SDM, and of the DA tools themselves, but noted several opportunities to improve the reach and continued use of them in routine care. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique Identifier: NCT03374891.
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Affiliation(s)
- Christopher E. Knoepke
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bryan C. Wallace
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Larry A. Allen
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carmen L. Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | - Pamela N. Peterson
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health Medical Center, Denver, CO, USA
| | - Daniel B. Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Paul D. Varosy
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
- Cardiology Section, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | | | - Wendy S. Tzou
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel D. Matlock
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
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18
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Darden D, Peterson PN, Xin X, Munir MB, Minges KE, Goldenberg I, Poole JE, Feld GK, Birgersdotter-Green U, Curtis JP, Hsu JC. Temporal trends and long-term outcomes among recipients of cardiac resynchronization therapy with defibrillator in the United States, 2011-2015: Insights from the National Cardiovascular Data Registry. Heart Rhythm O2 2022; 3:405-414. [PMID: 36097450 PMCID: PMC9463686 DOI: 10.1016/j.hroo.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Contemporary data on national trends and outcomes in cardiac resynchronization therapy with defibrillator (CRT-D) recipients following the 2012 updated guidelines has not been studied. Objectives This study assessed the trends in long-term outcomes among CRT-D Medicare-aged recipients implanted in 2011-2015. Methods Patients aged ≥65 years undergoing de novo CRT-D implantation in the National Cardiovascular Data Implantable Cardiac Defibrillator Registry from 2011-2015 with follow-up through 2017 using Medicare data were included and stratified by year of implant. Patient characteristics, in-hospital outcomes, and outcomes up to 2 years following implant were evaluated. Results Among 53,174 patients (aged 75.6-6.4 years, 29.7% women) implanted with CRT-D from 2011 to 2015, there was an increase in implantations based on guideline-concordant recommendations (81.0% to 84.7%, P < .001). Compared to 2011, in-hospital procedural complications decreased in 2015 (3.9% vs 2.9%; adjusted odds ratio, 0.76, 95% confidence interval, 0.66-0.88, P < .001), driven in part by decreased lead dislodgement (1.4% vs 1.0%). After multivariable adjustment, there was a lower risk of all-cause hospitalization, cardiovascular hospitalization, and mortality at 2-year follow-up in 2015 as compared to 2011, while there were no differences in heart failure hospitalizations at follow-up. Conclusion Among Medicare beneficiaries receiving CRT-D from 2011 to 2015, there was an increase in implantations based on guideline-concordant recommendations. Furthermore, there has been a reduction in in-hospital complications and long-term outcomes, including cardiovascular hospitalization, all-cause hospitalization, and mortality; however, there has been no difference in the risk of heart failure hospitalization after adjustment.
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Affiliation(s)
- Douglas Darden
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Pamela N. Peterson
- Division of Cardiology, Denver Health Medical Center, Denver, Colorado
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Xin Xin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Muhammad Bilal Munir
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Karl E. Minges
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ilan Goldenberg
- Division of Cardiology, University of Rochester Medical Center, Rochester, New York
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York
| | - Jeanne E. Poole
- University of Washington School of Medicine, Seattle, Washington
| | - Gregory K. Feld
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Ulrika Birgersdotter-Green
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan C. Hsu
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
- Address reprint requests and correspondence: Dr Jonathan C. Hsu, Associate Professor of Medicine, University of California San Diego, 9452 Medical Center Dr, MC7411, La Jolla, CA 92037.
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Bozkurt B, Das SR, Addison D, Gupta A, Jneid H, Khan SS, Koromia GA, Kulkarni PA, LaPoint K, Lewis EF, Michos ED, Peterson PN, Turagam MK, Wang TY, Yancy CW. 2022 AHA/ACC Key Data Elements and Definitions for Cardiovascular and Noncardiovascular Complications of COVID-19: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards. J Am Coll Cardiol 2022; 80:388-465. [PMID: 35753858 PMCID: PMC9222652 DOI: 10.1016/j.jacc.2022.03.355] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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20
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Bozkurt B, Das SR, Addison D, Gupta A, Jneid H, Khan SS, Koromia GA, Kulkarni PA, LaPoint K, Lewis EF, Michos ED, Peterson PN, Turagam MK, Wang TY, Yancy CW. 2022 AHA/ACC Key Data Elements and Definitions for Cardiovascular and Noncardiovascular Complications of COVID-19: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards. Circ Cardiovasc Qual Outcomes 2022; 15:e000111. [PMID: 35737748 PMCID: PMC9297692 DOI: 10.1161/hcq.0000000000000111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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21
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Gupta P, Durfee J, Andresen K, Vathsangam H, Waughtal J, Bull S, Peterson PN. MOBILE HEALTH: COMPARING PATIENT ENGAGEMENT VIA APPLICATION NOTIFICATION VERSUS TEXT MESSAGE. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02990-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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22
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Kini V, Breathett K, Groeneveld PW, Ho PM, Nallamothu BK, Peterson PN, Rush P, Wang TY, Zeitler EP, Borden WB. Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2022; 15:e000105. [PMID: 35189687 PMCID: PMC9909614 DOI: 10.1161/hcq.0000000000000105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Low-value health care services that provide little or no benefit to patients are common, potentially harmful, and costly. Nearly half of the patients in the United States will receive at least 1 low-value test or procedure annually, creating risk of avoidable complications from subsequent cascades of care and excess costs to patients and society. Reducing low-value care is of particular importance to cardiovascular health given the high prevalence and costs of cardiovascular disease in the United States. This scientific statement describes the current scope and impact of low-value cardiovascular care; reviews existing literature on patient-, clinician-, health system-, payer-, and policy-level interventions to reduce low-value care; proposes solutions to achieve meaningful and equitable reductions in low-value care; and suggests areas for future research priorities.
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Borne RT, Varosy P, Lan Z, Masoudi FA, Curtis JP, Matlock DD, Peterson PN. Trends in Use of Single- vs Dual-Chamber Implantable Cardioverter-Defibrillators Among Patients Without a Pacing Indication, 2010-2018. JAMA Netw Open 2022; 5:e223429. [PMID: 35315917 PMCID: PMC8941353 DOI: 10.1001/jamanetworkopen.2022.3429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Use of dual-chamber implantable cardioverter-defibrillator (ICD) systems among patients without a pacing indication is an example of low-value care given higher procedural risks, higher costs, and little evidence for benefit from an atrial lead. However, variation in the use of dual-chamber systems was present among patients without a pacing indication. OBJECTIVE To examine the temporal trends and hospital variation in use of single- and dual-chamber ICD implantation among patients without a pacing indication undergoing first-time ICD implantation. DESIGN, SETTING, AND PARTICIPANTS A multicenter cross-sectional study was conducted using the US National Cardiovascular Data Registry ICD Registry. A total of 266 182 patients undergoing initial implantation of a single- or dual-chamber transvenous ICD without a bradycardia pacing indication, class I or II cardiac resynchronization therapy indication, or history of atrial fibrillation or atrial flutter were included. The study was conducted from April 1, 2010, to December 31, 2018; data analysis was performed from October 19, 2020, to January 5, 2022. EXPOSURES Implantation of a single- or dual-chamber ICD. MAIN OUTCOMES AND MEASURES Temporal trends among patients undergoing single- vs dual-chamber ICDs were determined using the Cochran-Armitage trend test, and hospital-level variation using adjusted hospital median odds ratios was examined. RESULTS A total of 266 182 patients (single-chamber ICD, 134 925; dual-chamber ICD, 131 257) were included in this analysis; mean (SD) age was 58.0 (14.0) years and 91 990 patients (68.2%) were men. The use of dual-chamber ICDs decreased from 64.7% (n = 15 694) in 2010 to 42.2% (n = 9762) in 2018 (P < .001). Adjusted for patient characteristics, the median hospital-level proportion of single-chamber ICDs increased from 42.9% (95% CI, 42.6%-45.0%) in 2010 to 50.0% (95% CI, 47.8%-51.0%) in 2018. The median odds ratio for the use of dual-chamber ICDs, adjusted for patient characteristics, was 1.6 (95% CI, 1.6-1.8) in 2010 and 1.5 (95% CI, 1.5-1.8) in 2018, indicating decreasing but persistent variation in use. CONCLUSIONS AND RELEVANCE In this national study of US patients undergoing first-time ICD implantation without a clinical indication for an atrial lead, the use of dual-chamber devices decreased. However, institutional variability in the use of atrial leads persists, suggesting differences in individual or institutional cultures of real-world practice and opportunity to reduce this low-value practice.
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Affiliation(s)
- Ryan T. Borne
- Division of Cardiology, University of Colorado Health, Colorado Springs
| | - Paul Varosy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Cardiology Section, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Zhou Lan
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | - Frederick A. Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Research and Analytics, Ascension Health, St Louis, Missouri
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
- Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Daniel D. Matlock
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver
| | - Pamela N. Peterson
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Division of Cardiology, Denver Health Hospital, Denver, Colorado
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Breathett KK, Xu H, Sweitzer NK, Calhoun E, Matsouaka RA, Yancy CW, Fonarow GC, DeVore AD, Bhatt DL, Peterson PN. Is the affordable care act medicaid expansion associated with receipt of heart failure guideline-directed medical therapy by race and ethnicity? Am Heart J 2022; 244:135-148. [PMID: 34813771 PMCID: PMC8727506 DOI: 10.1016/j.ahj.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 09/17/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Uninsurance is a known contributor to racial/ethnic health inequities. Insurance is often needed for prescriptions and follow-up appointments. Therefore, we determined whether the Affordable Care Act(ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment(GDMT) at discharge among patients hospitalized with heart failure(HF) by race/ethnicity. METHODS Using Get With The Guidelines-HF registry, logistic regression was used to assess odds of receiving GDMT(HF medications; education; follow-up appointment) in early vs non-adopter states before(2012 - 2013) and after ACA Medicaid Expansion(2014 - 2019) within each race/ethnicity, accounting for patient-level covariates and within-hospital clustering. We tested for an interaction(p-int) between GDMT and pre/post Medicaid Expansion time periods. RESULTS Among 271,606 patients(57.5% early adopter, 42.5% non-adopter), 65.5% were White, 22.8% African American, 8.9% Hispanic, and 2.9% Asian race/ethnicity. Independent of ACA timing, Hispanic patients were more likely to receive all GDMT for residing in early adopter states compared to non-adopter states (P <.0001). In fully-adjusted analyses, ACA Medicaid Expansion was associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients [before ACA:OR 0.40(95%CI:0.13,1.23); after ACA:OR 2.46(1.10,5.51); P-int = .0002], but this occurred in the setting of an immediate decline in prescribing patterns, particularly among non-adopter states, followed by an increase that remained lowest in non-adopter states. The ACA was not associated with receipt of GDMT for other racial/ethnic groups. CONCLUSIONS Among GWTG-HF hospitals, Hispanic patients were more likely to receive all GDMT if they resided in early adopter states rather than non-adopter states, independent of ACA Medicaid Expansion timing. ACA implementation was only associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients. Additional steps are needed for improved GDMT delivery for all.
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Affiliation(s)
- Khadijah K. Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Haolin Xu
- Department of Biostatistics and Bioinformatics, Duke University,
Durham, NC
| | - Nancy K. Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Elizabeth Calhoun
- Center for Population Science and Discovery, University of Arizona,
Tucson, AZ
| | | | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of
Medicine, Chicago, IL
| | - Gregg C. Fonarow
- Division of Cardiology, University of California Los Angeles,
CA
| | | | - Deepak L. Bhatt
- Division of Cardiovascular Medicine, Brigham and Women’s
Hospital Heart & Vascular Center, Harvard Medical School, Boston,
MA
| | - Pamela N. Peterson
- Division of Cardiology, University of Colorado, Anschutz Medical
Campus, Aurora, CO and Division of Cardiology, Denver Health Medical Center,
Denver, CO
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25
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Shero ST, Benzo R, Cooper LS, Finkelstein J, Forman DE, Gaalema DE, Joseph L, Keteyian SJ, Peterson PN, Punturieri A, Zieman S, Fleg JL. Update on RFA Increasing Use of Cardiac and Pulmonary Rehabilitation in Traditional and Community Settings NIH-Funded Trials: ADDRESSING CLINICAL TRIAL CHALLENGES PRESENTED BY THE COVID-19 PANDEMIC. J Cardiopulm Rehabil Prev 2022; 42:10-14. [PMID: 34508036 PMCID: PMC8719437 DOI: 10.1097/hcr.0000000000000635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We previously described the design of six NIH-funded clinical trials designed to increase uptake and reduce disparities in the use of cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) based on age, gender, race/ethnicity, and socioeconomic status. The onset of the COVID-19 global pandemic necessitated signifi cant revisions to the trials to ensure the safety of participants and research staff. This article described necessary modifi cations for assessments, interventions, and data collection to support a no-contact approach centered on the use of virtual/remote techniques that maintain both safety and the original intent and integrity of the trials. The general shift from site-based to home-based interventions and hybrid models of CR and PR will be increasingly important in a post-COVID world.
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Affiliation(s)
- Susan T. Shero
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Roberto Benzo
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Lawton S. Cooper
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Joseph Finkelstein
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Daniel E. Forman
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Diann E. Gaalema
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Lyndon Joseph
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Steven J. Keteyian
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Pamela N. Peterson
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Antonello Punturieri
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Susan Zieman
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Jerome L. Fleg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
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Sandy LC, Glorioso TJ, Weinfurt K, Sugarman J, Peterson PN, Glasgow RE, Ho PM. Leave me out: Patients' characteristics and reasons for opting out of a pragmatic clinical trial involving medication adherence. Medicine (Baltimore) 2021; 100:e28136. [PMID: 34941059 PMCID: PMC8702195 DOI: 10.1097/md.0000000000028136] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/16/2021] [Indexed: 01/05/2023] Open
Abstract
Opt-out procedures are sometimes used instead of standard consent practices to enable patients to exercise their autonomous preferences regarding research participation while reducing patient and researcher burden. However, little is known about the characteristics of patients who opt-out of research and their reasons for doing so. We gathered such information in a large pragmatic clinical trial (PCT) evaluating the effect of theory informed text messages on medication adherence.Eligible patients, identified through electronic health records, were sent information about the study and provided with an opportunity to opt-out. Those opting out were asked to complete a voluntary survey regarding their reasons for doing so. Demographic data were compared among patients opting-out vs those included in the study using chi-squared tests and a log binomial regression model.Of 9046 patients receiving study packets, 906 (10.0%) patients returned opt-out forms. Of those, 451 (49.8%) returned the opt-out survey. Patients who opted out were more likely to be older, white, and nonHispanic than those who were included in the PCT. Survey respondents expressed high levels of trust in their health care providers, research, and system. Nearly half (46.6%) reported concerns about time as a reason to opt-out.In this PCT, 10% of patients receiving packets opted out, with significant differences in age, race, gender, and ethnicity compared to those included. Future trials should further investigate representativeness and reasons patients choose to opt-out of participating in research.
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Affiliation(s)
- Lisa Caputo Sandy
- General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- University of Colorado University of Colorado Anschutz Medical Campus, 13199 E Montview Blvd, Suite 300 Aurora, CO
| | | | - Kevin Weinfurt
- Department of Population and Health Sciences, Duke University, Durham, NC
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
| | - Pamela N. Peterson
- Department of Internal Medicine, Denver Health and Hospital Authority, Denver, CO
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Russell E. Glasgow
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P. Michael Ho
- VA Eastern Colorado Health Care System, Aurora, CO
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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Sopfe J, Marsh R, Frederick NN, Klosky JL, Chow EJ, Dorsey Holliman B, Peterson PN. Adolescent and young adult childhood cancer survivors' preferences for screening and education of sexual function. Pediatr Blood Cancer 2021; 68:e29229. [PMID: 34245209 DOI: 10.1002/pbc.29229] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Sexual dysfunction (SD) is a common yet underrecognized concern among childhood cancer survivors (CCS). CCS who are now adolescent and young adult (AYA-CCS) identify SD as an unmet need. This study sought to explore AYA-CCS preferences on how, when, where, and by whom SD-focused communication should occur. PROCEDURE This qualitative study utilized semi-structured interviews to explore AYA-CCS (now aged 15-24 years) experiences with, and preferences for, SD conversations. Thematic analysis methodology guided interpretation; themes were clustered into categories of who, how, when, and where SD conversations should occur. RESULTS AYA-CCS highlighted the importance of patient-provider rapport to facilitate SD conversations, but did not have consistent preferences regarding provider type or specialty. Providers should reduce discomfort by normalizing ongoing, personalized conversations. Some AYA-CCS mentioned that notification that such a conversation is going to occur would be appreciated, and most were in favor of a screening tool to facilitate conversations. Preferences for when and where SD conversations should occur were centered on maximizing privacy. CONCLUSIONS SD is an inadequately addressed concern in AYA-CCS, and providers must familiarize themselves with AYA-CCS preferences for discussing SD to reduce communication barriers and address this unmet need. In addition to corroborating prior studies' findings such as normalizing ongoing SD conversations, this study demonstrated novel ideas for reducing barriers, including use of a notification to prepare them prior to SD conversations, favoring the use of a screening tool, and the importance of establishing rapport prior to the SD conversations.
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Affiliation(s)
- Jenna Sopfe
- Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rebekah Marsh
- Adult & Child Consortium for Health Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Natasha N Frederick
- Center for Cancer and Blood Disorders, Connecticut Children's Medical Center, and Department of Pediatrics, University of Connecticut College of Medicine, Farmington, Connecticut, USA
| | - James L Klosky
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Brooke Dorsey Holliman
- Adult & Child Consortium for Health Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Pamela N Peterson
- Adult & Child Consortium for Health Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Denver Health Medical Center, Denver, Colorado, USA
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28
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Vaduganathan M, Greene SJ, Zhang S, Solomon N, Chiswell K, DeVore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Maddox KEJ, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Fonarow GC. Projected Clinical Benefits of Implementation of SGLT-2 Inhibitors among Medicare Beneficiaries Hospitalized for Heart Failure. J Card Fail 2021; 28:554-563. [PMID: 34785402 DOI: 10.1016/j.cardfail.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The sodium-glucose cotransporter-2 (SGLT-2) inhibitors form the latest pillar in the management of heart failure with reduced ejection fraction (HFrEF) and appear effective across a range of patient profiles. There is increasing interest around initiation of SGLT-2 inhibitor during hospitalization, yet little is known about the putative benefits of this implementation strategy. METHODS We evaluated Medicare beneficiaries with HFrEF (≤40%) hospitalized at 228 sites in the Get With The Guidelines®-Heart Failure (GWTG-HF) Registry in 2016 who had linked claims data for ≥1 year post-discharge. We identified those eligible for dapagliflozin under the latest US Food and Drug Administration label (excluding eGFR<25 mL/min per 1.73 m2, dialysis, or type 1 diabetes). We evaluated 1-year outcomes overall and among key subgroups (age≥75 years, sex, race, hospital region, kidney function, diabetes status, triple therapy). We then projected the potential benefits of implementation of dapagliflozin based on risk reductions from DAPA-HF. RESULTS Among 7,523 patients hospitalized for HFrEF, 6,576 (87%) would be dapagliflozin candidates (mean age 79±8 years, 39% women, 11% Black). Among eligible candidates, discharge use of β-blockers, ACEi/ARB, MRA, ARNI, and triple therapy (ACEi/ARB/ARNI+β-blocker+MRA) was recorded in 88%, 64%, 29%, 3%, and 20%, respectively. Among treatment-eligible patients, 1-year incidence (95% CI) of mortality was 37% (36-38%) and of HF readmission was 33% (32-34%), and each exceeded 25% across all key subgroups. Among 1,333 beneficiaries eligible for dapagliflozin who were already on triple therapy, 1-year incidence of mortality was 26% (24-29%) and 1-year HF readmission was 30% (27-32%). Applying the relative risk reductions observed in DAPA-HF, absolute risk reductions with complete implementation of dapagliflozin among treatment-eligible Medicare beneficiaries are projected to be 5% (1-9%) for mortality and 9% (5-12%) for HF readmission by 1 year. The projected number of Medicare beneficiaries that would need to be treated for 1 year to prevent 1 death is 19 (11-114) and 12 (8-21) would need to be treated to prevent 1 HF readmission. CONCLUSIONS Medicare beneficiaries with HFrEF eligible for dapagliflozin after HF hospitalization, including those well-treated with other disease-modifying therapies, face high risks of mortality and HF readmission by 1 year. If benefits in reduction in death and HF hospitalization observed in clinical trials can be fully realized, absolute benefits of implementation of SGLT-2 inhibitors among treatment eligible candidates are anticipated to be substantial in this high-risk post-discharge setting.
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Affiliation(s)
- Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | | | | | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | | | | | - Karen E Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, MO
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, CO; Department of Medicine, Anschutz Medical Center, Aurora, CO
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, University of Minnesota, MN, USA
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA.
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Affiliation(s)
| | - S Michelle Ogunwole
- Department of Medicine The Johns Hopkins University School of Medicine Baltimore MD.,The Johns Hopkins Center for Health Equity Baltimore MD
| | - Anika L Hines
- Department of Medicine The Johns Hopkins University School of Medicine Baltimore MD.,The Johns Hopkins Center for Health Equity Baltimore MD.,Department of Health Behavior and Policy Virginia Commonwealth University School of Medicine Richmond VA
| | - Pamela N Peterson
- Division of Cardiology University of Colorado, Anschutz Medical Campus Aurora CO.,Division of Cardiology Denver Health Medical Center Denver CO
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30
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Affiliation(s)
| | - Pamela N Peterson
- Denver Health Medical Center Denver CO.,University of Colorado Anschutz Medical Center Aurora CO
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Farasat M, Sanchez JM, West JJ, Burke JM, Prouse AF, Gore MO, Salame GA, Keach JW, Trent SA, Haigney MCP, Hogan SE, Peterson PN, Stauffer BL, Holland MR, Krantz MJ. A Point-of-Care Algorithm to Guide Proper Device Selection for Ambulatory Electrocardiography. Crit Pathw Cardiol 2021; 20:140-142. [PMID: 33731601 DOI: 10.1097/hpc.0000000000000259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the outpatient setting, ambulatory electrocardiography is the most frequently used diagnostic modality for the evaluation of patients in whom cardiac arrhythmias or conduction abnormalities are suspected. Proper selection of the device type and monitoring duration is critical for optimizing diagnostic yield and cost-effective resource utilization. However, despite guidance from major professional societies, the lack of systematic guidance for proper test selection in many institutions results in the need for repeat testing, which leads to not only increased resource utilization and cost of care, but also suboptimal patient care. To address this unmet need at our own institution, we formed a multidisciplinary panel to develop a concise, yet comprehensive algorithm, incorporating the most common indications for ambulatory electrocardiography, to efficiently guide clinicians to the most appropriate test option for a given clinical scenario, with the goal of maximizing diagnostic yield and optimizing resource utilization. The algorithm was designed as a single-page, color-coded flowchart to be utilized both as a rapid reference guide in printed form, and a decision support tool embedded within the electronic medical records system at the point of order entry. We believe that systematic adoption of this algorithm will optimize diagnostic efficiency, resource utilization, and importantly, patient care and satisfaction.
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Affiliation(s)
- Morteza Farasat
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jose M Sanchez
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - J Jason West
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Joseph M Burke
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Andrew F Prouse
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - M Odette Gore
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Gerard A Salame
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Department of Medicine, Division of Hospital Medicine, Denver Health and Hospital Authority, Denver, CO
| | - Joseph Walker Keach
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Department of Medicine, Division of Hospital Medicine, Denver Health and Hospital Authority, Denver, CO
| | - Stacey A Trent
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Mark C P Haigney
- Department of Medicine, Division of Cardiology, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Shea E Hogan
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Pamela N Peterson
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Brian L Stauffer
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Matthew R Holland
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Mori J Krantz
- From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
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Carnicelli AP, Li Z, Greiner MA, Lippmann SJ, Greene SJ, Mentz RJ, Hardy NC, Blumer V, Shen X, Yancy CW, Peterson PN, Allen LA, Fonarow GC, O'Brien EC. Sacubitril/Valsartan Adherence and Postdischarge Outcomes Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction. JACC Heart Fail 2021; 9:876-886. [PMID: 34509408 DOI: 10.1016/j.jchf.2021.06.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The authors sought to investigate associations between sacubitril/valsartan adherence and clinical outcomes after hospitalization for heart failure with reduced ejection fraction (HFrEF). BACKGROUND Sacubitril/valsartan improves outcomes in HFrEF, though the extent to which medication adherence is associated with outcomes in routine care is less well characterized. METHODS The authors analyzed patients aged ≥65 years hospitalized for HFrEF within the Get With the Guidelines-Heart Failure registry linked with Medicare claims between October 2015 and September 2018 who were discharged with sacubitril/valsartan. Sacubitril/valsartan adherence was assessed using medication fills to calculate proportion of days covered (PDC) through 90 days postdischarge. Associations between postdischarge adherence (PDC < or ≥80%) and risk of readmission and death within 1 year were examined by comparing cumulative incidences and adjusted event rates. RESULTS Among 897 patients prescribed sacubitril/valsartan at discharge, 295 (32.9%) had PDC ≥80% and 602 (67.1%) had PDC <80%. Baseline characteristics were balanced between groups. Compared with patients with PDC <80%, patients with PDC ≥80% had a significantly lower adjusted hazard of all-cause re-hospitalization (HR: 0.66; [95% CI: 0.48-0.89]) and death (HR: 0.42; [0.22-0.79]) at 90 days and at 1 year (HR: 0.69; [0.56-0.86] and HR: 0.53; [0.38-0.74], respectively). For every 5 percentage point increase in PDC, patients experienced a significant reduction in rehospitalization (HR: 0.98; [0.97-0.99]) and death (HR: 0.96; [0.94-0.97]) at 1 year. CONCLUSIONS In patients hospitalized for HFrEF and discharged on sacubitril/valsartan, high adherence to sacubitril/valsartan within 90 days after discharge was associated with substantially lower rates of readmission and death. Additional efforts to improve adherence with sacubitril/valsartan and other guideline-directed medical therapies in HFrEF are warranted.
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Affiliation(s)
- Anthony P Carnicelli
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zhen Li
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vanessa Blumer
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Xian Shen
- Health Economics and Outcomes Research, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Pamela N Peterson
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA; Division of Cardiology, Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Larry A Allen
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.
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Greene SJ, Choi S, Lippmann SJ, Mentz RJ, Greiner MA, Hardy NC, Hammill BG, Luo N, Samsky MD, Heidenreich PA, Laskey WK, Yancy CW, Peterson PN, Curtis LH, Hernandez AF, Fonarow GC, O'Brien EC. Clinical Effectiveness of Sacubitril/Valsartan Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction. J Am Heart Assoc 2021; 10:e021459. [PMID: 34350772 PMCID: PMC8475054 DOI: 10.1161/jaha.121.021459] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Sacubitril/Valsartan has been highly efficacious in randomized trials of heart failure with reduced ejection fraction (HFrEF). However, the effectiveness of sacubitril/valsartan in older patients hospitalized for HFrEF in real‐world US practice is unclear. Methods and Results This study included Medicare beneficiaries age ≥65 years who were hospitalized for HFrEF ≤40% in the Get With The Guidelines–Heart Failure registry between October 2015 and December 2018, and eligible for sacubitril/valsartan. Associations between discharge prescription of sacubitril/valsartan and clinical outcomes were assessed after inverse probability of treatment weighting and adjustment for other HFrEF medications. Overall, 1551 (10.9%) patients were discharged on sacubitril/valsartan. Of those not prescribed sacubitril/valsartan, 7857 (62.0%) were prescribed an angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker. Over 12‐month follow‐up, compared with a discharge prescription of angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker, sacubitril/valsartan was independently associated with lower all‐cause mortality (adjusted hazard ratio [HR], 0.82; 95% CI, 0.72–0.94; P=0.004) but not all‐cause hospitalization (adjusted HR, 0.97; 95% CI, 0.89–1.07; P=0.55) or heart failure hospitalization (adjusted HR, 1.04; 95% CI, 0.91–1.18; P=0.59). Patients prescribed sacubitril/valsartan versus those without a prescription had lower risk of all‐cause mortality (adjusted HR, 0.69; 95% CI, 0.60–0.79; P<0.001), all‐cause hospitalization (adjusted HR, 0.90; 95% CI, 0.82–0.98; P=0.02), but not heart failure hospitalization (adjusted HR, 0.94; 95% CI, 0.82–1.08; P=0.40). Conclusions Among patients hospitalized for HFrEF, prescription of sacubitril/valsartan at discharge was independently associated with reduced postdischarge mortality compared with angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker, and reduced mortality and all‐cause hospitalization compared with no sacubitril/valsartan. These findings support the use of sacubitril/valsartan to improve postdischarge outcomes among older patients hospitalized for HFrEF in routine US clinical practice.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Sujung Choi
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Steven J Lippmann
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Robert J Mentz
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Melissa A Greiner
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - N Chantelle Hardy
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Bradley G Hammill
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Nancy Luo
- Dignity Health Heart and Vascular Institute Sacramento CA
| | - Marc D Samsky
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Paul A Heidenreich
- Department of Medicine Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Warren K Laskey
- Division of Cardiology University of New Mexico School of Medicine Albuquerque NM
| | - Clyde W Yancy
- Division of Cardiology Northwestern University Feinberg School of Medicine Chicago IL
| | - Pamela N Peterson
- Division of Cardiology University of Colorado, Anschutz Medical Campus Aurora CO.,Division of Cardiology Denver Health Medical Center Denver CO
| | - Lesley H Curtis
- Duke Clinical Research Institute Durham NC.,Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Adrian F Hernandez
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center University of California Los Angeles Los Angeles CA
| | - Emily C O'Brien
- Duke Clinical Research Institute Durham NC.,Department of Population Health Sciences Duke University School of Medicine Durham NC
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Carnicelli AP, Lippmann SJ, Greene SJ, Mentz RJ, Greiner MA, Hardy NC, Hammill BG, Shen X, Yancy CW, Peterson PN, Allen LA, Fonarow GC, O'Brien EC. Sacubitril/Valsartan Initiation and Postdischarge Adherence Among Patients Hospitalized for Heart Failure. J Card Fail 2021; 27:826-836. [PMID: 34364659 DOI: 10.1016/j.cardfail.2021.03.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND We investigated associations between timing of sacubitril/valsartan initiation and postdischarge adherence among patients hospitalized for heart failure with reduced ejection fraction (HFrEF). Clinical trials support initiation of sacubitril/valsartan among patients hospitalized with HFrEF. The association between timing of initiation and postdischarge adherence is unknown. METHODS AND RESULTS We analyzed patients hospitalized for HFrEF (EF of ≤40%) within the Get With The Guidelines Heart Failure registry linked with Medicare claims between October 2015 and September 2017 who were eligible for sacubitril/valsartan. Follow-up was through December 2018. Patients were grouped by timing of sacubitril/valsartan initiation. Sacubitril/valsartan adherence at 90 and 365 days after discharge was assessed by calculating proportion of days covered (PDC) using medication fills. Among 4666 patients, 108 (2.3%) were continued on sacubitril/valsartan (on sacubitril/valsartan at admission and discharge), 191 (4.1%) were initiated as inpatients, 130 (2.8%) were initiated at discharge, and 4237 (90.1%) were discharged without sacubitril/valsartan. Median (25th, 75th) proportion of days covered through 90 days among those continued, initiated as inpatients, and initiated at discharge was 0.9 (0.6-0.1), 0.3 (0.0-0.7), and 0.0 (0.0-0.7), respectively (P < .001). Patients discharged without sacubitril/valsartan had very low rates of any sacubitril/valsartan fills within 90 and 365 days of discharge (2.1% and 7.7% of surviving patients, respectively). CONCLUSIONS In 2015-2017 US clinical practice, more than 90% of eligible patients hospitalized for HFrEF were discharged without sacubitril/valsartan. Patients initiated as inpatients had a higher postdischarge proportion of days covered than patients initiated at discharge. Patients discharged without sacubitril/valsartan were unlikely to receive it during follow-up. These findings highlight the importance of initiating sacubitril/valsartan during hospitalization to improve the quality of care.
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Affiliation(s)
- Anthony P Carnicelli
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Bradley G Hammill
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Pamela N Peterson
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Denver, Colorado
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Denver, Colorado
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.
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Patel RB, Fonarow GC, Greene SJ, Zhang S, Alhanti B, DeVore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Vaduganathan M. Kidney Function and Outcomes in Patients Hospitalized With Heart Failure. J Am Coll Cardiol 2021; 78:330-343. [PMID: 33989713 DOI: 10.1016/j.jacc.2021.05.002] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [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: 04/19/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Few contemporary data exist evaluating care patterns and outcomes in heart failure (HF) across the spectrum of kidney function. OBJECTIVES This study sought to characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction. METHODS Guideline-directed medical therapies were evaluated among patients hospitalized with HF at 418 sites in the GWTG-HF (Get With The Guidelines-Heart Failure) registry from 2014 to 2019 by discharge CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)-derived estimated glomerular filtration rate (eGFR). We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality. RESULTS Among 365,494 hospitalizations (age 72 ± 15 years, left ventricular ejection fraction [EF]: 43 ± 17%), median discharge eGFR was 51 ml/min/1.73 m2 (interquartile range: 34 to 72 ml/min/1.73 m2), 234,332 (64%) had eGFR <60 ml/min/1.73 m2, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014 to 2019. Among 157,439 patients with HF with reduced EF (≤40%), discharge guideline-directed medical therapies, including beta-blockers, were lowest in discharge eGFR <30 mL/min/1.73 m2 or dialysis (p < 0.001). "Triple therapy" with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor + beta-blocker + mineralocorticoid receptor antagonist was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60 to 89, 45 to 59, 30 to 44, <30 ml/min/1.73 m2, and dialysis, respectively; p < 0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; p < 0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger for HF with reduced EF compared with HF with mid-range or preserved EF (pinteraction = 0.045). CONCLUSIONS Despite facing elevated risks of mortality, patients with comorbid HF with reduced EF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.
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Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA. https://twitter.com/RBPatelMD
| | - Gregg C Fonarow
- Ahmanson-University of California, Los Angeles Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA.
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/SJGreene_md
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/_adevore
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA. https://twitter.com/JavedButler1
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, California, USA. https://twitter.com/MKIttlesonMD
| | - Karen E Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri, USA. https://twitter.com/kejoynt
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. https://twitter.com/tikuowens
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA; Department of Medicine, Anschutz Medical Center, Aurora, Colorado, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/scottdsolomon
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, University of Minnesota, Minnesota, USA. https://twitter.com/orlyvardeny
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/mvaduganathan
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Fletcher DR, Grunwald GK, Battaglia C, Ho PM, Lindrooth RC, Peterson PN. Association Between Increased Hospital Reimbursement for Cardiac Rehabilitation and Utilization of Cardiac Rehabilitation by Medicare Beneficiaries: An Interrupted Time Series. Circ Cardiovasc Qual Outcomes 2021; 14:e006572. [PMID: 33677975 PMCID: PMC8035974 DOI: 10.1161/circoutcomes.120.006572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although cardiac rehabilitation (CR) is a Class I Guideline recommendation, and has been shown to be a cost-effective intervention after a cardiac event, it has been reimbursed at levels insufficient to cover hospital operating costs. In January 2011, Medicare increased payment for CR in hospital outpatient settings by ≈180%. We evaluated the association between this payment increase and participation in CR of eligible Medicare beneficiaries to better understand the relationship between reimbursement policy and CR utilization. METHODS From a 5% Medicare claims sample, we identified patients with acute myocardial infarction, coronary artery bypass surgery, percutaneous coronary intervention, or cardiac valve surgery between January 1, 2009 and September 30, 2012, alive 30 days after their event, with continuous enrollment in Medicare fee-for-service, Part A/B for 4 months. Trends and changes in CR participation were estimated using an interrupted time series approach with a hierarchical logistic model, hospital random intercepts, adjusted for patient, hospital, market, and seasonality factors. Estimates were expressed using average marginal effects on a percent scale. RESULTS Among 76 695 eligible patients, average annual CR participation was 19.5% overall. In the period before payment increase, adjusted annual participation grew by 1.1 percentage points (95% CI, 0.48-2.4). No immediate change occurred in CR participation when the new payment was implemented. In the period after payment increase, on average, 20% of patients participated in CR annually. The annual growth rate in CR participation slowed in the post-period by 1.3 percentage points (95% CI, -2.4 to -0.12) compared with the prior period. Results were somewhat sensitive to time window variations. CONCLUSIONS The 2011 increase in Medicare reimbursement for CR was not associated with an increase in participation. Future studies should evaluate whether payment did not reach a threshold to incentivize hospitals or if hospitals were not sensitive to reimbursement changes.
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Affiliation(s)
- Dana R Fletcher
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gary K Grunwald
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - Catherine Battaglia
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - P Michael Ho
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- VA Eastern Colorado Health Care System, Aurora, CO, USA
| | | | - Pamela N Peterson
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Denver Health Medical Center, Denver, CO, USA
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Breathett K, Spatz ES, Kramer DB, Essien UR, Wadhera RK, Peterson PN, Ho PM, Nallamothu BK. The Groundwater of Racial and Ethnic Disparities Research: A Statement From Circulation: Cardiovascular Quality and Outcomes. Circ Cardiovasc Qual Outcomes 2021; 14:e007868. [PMID: 33567860 DOI: 10.1161/circoutcomes.121.007868] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson (K.B.)
| | - Erica S Spatz
- Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.)
| | - Daniel B Kramer
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA (D.B.K., R.K.W.)
| | - Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, PA (U.R.E.)
| | - Rishi K Wadhera
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA (D.B.K., R.K.W.)
| | - Pamela N Peterson
- Division of Cardiovascular Medicine, University of Colorado, Anschutz Medical Campus, Aurora (P.N.P., P.M.H.).,Division of Cardiology, Denver Health Medical Center, CO (P.N.P.)
| | - P Michael Ho
- Division of Cardiovascular Medicine, University of Colorado, Anschutz Medical Campus, Aurora (P.N.P., P.M.H.)
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Samsky MD, Lin L, Greene SJ, Lippmann SJ, Peterson PN, Heidenreich PA, Laskey WK, Yancy CW, Greiner MA, Hardy NC, Kavati A, Park S, Mentz RJ, Fonarow GC, O'Brien EC. Patient Perceptions and Familiarity With Medical Therapy for Heart Failure. JAMA Cardiol 2021; 5:292-299. [PMID: 31734700 DOI: 10.1001/jamacardio.2019.4987] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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: 12/11/2022]
Abstract
Importance There are major gaps in use of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). Patient-reported data outlining patient goals and preferences associated with GDMT are not available. Objective To survey patients with chronic HF to better understand their experiences and perceptions of living with HF, including their familiarity and concerns with important GDMT therapies. Design, Setting, and Participants Study participants were recruited from the GfK KnowledgePanel, a probability-sampled online panel representative of the US adult population. English-speaking adults who met the following criteria were eligible if they were (1) previously told by a physician that they had HF; (2) currently taking medications for HF; and (3) had no history of left ventricular assist device or cardiac transplant. Data were collected between October and November 2018. Analysis began in December 2018. Main Outcomes and Measures The survey included 4 primary domains: (1) relative importance of disease-related goals, (2) challenges associated with living with HF, (3) decision-making process associated with HF medication use, and (4) awareness and concerns about available HF medications. Results Of 30 707 KnowledgePanel members who received the initial survey, 15 091 (49.1%) completed the screening questions, 440 were eligible and began the survey, and 429 completed the survey. The median (interquartile range) age was 68 (60-75) years and most were white (320 [74.6%]), male (304 [70.9%]), and had at least a high school education (409 [95.3%]). Most survey responders reported familiarity with β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. Overall, 107 (24.9%) reported familiarity with angiotensin receptor-neprilysin inhibitors or mineralocorticoid receptor antagonists. Overall, 136 patients (42.5%) reported have safety concerns regarding angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 133 (38.5%) regarding β-blockers, 35 (37.9%) regarding mineralocorticoid receptor antagonists, 38 (36.5%) regarding angiotensin receptor-neprilysin inhibitors, and 123 (37.2%) regarding diuretics. Between 27.7% (n = 26) and 38.5% (n = 136) reported concerns regarding the effectiveness of β-blockers, angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists, or diuretics, while 41% (n = 132) were concerned with the effectiveness of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. Conclusions and Relevance In this survey study, many patients were not familiar with GDMT for HF, with familiarity lowest for angiotensin receptor-neprilysin inhibitors and mineralocorticoid receptor antagonists. Among patients not familiar with these therapies, significant proportions questioned their effectiveness and/or safety. Enhanced patient education and shared decision-making support may be effective strategies to improve the uptake of GDMT for HF in US clinical practice.
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Affiliation(s)
- Marc D Samsky
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Li Lin
- Duke Clinical Research Institute, Durham, North Carolina
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Pamela N Peterson
- Division of Cardiology, University of Colorado, Anschutz Medical Campus, Aurora.,Division of Cardiology, Denver Health Medical Center, Denver, Colorado
| | - Paul A Heidenreich
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Warren K Laskey
- Division of Cardiology, University of New Mexico School of Medicine, Albuquerque
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Deputy Editor
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Abhishek Kavati
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Siyeon Park
- Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, Baltimore
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C Fonarow
- Ahmanson-University of California, Los Angeles, Cardiomyopathy Center, University of California, Los Angeles.,Section Editor
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Borne RT, Masoudi FA, Curtis JP, Zipse MM, Sandhu A, Hsu JC, Peterson PN. Use and Outcomes of Dual Chamber or Cardiac Resynchronization Therapy Defibrillators Among Older Patients Requiring Ventricular Pacing in the National Cardiovascular Data Registry Implantable Cardioverter Defibrillator Registry. JAMA Netw Open 2021; 4:e2035470. [PMID: 33496796 PMCID: PMC7838925 DOI: 10.1001/jamanetworkopen.2020.35470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Frequent right ventricular (RV) pacing can cause and exacerbate heart failure. Cardiac resynchronization therapy (CRT) has been shown to be associated with improved outcomes among patients with reduced left ventricular ejection fraction who need frequent RV pacing, but the patterns of use of CRT vs dual chamber (DC) devices and the associated outcomes among these patients in clinical practice is not known. OBJECTIVE To assess outcomes, variability in use of device type, and trends in use of device type over time among patients undergoing implantable cardioverter defibrillator (ICD) implantation who were likely to require frequent RV pacing but who did not have a class I indication for CRT. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the National Cardiovascular Data Registry (NCDR) ICD Registry. A total of 3100 Medicare beneficiaries undergoing first-time implantation of CRT defibrillator (CRT-D) or DC-ICD from 2010 to 2016 who had a class I or II guideline ventricular bradycardia pacing indication but not a class I indication for CRT were included. Data were analyzed from August 2018 to October 2019. EXPOSURES Implantation of a CRT-D or DC-ICD. MAIN OUTCOMES AND MEASURES All-cause mortality, heart failure hospitalization, and complications were ascertained from Medicare claims data. Multivariable Cox proportional hazards models and Fine-Gray models were used to evaluate 1-year mortality and heart failure hospitalization, respectively. Multivariable logistic regression was used to evaluate 30-day and 90-day complications. All models accounted for clustering. The median odds ratio (MOR) was used to assess variability and represents the odds that a randomly selected patient receiving CRT-D at a hospital with high implant rates would receive CRT-D if they had been treated at a hospital with low CRT-D implant rates. RESULTS A total of 3100 individuals were included. The mean (SD) age was 76.3 (6.4) years, and 2500 (80.6%) were men. The 1698 patients (54.7%) receiving CRT-D were more likely than those receiving DC-ICD to have third-degree atrioventricular block (828 [48.8%] vs 432 [30.8%]; P < .001), nonischemic cardiomyopathy (508 [29.9%] vs 255 [18.2%]; P < .001), and prior heart failure hospitalizations (703 [41.4%] vs 421 [30.0%]; P < .001). Following adjustment, CRT-D was associated with lower 1-year mortality (hazard ratio [HR], 0.70; 95% CI, 0.57-0.87; P = .001) and heart failure hospitalization (subdistribution HR, 0.77; 95% CI, 0.61-0.97; P = .02) and no difference in complications compared with DC-ICD. Hospital variation in use of CRT was present (MOR, 2.00), and the use of CRT in this cohort was higher over time (654 of 1351 [48.4%] in 2010 vs 362 of 594 [60.9%] in 2016; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study of older patients in contemporary practice undergoing ICD implantation with a bradycardia pacing indication but without a class I indication for CRT, CRT-D was associated with better outcomes compared with DC devices. Variability in use of device type was observed, and the rate of CRT implantation increased over time.
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Affiliation(s)
- Ryan T. Borne
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | | | - Jeptha P. Curtis
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Matthew M. Zipse
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Amneet Sandhu
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Jonathan C. Hsu
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Diego, La Jolla
| | - Pamela N. Peterson
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Division of Cardiology, Denver Health Hospital, Denver, Colorado
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Allen LA, Venechuk G, McIlvennan CK, Page RL, Knoepke CE, Helmkamp LJ, Khazanie P, Peterson PN, Pierce K, Harger G, Thompson JS, Dow TJ, Richards L, Huang J, Strader JR, Trinkley KE, Kao DP, Magid DJ, Buttrick PM, Matlock DD. An Electronically Delivered Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure With Reduced Ejection Fraction: The EPIC-HF Trial. Circulation 2020; 143:427-437. [PMID: 33201741 DOI: 10.1161/circulationaha.120.051863] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Major gaps exist in the routine initiation and dose up-titration of guideline-directed medical therapies (GDMT) for patients with heart failure with reduced ejection fraction. Without novel approaches to improve prescribing, the cumulative benefits of heart failure with reduced ejection fraction treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients. METHODS The EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) trial randomized patients with heart failure with reduced ejection fraction from a diverse health system to usual care versus patient activation tools-a 3-minute video and 1-page checklist-delivered electronically 1 week before, 3 days before, and 24 hours before a cardiology clinic visit. The tools encouraged patients to work collaboratively with their clinicians to "make one positive change" in heart failure with reduced ejection fraction prescribing. The primary endpoint was the percentage of patients with GDMT medication initiations and dose intensifications from immediately preceding the cardiology clinic visit to 30 days after, compared with usual care during the same period. RESULTS EPIC-HF enrolled 306 patients, 290 of whom attended a clinic visit during the study period: 145 were sent the patient activation tools and 145 were controls. The median age of patients was 65 years; 29% were female, 11% were Black, 7% were Hispanic, and the median ejection fraction was 32%. Preclinic data revealed significant GDMT opportunities, with no patients on target doses of β-blocker, sacubitril/valsartan, and mineralocorticoid receptor antagonists. From immediately preceding the cardiology clinic visit to 30 days after, 49.0% in the intervention and 29.7% in the control experienced an initiation or intensification of their GDMT (P=0.001). The majority of these changes were made at the clinician encounter itself and involved dose uptitrations. There were no deaths and no significant differences in hospitalization or emergency department visits at 30 days between groups. CONCLUSIONS A patient activation tool delivered electronically before a cardiology clinic visit improved clinician intensification of GDMT. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334188.
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Affiliation(s)
- Larry A Allen
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Grace Venechuk
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Colleen K McIlvennan
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Robert L Page
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora (R.L.P., K.E.T.)
| | | | - Laura J Helmkamp
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Prateeti Khazanie
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Pamela N Peterson
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.).,Denver Health Medical Center, CO (P.N.P.)
| | - Kenneth Pierce
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Geoffrey Harger
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Jocelyn S Thompson
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Tristan J Dow
- University of Colorado Health Poudre Valley Hospital, Loveland (T.J.D., L.R.)
| | - Lance Richards
- University of Colorado Health Poudre Valley Hospital, Loveland (T.J.D., L.R.)
| | - Janice Huang
- University of Colorado Health Memorial Hospital, Colorado Springs (J.H., J.R.S.)
| | - James R Strader
- University of Colorado Health Memorial Hospital, Colorado Springs (J.H., J.R.S.)
| | - Katy E Trinkley
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.).,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora (R.L.P., K.E.T.)
| | - David P Kao
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - David J Magid
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Peter M Buttrick
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Daniel D Matlock
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
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Vaduganathan M, Greene SJ, Zhang S, Grau-Sepulveda M, DeVore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Fonarow GC. Applicability of US Food and Drug Administration Labeling for Dapagliflozin to Patients With Heart Failure With Reduced Ejection Fraction in US Clinical Practice: The Get With the Guidelines-Heart Failure (GWTG-HF) Registry. JAMA Cardiol 2020; 6:2773092. [PMID: 33185662 PMCID: PMC7666432 DOI: 10.1001/jamacardio.2020.5864] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 10/07/2020] [Indexed: 12/22/2022]
Abstract
IMPORTANCE In May 2020, dapagliflozin was approved by the US Food and Drug Administration (FDA) as the first sodium-glucose cotransporter 2 inhibitor for heart failure with reduced ejection fraction (HFrEF), based on the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial. Limited data are available characterizing the generalizability of dapagliflozin to US clinical practice. OBJECTIVE To evaluate candidacy for initiation of dapagliflozin based on the FDA label among contemporary patients with HFrEF in the US. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 154 714 patients with HFrEF (left ventricular ejection fraction ≤40%) hospitalized at 406 sites in the Get With the Guidelines-Heart Failure (GWTG-HF) registry admitted between January 1, 2014, and September 30, 2019. Patients who left against medical advice, transferred to an acute care facility or to hospice, or had missing data were excluded. The FDA label (which excluded patients with an estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2, those undergoing dialysis, and those with type 1 diabetes) was applied to the GWTG-HF registry sample. Data analyses were conducted from April 1 to June 30, 2020. MAIN OUTCOMES AND MEASURES The proportion of patients hospitalized with HFrEF who would be candidates for dapagliflozin under the FDA label. RESULTS Among 154 714 patients hospitalized with HFrEF, 125 497 (81.1%; 83 481 men [66.5%]; mean [SD] age, 68 [15] years) would be candidates for dapagliflozin according to the FDA label. Across 355 sites with patients with 10 or more hospitalizations, the median proportion of candidates for dapagliflozin according to the FDA label was 81.1% (interquartile range, 77.8%-84.6%) at each site. This proportion was similar across all study years (interquartile range, 80.4%-81.7%) and was higher among those without type 2 diabetes than with type 2 diabetes (85.5% vs 75.6%). Among GWTG-HF participants, the most frequent reason for not meeting the FDA label criteria was eGFR less than 30 mL/min/1.73 m2 at discharge (18.5%). Among 75 654 patients with available paired admission and discharge data, 14.2% had an eGFR less than 30 mL/min/1.73 m2 at both time points, while 3.8% developed an eGFR less than 30 mL/min/1.73 m2 by discharge. Although there were more older adults, women, and Black patients in the GWTG-HF registry than in the DAPA-HF trial, most clinical characteristics were qualitatively similar between the 2 groups. Compared with the DAPA-HF trial cohort, there was lower use of evidence-based HF therapies among patients in GWTG-HF. CONCLUSIONS AND RELEVANCE These data from a large, contemporary US registry of patients hospitalized with heart failure suggest that 4 of 5 patients with HFrEF (with or without type 2 diabetes) would be candidates for initiation of dapagliflozin, supporting its broad generalizability to US clinical practice.
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Affiliation(s)
- Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen J. Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Shuaiqi Zhang
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Maria Grau-Sepulveda
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Adam D. DeVore
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Paul A. Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, California
| | - Karen E. Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia
| | | | - Scott D. Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System and University of Minnesota, Minneapolis
| | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Deputy Editor, JAMA Cardiology
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles
- Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
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Annapureddy AR, Henien S, Wang Y, Minges KE, Ross JS, Spatz ES, Desai NR, Peterson PN, Masoudi FA, Curtis JP. Association Between Industry Payments to Physicians and Device Selection in ICD Implantation. JAMA 2020; 324:1755-1764. [PMID: 33141208 PMCID: PMC7610190 DOI: 10.1001/jama.2020.17436] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Little is known about the association between industry payments and medical device selection. OBJECTIVE To examine the association between payments from device manufacturers to physicians and device selection for patients undergoing first-time implantation of a cardioverter-defibrillator (ICD) or cardiac resynchronization therapy-defibrillator (CRT-D). DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, patients who received a first-time ICD or CRT-D device from any of the 4 major manufacturers (January 1, 2016-December 31, 2018) were identified. The data from the National Cardiovascular Data Registry ICD Registry was linked with the Open Payments Program's payment data. Patients were categorized into 4 groups (A, B, C, and D) corresponding to the manufacturer from which the physician who performed the implantation received the largest payment. For each patient group, the proportion of patients who received a device from the manufacturer that provided the largest payment to the physician who performed implantation was determined. Within each group, the absolute difference in proportional use of devices between the manufacturer that made the highest payment and the proportion of devices from the same manufacturer in the entire study cohort (expected prevalence) was calculated. EXPOSURES Manufacturers' payments to physicians who performed an ICD or CRT-D implantation. MAIN OUTCOMES AND MEASURES The primary outcome of the study was the manufacturer of the device used for the implantation. RESULTS Over a 3-year period, 145 900 patients (median age, 65 years; 29.6% women) received ICD or CRT-D devices from the 4 manufacturers implanted by 4435 physicians at 1763 facilities. Among these physicians, 4152 (94%) received payments from device manufacturers ranging from $2 to $323 559 with a median payment of $1211 (interquartile range, $390-$3702). Between 38.5% and 54.7% of patients received devices from the manufacturers that had provided physicians with the largest payments. Patients were substantially more likely to receive devices made by the manufacturer that provided the largest payment to the physician who performed implantation than they were from each other individual manufacturer. The absolute differences in proportional use from the expected prevalence were 22.4% (95% CI, 21.9%-22.9%) for manufacturer A; 14.5% (95% CI, 14.0%-15.0%) for manufacturer B; 18.8% (95% CI, 18.2%-19.4%) for manufacturer C; and 30.6% (95% CI, 30.0%-31.2%) for manufacturer D. CONCLUSIONS AND RELEVANCE In this cross-sectional study, a large proportion of ICD or CRT-D implantations were performed by physicians who received payments from device manufacturers. Patients were more likely to receive ICD or CRT-D devices from the manufacturer that provided the highest total payment to the physician who performed an ICD or CRT-D implantation than each other manufacturer individually.
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Affiliation(s)
- Amarnath R. Annapureddy
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Shady Henien
- Section of Cardiovascular Medicine, Department of Internal Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Karl E. Minges
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Erica S. Spatz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nihar R. Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pamela N. Peterson
- Department of Medicine, Denver Health Medical Center, Denver, Colorado
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Frederick A. Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Sopfe J, Marsh R, Ziniel SI, Klosky JL, Chow EJ, Dorsey Holliman B, Peterson PN. Evaluation of the v2.0 Brief Profiles for Sexual Function and Satisfaction PROMIS in Adolescent and Young Adult Childhood Cancer Survivors. J Adolesc Young Adult Oncol 2020; 10:418-424. [PMID: 33136468 DOI: 10.1089/jayao.2020.0166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Purpose: Sexual dysfunction (SD) is a common, but often unrecognized potential late effect among childhood cancer survivors (CCS). Unfortunately, both patients and providers report low levels of routine screening and identify multiple barriers, including lack of knowledge, discomfort, and limited time. This is particularly true among CCS who are adolescent or young adult aged (AYA-CCS). One potential way to increase screening, detection, and treatment for SD among AYA-CCS is to employ patient-reported outcomes measures. While adult screening tools exist, no SD screening tool has been evaluated specifically among this younger population. Methods: This qualitative study used Think-Aloud and cognitive interviewing methods to obtain feedback from AYA-CCS on acceptability, usefulness, and validity of the Patient-Reported Outcomes Measurement Information System® (PROMIS®) v2.0 Brief Profiles for Sexual Function and Satisfaction (SexFS Brief) in CCS now 15-24 years of age. Results: The SexFS Brief demonstrated acceptability, response process and content validity, and usefulness among AYA-CCS. There were no detectable differences by age or gender. This study did not reveal any necessary modification to the SexFS Brief for this population. Conclusion: The PROMIS SexFS Brief is an acceptable and useful tool, with demonstrated response process and content validity, and may facilitate improved screening and diagnosis of SD among AYA-CCS. Furthermore, this tool was viewed favorably by AYA-CCS as a way to reduce barriers such as discomfort and lack of knowledge on the part of patients. Further evaluation of its effectiveness and acceptability in a clinical setting is warranted.
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Affiliation(s)
- Jenna Sopfe
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rebekah Marsh
- Adult & Child Consortium for Health Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sonja I Ziniel
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - James L Klosky
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Brooke Dorsey Holliman
- Adult & Child Consortium for Health Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Family Medicine and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Pamela N Peterson
- Adult & Child Consortium for Health Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,Denver Health Medical Center, Denver, Colorado, USA
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Venechuk GE, Khazanie P, Page RL, Knoepke CE, Helmkamp LJ, Peterson PN, Pierce K, Thompson JS, Huang J, Strader JR, Dow TJ, Richards L, Trinkley KE, Kao DP, McIlvennan CK, Magid DJ, Buttrick PM, Matlock DD, Allen LA. An Electronically delivered, Patient-activation tool for Intensification of medications for Chronic Heart Failure with reduced ejection fraction: Rationale and design of the EPIC-HF trial. Am Heart J 2020; 229:144-155. [PMID: 32866454 DOI: 10.1016/j.ahj.2020.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Heart failure with reduced ejection fraction (HFrEF) benefits from initiation and intensification of multiple pharmacotherapies. Unfortunately, there are major gaps in the routine use of these drugs. Without novel approaches to improve prescribing, the cumulative benefits of HFrEF treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients. HYPOTHESIS Encouraging patients to engage providers in HFrEF prescribing decisions will improve the use of guideline-directed medical therapies. DESIGN The Electronically delivered, Patient-activation tool for Intensification of Chronic medications for Heart Failure with reduced ejection fraction (EPIC-HF) trial randomizes patients with HFrEF to usual care versus patient-activation tools-a 3-minute video and 1-page checklist-delivered prior to cardiology clinic visits that encourage patients to work collaboratively with their clinicians to intensify HFrEF prescribing. The study assesses the effectiveness of the EPIC-HF intervention to improve guideline-directed medical therapy in the month after its delivery while using an implementation design to also understand the reach, adoption, implementation, and maintenance of this approach within the context of real-world care delivery. Study enrollment was completed in January 2020, with a total 305 patients. Baseline data revealed significant opportunities, with <1% of patients on optimal HFrEF medical therapy. SUMMARY The EPIC-HF trial assesses the implementation, effectiveness, and safety of patient engagement in HFrEF prescribing decisions. If successful, the tool can be easily disseminated and may inform similar interventions for other chronic conditions.
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Wallace BC, Allen LA, Knoepke CE, Glasgow RE, Lewis CL, Fairclough DL, Helmkamp LJ, Fitzgerald MD, Tzou WS, Kramer DB, Varosy PD, Gupta SK, Mandrola JM, Brancato SC, Peterson PN, Matlock DD. A multicenter trial of a shared DECision Support Intervention for Patients offered implantable Cardioverter-DEfibrillators: DECIDE-ICD rationale, design, Medicare changes, and pilot data. Am Heart J 2020; 226:161-173. [PMID: 32599257 DOI: 10.1016/j.ahj.2020.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 04/15/2020] [Indexed: 01/15/2023]
Abstract
Shared decision making (SDM) facilitates delivery of medical therapies that are in alignment with patients' goals and values. Medicare national coverage decision for several interventions now includes SDM mandates, but few have been evaluated in nationwide studies. Based upon a detailed needs assessment with diverse stakeholders, we developed pamphlet and video patient decision aids (PtDAs) for implantable cardioverter/defibrillator (ICD) implantation, ICD replacement, and cardiac resynchronization therapy with defibrillation to help patients contemplate, forecast, and deliberate their options. These PtDAs are the foundation of the Multicenter Trial of a Shared Decision Support Intervention for Patients Offered Implantable Cardioverter-Defibrillators (DECIDE-ICD), a multicenter, randomized trial sponsored by the National Heart, Lung, and Blood Institute aimed at understanding the effectiveness and implementation of an SDM support intervention for patients considering ICDs. Finalization of a Medicare coverage decision mandating the inclusion of SDM for new ICD implantation occurred shortly after trial initiation, raising novel practical and statistical considerations for evaluating study end points. METHODS/DESIGN: A stepped-wedge randomized controlled trial was designed, guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) planning and evaluation framework using an effectiveness-implementation hybrid type II design. Six electrophysiology programs from across the United States will participate. The primary effectiveness outcome is decision quality (defined by knowledge and values-treatment concordance). Patients with heart failure who are clinically eligible for an ICD are eligible for the study. Target enrollment is 900 participants. DISCUSSION: Study findings will provide a foundation for implementing decision support interventions, including PtDAs, with patients who have chronic progressive illness and are facing decisions involving invasive, preference-sensitive therapy options.
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46
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Ambrosy AP, Gurwitz JH, Tabada GH, Artz A, Schrier S, Rao SV, Barnhart HX, Reynolds K, Smith DH, Peterson PN, Sung SH, Cohen HJ, Go AS. Incident anaemia in older adults with heart failure: rate, aetiology, and association with outcomes. Eur Heart J Qual Care Clin Outcomes 2020; 5:361-369. [PMID: 30847487 DOI: 10.1093/ehjqcco/qcz010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 02/15/2019] [Accepted: 03/05/2019] [Indexed: 12/11/2022]
Abstract
AIMS Limited data exist on the epidemiology, evaluation, and prognosis of otherwise unexplained anaemia of the elderly in heart failure (HF). Thus, we aimed to determine the incidence of anaemia, to characterize diagnostic testing patterns for potentially reversible causes of anaemia, and to evaluate the independent association between incident anaemia and long-term morbidity and mortality. METHODS AND RESULTS Within the Cardiovascular Research Network (CVRN), we identified adults age ≥65 years with diagnosed HF between 2005 and 2012 and no anaemia at entry. Incident anaemia was defined using World Health Organization (WHO) haemoglobin thresholds (<13.0 g/dL in men; <12.0 g/dL in women). All-cause death and hospitalizations for HF and any cause were identified from electronic health records. Among 38 826 older HF patients, 22 163 (57.1%) developed incident anaemia over a median (interquartile range) follow-up of 2.9 (1.2-5.6) years. The crude rate [95% confidence interval (CI)] per 100 person-years of incident anaemia was 26.4 (95% CI 26.0-26.7) and was higher for preserved ejection fraction (EF) [29.2 (95% CI 28.6-29.8)] compared with borderline EF [26.5 (95% CI 25.4-27.7)] or reduced EF [26.6 (95% CI 25.8-27.4)]. Iron indices, vitamin B12 level, and thyroid testing were performed in 20.9%, 14.9%, and 40.2% of patients, respectively. Reduced iron stores, vitamin B12 deficiency, and/or hypothyroidism were present in 29.7%, 3.2%, and 18.6% of tested patients, respectively. In multivariable analyses, incident anaemia was associated with excess mortality [hazard ratio (HR) 2.14, 95% CI 2.07-2.22] as well as hospitalization for HF (HR 1.80, 95% CI 1.72-1.88) and any cause (HR 1.77, 95% CI 1.72-1.83). CONCLUSION Among older adults with HF, incident anaemia is common and independently associated with substantially increased risks of morbidity and mortality. Additional research is necessary to clarify the value of routine evaluation and treatment of potentially reversible causes of anaemia.
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Affiliation(s)
- Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA.,Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, USA
| | - Jerry H Gurwitz
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA, USA.,Meyers Primary Care Institute, Worcester, MA, USA
| | - Grace H Tabada
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, USA
| | - Andrew Artz
- Section of Hematology/Oncology, The University of Chicago, Chicago, IL, USA
| | - Stanley Schrier
- Division of Hematology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sunil V Rao
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Duke University Medical School, Durham, NC, USA
| | - Huiman X Barnhart
- Duke Clinical Research Institute, Duke University Medical School, Durham, NC, USA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - David H Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Pamela N Peterson
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,Denver Health Medical Center, Denver, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, USA
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, USA.,Department of Epidemiology, Biostatistics and Medicine, University of California at San Francisco, San Francisco, CA, USA.,Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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47
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Ambrosy AP, Fitzpatrick JK, Tabada GH, Gurwitz JH, Artz A, Schrier SL, Rao SV, Reynolds K, Smith DH, Peterson PN, Fortmann SP, Sung SH, Cohen HJ, Go AS. A reduced transferrin saturation is independently associated with excess morbidity and mortality in older adults with heart failure and incident anemia. Int J Cardiol 2020; 309:95-99. [DOI: 10.1016/j.ijcard.2020.03.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/28/2020] [Accepted: 03/09/2020] [Indexed: 10/24/2022]
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48
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Sopfe J, Marsh R, Appiah LC, Klosky JL, Peterson PN, DorseyHolliman B. Evaluating sexual function in adolescent and young adult childhood cancer survivors. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e24180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e24180 Background: Up to half of adolescent and young adult (AYA) childhood cancer survivors (CCS) experience sexual dysfunction (SD) as a result cancer or its treatment. SD in CCS is under-recognized, with low levels of routine screening due to barriers such as discomfort, time, and awareness. This study explores solutions to these barriers by describing AYA CCS preferences for implementation of screening for SD and evaluating the utility of a validated adult screening tool (PROMIS SexFS Brief) in this population. Methods: 16 AYA CCS (aged 15-24 years) completed semi-structured interviews followed by questionnaire completion. Interviews explored patients’ prior experiences with SD screening, along with preferences for screening type (e.g., discussion, screening tool), delivery modality, and timing. Patients then completed the PROMIS SexFS Brief while verbalizing their thoughts and providing open-ended responses to each item. Transcribed interviews were inductively coded and analyzed, guided by content analysis methodology. Results: This analysis represents 2/3 of planned interviews, and all will be completed by April 1, 2020. Interviews were performed with 11 females and 5 males (median age 21). Preliminary analysis demonstrates that participants had minimal experience with SD conversations, but had preferences regarding by whom, how, and when screening/education should occur. Who: Participants felt providers should have preexisting rapport with their patients; preferences existed for provider role and sex/age. How: A combination of written materials and in-person conversations was preferred. Several acknowledged a desire to have a “warning” that the conversation would happen, such as through a questionnaire. Participants did not have a preference regarding delivery modality (paper vs. online). The PROMIS SexFS Brief appeared to demonstrate content validity and acceptability in AYA CCS. When: Participants wanted education and screening to occur regularly throughout cancer therapy and survivorship. SD conversations should be tailored developmentally to the patient. Conclusions: Our results demonstrate a theme throughout interviews of the importance of patient/provider rapport. Further, while AYA CCS prefer in-person conversations about SD, conversations should be preceded by written information or a questionnaire to increase patient preparedness/comfort. Preliminary findings suggest that the PROMIS SexFS Brief is a promising tool for screening SD in this population; further studies evaluating use in clinical settings is warranted.
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Affiliation(s)
| | - Rebekah Marsh
- University of Colorado School of Medicine, Aurora, CO
| | | | - James L. Klosky
- The Aflac Cancer & Blood Disorders Center at Children's Healthcare of Atlanta, Emory University, Department of Pediatrics, Atlanta, GA
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Sopfe J, Gupta A, Appiah LC, Chow EJ, Peterson PN. Sexual Dysfunction in Adolescent and Young Adult Survivors of Childhood Cancer: Presentation, Risk Factors, and Evaluation of an Underdiagnosed Late Effect: A Narrative Review. J Adolesc Young Adult Oncol 2020; 9:549-560. [PMID: 32380878 DOI: 10.1089/jayao.2020.0025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
An area of concern affecting the quality of life of childhood cancer survivors (CCS) is that of sexual dysfunction (SD), which may be a result of both physical and psychosexual challenges associated with cancer and its treatment. This is especially pertinent as CCS are known to experience diminished quality of life compared to peers. Relevant to SD, cancer and its associated treatment are associated with negative effects on body image and romantic relationships, as well as overall physical and mental health. Although CCS have been shown to have SD at higher rates than the general population, this is often under-recognized and CCS commonly report that it is not addressed by their health care providers. To guide future research and improve clinical screening and treatment practices for SD, we performed a narrative review of this understudied topic to summarize existing knowledge of the incidence, risk factors, pathophysiology, and rates of screening for SD in CCS. We also outline current gaps in knowledge and directions for future research.
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Affiliation(s)
- Jenna Sopfe
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Abha Gupta
- Division of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada.,Division of Hematology/Oncology, Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Leslie C Appiah
- Department of Obstetrics/Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Pamela N Peterson
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Denver Health Medical Center, Denver, Colorado, USA
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50
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Affiliation(s)
- Pamela N Peterson
- Department of Medicine Denver Health Medical Center Denver CO.,Department of Medicine University of Colorado Anschutz Medical Center Aurora CO
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