Journal: Circ Cardiovasc Qual Outcomes

Sorted by: date / impact
Abstract

Sex Differences in Characteristics, Treatments, and Outcomes Among Patients Hospitalized for Non-ST-Segment-Elevation Myocardial Infarction in China: 2006 to 2015.

Guo W, Du X, Gao Y, Hu S, ... Krumholz HM, Zheng X
Background
Sex differences in clinical characteristics and in-hospital outcomes among patients with non-ST-segment-elevation myocardial infarction have been described in Western countries, but whether these differences exist in China is unknown.
Methods
We used a 2-stage random sampling design to create a nationally representative sample of patients admitted to 151 Chinese hospitals for non-ST-segment-elevation myocardial infarction in 2006, 2011, and 2015 and examined sex differences in clinical profiles, treatments, and in-hospital outcomes over this time. Multivariable logistic regression models adjusting for age or other potentially confounding clinical covariates were used to estimate these sex-specific differences.
Results
Among 4611 patients, the proportion of women (39.8%) was unchanged between 2006 and 2015. Women were older with higher rates of hypertension, diabetes, and dyslipidemia. Among patients without contraindications, women were less likely to receive treatments than men, with significant differences for aspirin in 2015 (90.3% versus 93.9%) and for invasive strategy in 2011 (28.7% versus 45.7%) and 2015 (34.0% versus 48.4%). After adjusting for age, such differences in aspirin and invasive strategy in 2015 were not significant, but the difference in invasive strategy in 2011 persisted. The sex gaps in the use of invasive strategy did not narrow. From 2006 to 2015, a significant decrease in in-hospital mortality was observed in men (from 16.9% to 8.7%), but not in women (from 11.8% to 12.0%), with significant interaction between sex and study year (P=0.023). After adjustment, in-hospital mortality in women was significantly lower than men in 2006, but not in 2011 or 2015.
Conclusions
Sex differences in cardiovascular risk factors and invasive strategy after non-ST-segment-elevation myocardial infarction were observed between 2011 and 2015 in China. Although sex gaps in in-hospital mortality were largely explained by age differences, efforts to narrow sex-related disparities in quality of care should remain a focus.
Registration
URL: http://www.
Clinicaltrials
gov; Unique identifier: NCT01624883.



Circ Cardiovasc Qual Outcomes: 24 May 2022:101161CIRCOUTCOMES121008535; epub ahead of print
Guo W, Du X, Gao Y, Hu S, ... Krumholz HM, Zheng X
Circ Cardiovasc Qual Outcomes: 24 May 2022:101161CIRCOUTCOMES121008535; epub ahead of print | PMID: 35607994
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Preventing and Managing Falls in Adults With Cardiovascular Disease: A Scientific Statement From the American Heart Association.

Denfeld QE, Turrise S, MacLaughlin EJ, Chang PS, ... Goodlin SJ, American Heart Association Cardiovascular Disease in Older Populations Committee of the Council on Clinical Cardiology and Council on Cardiovascular and Stroke Nursing; Council on Lifestyle and Cardiometabolic Health; and Stroke Council
Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record-based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.



Circ Cardiovasc Qual Outcomes: 19 May 2022:101161HCQ0000000000000108; epub ahead of print
Denfeld QE, Turrise S, MacLaughlin EJ, Chang PS, ... Goodlin SJ, American Heart Association Cardiovascular Disease in Older Populations Committee of the Council on Clinical Cardiology and Council on Cardiovascular and Stroke Nursing; Council on Lifestyle and Cardiometabolic Health; and Stroke Council
Circ Cardiovasc Qual Outcomes: 19 May 2022:101161HCQ0000000000000108; epub ahead of print | PMID: 35587567
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Variation in Cardiac Rehabilitation Participation During Aortic Valve Replacement Episodes of Care.

Guduguntla V, Yaser JM, Keteyian SJ, Pagani FD, ... Sukul D, Thompson MP
Background: Despite reported benefit in the setting of aortic valve replacement (AVR), cardiac rehabilitation (CR) utilization remains low, with few studies evaluating hospital and patient-level variation in CR participation. We explored determinants of CR variability during AVR episodes of care: transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).
Methods:
A cohort of 10,124 AVR episodes of care (TAVR n=5,121 from 24 hospitals; SAVR n=5,003 from 32 hospitals) were identified from the Michigan Value Collaborative statewide multipayer registry (2015 to 2019). CR enrollment was defined as the presence of a single professional or facility claim within 90 days of discharge: 93797, 93798, G0422, G0423. Annual trends and hospital variation in CR were described for TAVR, SAVR, and all AVR. Multilevel logistic regression was used to estimate effects of predictors and hospital risk-adjusted rates of CR enrollment.
Results:
Overall, 4,027 (39.8%) patients enrolled in CR, with significant differences by treatment strategy: SAVR=50.9%, TAVR=28.9% (p<0.001). CR use after SAVR was significantly higher than after TAVR and increased over time for both modalities (p<0.001). There were significant differences in CR enrollment across age, gender, payer, and some comorbidities (p<.05). At the hospital-level, CR participation rates for all AVR varied 10-fold (4.8% to 68.7%) and were moderately correlated between SAVR and TAVR (Pearson r=0.56, p<0.01). Conclusions: Substantial variation exists in CR participation during AVR episodes of care across hospitals. However, within-hospital CR participation rates were significantly correlated across treatment strategies. These findings suggest that CR participation is the product of hospital-specific practice patterns. Identifying hospital practices associated with higher CR participation can help assist future quality improvement efforts to increase CR use after AVR.




Circ Cardiovasc Qual Outcomes: 13 May 2022; epub ahead of print
Guduguntla V, Yaser JM, Keteyian SJ, Pagani FD, ... Sukul D, Thompson MP
Circ Cardiovasc Qual Outcomes: 13 May 2022; epub ahead of print | PMID: 35559710
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Relation of Household Income to Access and Adherence to Combination Sacubitril/Valsartan in Heart Failure: A Retrospective Analysis of Commercially Insured Patients.

Johnson AE, Swabe GM, Addison D, Essien UR, ... Mohammed SF, Magnani JW
Background: Outcomes in heart failure with reduced ejection fraction (HFrEF), are influenced by access and adherence to guideline-directed medical therapy. Our objective was to study the association between annual household income and: (1) the odds of having a claim for sacubitril/valsartan among insured patients with HFrEF and (2) medication adherence (measured as the proportion of days covered [PDC]). We hypothesized that lower annual household income is associated with decreased odds of having a claim for and adhering to sacubitril/valsartan.
Methods:
Using the Optum de-identified Clinformatics® Data Mart, patients with HFrEF and ≥6 months of enrollment for follow up (2016-2020) were included. Covariates included age, sex, race, ethnicity, educational attainment, US region, number of prescribed medications, and Elixhauser Comorbidity Index. Prescription for sacubitril/valsartan was defined by the presence of a claim within 6 months of HFrEF diagnosis. Adherence was defined as PDC≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates.
Results:
Among 322,007 individuals with incident HFrEF, 135,282 had complete data for analysis. Of the patients eligible for sacubitril/valsartan, 4.7% (6,372) had a claim within 6 months of HFrEF diagnosis. Following multivariable adjustment, individuals in the lowest annual income category (<$40,000) were significantly less likely (OR=0.83, 95% CI [0.76, 0.90]) to have a sacubitril/valsartan claim within 6 months of HFrEF diagnosis than those in the highest annual income category (≥$100,000). Annual income <$40,000 was associated with lower odds of PDC≥80% compared with income ≥$100,000 (OR=0.70, 95% CI [0.59, 0.83]). Conclusions: Lower household income is associated with decreased likelihood of a sacubitril/valsartan claim and medication adherence within 6 months of HFrEF diagnosis, even after adjusting for sociodemographic and clinical factors. Future analyses are needed to identify additional social factors associated with delays in sacubitril/valsartan initiation and long-term adherence.




Circ Cardiovasc Qual Outcomes: 13 May 2022; epub ahead of print
Johnson AE, Swabe GM, Addison D, Essien UR, ... Mohammed SF, Magnani JW
Circ Cardiovasc Qual Outcomes: 13 May 2022; epub ahead of print | PMID: 35549378
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Understanding Baseline Physical Activity in Cardiac Rehabilitation Enrollees Using Mobile Health Technologies.

Golbus JR, Gupta K, Stevens R, Jeganathan VS, ... Kohnstamm S, Nallamothu BK
Background: Baseline physical activity in patients when they initiate cardiac rehabilitation is poorly understood. We used mobile health (mHealth) technology to understand baseline physical activity of patients initiating cardiac rehabilitation within a clinical trial to potentially inform personalized care.
Methods:
The Virtual AppLication-Supported ENvironment To INcrease Exercise During Cardiac Rehabilitation Study (VALENTINE) Study is a prospective, randomized-controlled, remotely administered trial designed to evaluate an mHealth intervention to supplement cardiac rehabilitation for low and moderate risk patients. All participants receive a smartwatch and usual care. Baseline physical activity was assessed remotely after enrollment and included 1) 6-minute walk distance, 2) daily step count, and 3) daily exercise minutes, both over 7 days and for compliant days, defined by ≥8 hours of watch wear time. Multivariable linear regression identified patient-level features associated with these 3 measures of baseline physical activity.
Results:
From October 2020 to March 2022, 220 participants enrolled in the study. Participants are mostly White [184 (83.6%)]; 67 (30.5%) are female and 84 (38.2%) are ≥ 65 years old. Most participants enrolled in cardiac rehabilitation after percutaneous coronary intervention [105 (47.7%)] or coronary artery bypass surgery [39 (17.7 %)]. Clinical diagnoses include coronary artery disease (78.6%), heart failure (17.3%), and valve repair or replacement (26.4%). Baseline mean 6-minute walk distance was 489.6 (standard deviation [SD], 143.4) meters, daily step count was 6845 (SD, 3353), and exercise minutes was 37.5 (SD, 33.5). In a multivariable model, 6-minute walk distance was significantly associated with age and sex, but not cardiac rehabilitation indication. Sex but not age or cardiac rehabilitation indication was significantly associated with daily step count and exercise minutes. Conclusions: Baseline physical activity varies substantially in low and moderate risk patients enrolled in cardiac rehabilitation. Future studies are warranted to explore whether personalizing cardiac rehabilitation programs using mHealth technologies could optimize recovery. Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT04587882.




Circ Cardiovasc Qual Outcomes: 13 May 2022; epub ahead of print
Golbus JR, Gupta K, Stevens R, Jeganathan VS, ... Kohnstamm S, Nallamothu BK
Circ Cardiovasc Qual Outcomes: 13 May 2022; epub ahead of print | PMID: 35559648
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cardiovascular and Cerebrovascular Disease Mortality in Asian American Subgroups.

Shah NS, Xi K, Kapphahn KI, Srinivasan M, ... Zhang H, Palaniappan LP
Background
Asian American individuals comprise the fastest-growing race and ethnic group in the United States. Certain subgroups may be at disproportionately high cardiovascular risk. This analysis aimed to identify cardiovascular and cerebrovascular disease mortality trends in Asian American subgroups.
Methods
Age-standardized mortality rates (ASMR), average annual percent change of ASMR calculated by regression, and proportional mortality ratios of ischemic heart disease, heart failure, and cerebrovascular disease were calculated by sex in non-Hispanic Asian American subgroups (Chinese, Filipino, Asian Indian, Japanese, Korean, and Vietnamese), non-Hispanic White, and Hispanic individuals from US death certificates, 2003 to 2017.
Results
Among 618 004 non-Hispanic Asian American, 30 267 178 non-Hispanic White, and 2 292 257 Hispanic deaths from all causes, ASMR from ischemic heart disease significantly decreased in all subgroups of Asian American women and in non-Hispanic White and Hispanic women; significantly decreased in Chinese, Filipino, Japanese, and Korean men and non-Hispanic White and Hispanic men and remained stagnant in Asian Indian and Vietnamese men. The highest 2017 ASMR from ischemic heart disease among Asian American decedents was in Asian Indian women (77 per 100 000) and men (133 per 100 000). Heart failure ASMR remained stagnant in Chinese, Korean, and non-Hispanic White women, and Chinese and Vietnamese men. Heart failure ASMR significantly increased in both sexes in Filipino, Asian Indian, and Japanese individuals, Vietnamese women, and Korean men, with highest 2017 ASMR among Asian American subgroups in Asian Indian women (14 per 100 000) and Asian Indian men (15 per 100 000). Cerebrovascular disease ASMR decreased in Chinese, Filipino, and Japanese women and men between 2003 and 2017, and remained stagnant in Asian Indian, Korean, and Vietnamese women and men. The highest cerebrovascular disease ASMR among Asian American subgroups in 2017 was in Vietnamese women (46 per 100 000) and men (47 per 100 000).
Conclusions
There was heterogeneity in cardiovascular and cerebrovascular mortality among Asian American subgroups, with stagnant or increasing mortality trends in several subgroups between 2003 and 2017.



Circ Cardiovasc Qual Outcomes: 10 May 2022:101161CIRCOUTCOMES121008651; epub ahead of print
Shah NS, Xi K, Kapphahn KI, Srinivasan M, ... Zhang H, Palaniappan LP
Circ Cardiovasc Qual Outcomes: 10 May 2022:101161CIRCOUTCOMES121008651; epub ahead of print | PMID: 35535589
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cardiovascular Risk Assessment Using Artificial Intelligence-Enabled Event Adjudication and Hematologic Predictors.

Truslow JG, Goto S, Homilius M, Mow C, ... MacRae CA, Deo RC
Background
Researchers routinely evaluate novel biomarkers for incorporation into clinical risk models, weighing tradeoffs between cost, availability, and ease of deployment. For risk assessment in population health initiatives, ideal inputs would be those already available for most patients. We hypothesized that common hematologic markers (eg, hematocrit), available in an outpatient complete blood count without differential, would be useful to develop risk models for cardiovascular events.
Methods
We developed Cox proportional hazards models for predicting heart attack, ischemic stroke, heart failure hospitalization, revascularization, and all-cause mortality. For predictors, we used 10 hematologic indices (eg, hematocrit) from routine laboratory measurements, collected March 2016 to May 2017 along with demographic data and diagnostic codes. As outcomes, we used neural network-based automated event adjudication of 1 028 294 discharge summaries. We trained models on 23 238 patients from one hospital in Boston and evaluated them on 29 671 patients from a second one. We assessed calibration using Brier score and discrimination using Harrell\'s concordance index. In addition, to determine the utility of high-dimensional interactions, we compared our proportional hazards models to random survival forest models.
Results
Event rates in our cohort ranged from 0.0067 to 0.075 per person-year. Models using only hematology indices had concordance index ranging from 0.60 to 0.80 on an external validation set and showed the best discrimination when predicting heart failure (0.80 [95% CI, 0.79-0.82]) and all-cause mortality (0.78 [0.77-0.80]). Compared with models trained only on demographic data and diagnostic codes, models that also used hematology indices had better discrimination and calibration. The concordance index of the resulting models ranged from 0.75 to 0.85 and the improvement in concordance index ranged up to 0.072. Random survival forests had minimal improvement over proportional hazards models.
Conclusions
We conclude that low-cost, ubiquitous inputs, if biologically informative, can provide population-level readouts of risk.



Circ Cardiovasc Qual Outcomes: 28 Apr 2022:101161CIRCOUTCOMES121008007; epub ahead of print
Truslow JG, Goto S, Homilius M, Mow C, ... MacRae CA, Deo RC
Circ Cardiovasc Qual Outcomes: 28 Apr 2022:101161CIRCOUTCOMES121008007; epub ahead of print | PMID: 35477255
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Comparative Efficacy of 5 Exercise Types on Cardiometabolic Health in Overweight and Obese Adults: A Systematic Review and Network Meta-Analysis of 81 Randomized Controlled Trials.

Batrakoulis A, Jamurtas AZ, Metsios GS, Perivoliotis K, ... Poulios A, Fatouros IG
Background
Although regular exercise is recommended for preventing and treating overweight/obesity, the most effective exercise type for improving cardiometabolic health in individuals with overweight/obesity remains largely undecided. This network meta-analysis aimed to evaluate and rank the comparative efficacy of 5 exercise modalities on cardiometabolic health measures in individuals with overweight/obesity.
Methods
A database search was conducted in MEDLINE, Embase, Scopus, and Web of Science from inception up to September 2020. The review focused on randomized controlled trials involving exercise interventions consisting of continuous endurance training, interval training, resistance training, combined aerobic and resistance training (combined training), and hybrid-type training. Exercise interventions aimed to improve somatometric variables, body composition, lipid metabolism, glucose control, blood pressure, cardiorespiratory fitness, and muscular strength. The Cochrane risk of bias tool was used to evaluate eligible studies. A random-effects network meta-analysis was performed within a frequentist framework. The intervention ranking was carried out using a Bayesian model where mean and SD were equal to the respective frequentist estimates.
Results
A total of 4331 participants (59% female; mean age: 38.7±12.3 years) from 81 studies were included. Combined training was the most effective modality and hybrid-type training the second most effective in improving cardiometabolic health-related outcomes in these populations suggesting a higher efficacy for multicomponent exercise interventions compared to single-component modalities, that is, continuous endurance training, interval training, and resistance training. A subgroup analysis revealed that the effects from different exercise types were mediated by gender.
Conclusions
These findings corroborate the latest guidelines on exercise for individuals with overweight/obesity highlighting the importance of a multicomponent exercise approach to improve cardiometabolic health. Physicians and healthcare professionals should consider prescribing multicomponent exercise interventions to adults with overweight/obesity to maximize clinical outcomes.
Registration
URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42020202647.



Circ Cardiovasc Qual Outcomes: 28 Apr 2022:101161CIRCOUTCOMES121008243; epub ahead of print
Batrakoulis A, Jamurtas AZ, Metsios GS, Perivoliotis K, ... Poulios A, Fatouros IG
Circ Cardiovasc Qual Outcomes: 28 Apr 2022:101161CIRCOUTCOMES121008243; epub ahead of print | PMID: 35477256
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Compounding Benefits of Cholesterol-Lowering Therapy for the Reduction of Major Cardiovascular Events: Systematic Review and Meta-Analysis.

Wang N, Woodward M, Huffman MD, Rodgers A
Background
Mendelian randomization studies use genetic variants as natural experiments to provide evidence about causal relations between modifiable risk factors and disease. Recent Mendelian randomization studies suggest each mmol/L reduction in low-density lipoprotein cholesterol (LDL-C) sustained over a lifetime can reduce the risk of cardiovascular disease by more than half. However, these findings have not been replicated in randomized clinical trials, and the effect of treatment duration on the magnitude of risk reduction remains uncertain. The aim of this article was to evaluate the relationship between lipid-lowering drug exposure time and relative risk reduction of major cardiovascular events in randomized clinical trials.
Methods
We conducted a systematic review and meta-analysis of randomized clinical trials of statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 inhibitors that report LDL-C levels and effect sizes for each year of follow-up. The primary end point was major vascular events, defined as the composite of cardiovascular death, myocardial infarction, stroke, and coronary revascularization. Hazard ratios during each year of follow-up were meta-analyzed using random-effects models.
Results
A total of 21 trials with 184 012 patients and an average mean follow-up of 4.4 years were included. Meta-regression showed there was greater relative risk reduction in major vascular events with increasing duration of treatment (P<0.001). For example, each mmol/L LDL-C lowered was associated with a relative risk reduction in major vascular events of 12% (95% CI, 8%-16%) for year 1, 20% (95% CI, 16%-24%) for year 3, 23% (95% CI, 18%-27%) for year 5, and 29% (95% CI, 14%-42%) for year 7.
Conclusions
The benefits of LDL-C lowering do not seem to be fixed but increase steadily with longer durations of treatment. The results from short-term randomized trials are compatible with the very strong associations between LDL-C and cardiovascular events seen in Mendelian randomization studies.



Circ Cardiovasc Qual Outcomes: 18 Apr 2022:101161CIRCOUTCOMES121008552; epub ahead of print
Wang N, Woodward M, Huffman MD, Rodgers A
Circ Cardiovasc Qual Outcomes: 18 Apr 2022:101161CIRCOUTCOMES121008552; epub ahead of print | PMID: 35430872
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Relationship Between Social Vulnerability Indicators and Trial Participant Attrition: Findings From the HYVALUE Trial.

Henderson KH, Helmkamp LJ, Steiner JF, Havranek EP, ... Dickinson M, Daugherty SL
Background
Social vulnerability indicators are associated with health care inequities and may similarly impede ongoing participation in research studies. We evaluated the association of social vulnerability indicators and research participant attrition in a trial focused on reducing health disparities.
Methods
Self-identified White or Black adults enrolled in the HYVALUE trial (Hypertension and VALUEs), a randomized trial testing a values-affirmation intervention on medication adherence, from February 2017 to September 2019 were included. The self-reported measures of social vulnerability indicators included: (1) Black race; (2) female gender; (3) no health insurance; (4) unemployment; (5) a high school diploma or less; and (6) financial-resource strain. Full attrition was defined as not completing at least one 3- or 6-month follow-up study visit. Log-binomial regression models adjusted for age, gender, race, medical comorbidities, and the other social vulnerability indicators to estimate the relative risk of each social vulnerability indicator with study attrition.
Results
Among 825 participants, the mean age was 63.3 years (±11.7 years), 60% were women, 54% were Black, and 97% reported at least one social vulnerability. Overall, 21% participants had full attrition after study enrollment. After adjustment for all other social vulnerabilities, only financial-resource strain remained consistently associated with full attrition (relative risk, 1.71 [95% CI, 1.28-2.29]). In a secondary analysis of partial attrition (completed only one follow-up visit), financial-resource strain (relative risk, 1.40 [95% CI, 1.09-1.81]) and being uninsured (relative risk, 1.54 [95% CI, 1.01-2.34]) were associated with partial attrition.
Conclusions
In a trial aimed at reducing disparities in medication adherence, participants who reported financial-resource strain had a higher risk of participant attrition independent of race or gender. Our findings suggest that efforts to retain diverse populations in clinical trials should extend beyond race and gender to consider other social vulnerability indicators.
Registration
URL: https://www.
Clinicaltrials
gov; Unique identifier: NCT03028597.



Circ Cardiovasc Qual Outcomes: 14 Apr 2022:101161CIRCOUTCOMES120007709; epub ahead of print
Henderson KH, Helmkamp LJ, Steiner JF, Havranek EP, ... Dickinson M, Daugherty SL
Circ Cardiovasc Qual Outcomes: 14 Apr 2022:101161CIRCOUTCOMES120007709; epub ahead of print | PMID: 35418247
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Influence of Hospital Characteristics on Hospital Transfer Destinations for Patients With Stroke.

Zachrison KS, Amati V, Schwamm LH, Yan Z, ... Lomi A, Onnela JP
Background
Patients with stroke are frequently transferred between hospitals. This may have implications on the quality of care received by patients; however, it is not well understood how the characteristics of sending and receiving hospitals affect the likelihood of a transfer event. Our objective was to identify hospital characteristics associated with sending and receiving patients with stroke.
Methods
Using a comprehensive statewide administrative dataset, including all 78 Massachusetts hospitals, we identified all transfers of patients with ischemic stroke between October 2007 and September 2015 for this observational study. Hospital variables included reputation (US News and World Report ranking), capability (stroke center status, annual stroke volume, and trauma center designation), and institutional affiliation. We included network variables to control for the structure of hospital-to-hospital transfers. We used relational event modeling to account for complex temporal and relational dependencies associated with transfers. This method decomposes a series of patient transfers into a sequence of decisions characterized by transfer initiations and destinations, modeling them using a discrete-choice framework.
Results
Among 73 114 ischemic stroke admissions there were 7189 (9.8%) transfers during the study period. After accounting for travel time between hospitals and structural network characteristics, factors associated with increased likelihood of being a receiving hospital (in descending order of relative effect size) included shared hospital affiliation (5.8× higher), teaching hospital status (4.2× higher), stroke center status (4.3× and 3.8× higher when of the same or higher status), and hospitals of the same or higher reputational ranking (1.5× higher).
Conclusions
After accounting for distance and structural network characteristics, in descending order of importance, shared hospital affiliation, hospital capabilities, and hospital reputation were important factor in determining transfer destination of patients with stroke. This study provides a starting point for future research exploring how relational coordination between hospitals may ensure optimized allocation of patients with stroke for maximal patient benefit.



Circ Cardiovasc Qual Outcomes: 04 Apr 2022:101161CIRCOUTCOMES121008269; epub ahead of print
Zachrison KS, Amati V, Schwamm LH, Yan Z, ... Lomi A, Onnela JP
Circ Cardiovasc Qual Outcomes: 04 Apr 2022:101161CIRCOUTCOMES121008269; epub ahead of print | PMID: 35369714
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Presenting Symptoms in Patients Undergoing Coronary Artery Disease Evaluation: Association With Noninvasive Test Results and Clinical Outcomes in the PROMISE Trial.

Lowenstern A, Alexander KP, Pagidipati NJ, Hill CL, ... Mark DB, Douglas PS
Background
Patients evaluated for coronary artery disease have a range of symptoms and underlying risk. The relationships between patient-described symptoms, clinician conclusions, and subsequent clinical management and outcomes remain incompletely described.
Methods
In this secondary analysis, we examined the association between 4 types of presenting symptoms (substernal/left-sided chest pain, other chest/neck/arm pain, dyspnea, and other symptoms) and patient risk, noninvasive test results, clinical management, and outcomes for stable outpatients randomized in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. Multivariable regression models were used to evaluate differences in noninvasive test result, all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/myocardial infarction by symptom type.
Results
Among 9996 patients, most presented with chest pain (47.2% substernal, 29.2% other), followed by dyspnea (14.9%), and other symptoms (8.7%). Patients with dyspnea were older (median age 63 versus 60, P≤0.02) with higher baseline risk (78.2% with atherosclerotic cardiovascular disease >7.5% versus 67.6%, P≤0.02). Using patients with substernal chest pain as a reference, there was no difference in noninvasive test positivity across symptom groups (all P>0.05), but test-positive patients with dyspnea (adjusted odds ratio, 0.66 [95% CI, 0.51-0.85]) or other symptoms (adjusted odds ratio, 0.65 [95% CI, 0.47-0.90]) were less likely to be referred for cardiac catheterization. While symptom type alone was not associated with outcomes, symptom presentation with chest pain or dyspnea did modify the association between a positive noninvasive test and clinical outcome (interaction P=0.025 for both all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/MI).
Conclusions
Among low-risk outpatients evaluated for coronary artery disease, typicality of symptoms was not closely associated with higher baseline risk but was related to differences in processes of care and the prognostic value of a positive test. Adverse events were not associated with clinician risk estimates or symptoms alone. These unexpected findings highlight the limitation of relying solely on symptom presentation or clinician risk estimation to evaluate patients for suspected coronary artery disease.
Registration
URL: https://www.
Clinicaltrials
gov; Unique identifier: NCT01174550.



Circ Cardiovasc Qual Outcomes: 04 Apr 2022:101161CIRCOUTCOMES121008298; epub ahead of print
Lowenstern A, Alexander KP, Pagidipati NJ, Hill CL, ... Mark DB, Douglas PS
Circ Cardiovasc Qual Outcomes: 04 Apr 2022:101161CIRCOUTCOMES121008298; epub ahead of print | PMID: 35369715
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Generalizability of Cardiovascular Disease Clinical Prediction Models: 158 Independent External Validations of 104 Unique Models.

Gulati G, Upshaw J, Wessler BS, Brazil RJ, ... Van Calster B, Kent DM
Background
While clinical prediction models (CPMs) are used increasingly commonly to guide patient care, the performance and clinical utility of these CPMs in new patient cohorts is poorly understood.
Methods
We performed 158 external validations of 104 unique CPMs across 3 domains of cardiovascular disease (primary prevention, acute coronary syndrome, and heart failure). Validations were performed in publicly available clinical trial cohorts and model performance was assessed using measures of discrimination, calibration, and net benefit. To explore potential reasons for poor model performance, CPM-clinical trial cohort pairs were stratified based on relatedness, a domain-specific set of characteristics to qualitatively grade the similarity of derivation and validation patient populations. We also examined the model-based C-statistic to assess whether changes in discrimination were because of differences in case-mix between the derivation and validation samples. The impact of model updating on model performance was also assessed.
Results
Discrimination decreased significantly between model derivation (0.76 [interquartile range 0.73-0.78]) and validation (0.64 [interquartile range 0.60-0.67], P<0.001), but approximately half of this decrease was because of narrower case-mix in the validation samples. CPMs had better discrimination when tested in related compared with distantly related trial cohorts. Calibration slope was also significantly higher in related trial cohorts (0.77 [interquartile range, 0.59-0.90]) than distantly related cohorts (0.59 [interquartile range 0.43-0.73], P=0.001). When considering the full range of possible decision thresholds between half and twice the outcome incidence, 91% of models had a risk of harm (net benefit below default strategy) at some threshold; this risk could be reduced substantially via updating model intercept, calibration slope, or complete re-estimation.
Conclusions
There are significant decreases in model performance when applying cardiovascular disease CPMs to new patient populations, resulting in substantial risk of harm. Model updating can mitigate these risks. Care should be taken when using CPMs to guide clinical decision-making.



Circ Cardiovasc Qual Outcomes: 31 Mar 2022:101161CIRCOUTCOMES121008487; epub ahead of print
Gulati G, Upshaw J, Wessler BS, Brazil RJ, ... Van Calster B, Kent DM
Circ Cardiovasc Qual Outcomes: 31 Mar 2022:101161CIRCOUTCOMES121008487; epub ahead of print | PMID: 35354282
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

One-Year Outcomes and Factors Associated With Mortality Following Acute Myocardial Infarction in Northern Tanzania.

Hertz JT, Sakita FM, Kweka GL, Tarimo TG, ... Thielman NM, Bloomfield GS
Background
Little is known about long-term outcomes and uptake of secondary preventative therapies following acute myocardial infarction (AMI) in sub-Saharan Africa.
Methods
Consecutive patients presenting with AMI (as defined by the Fourth Universal Definition of AMI Criteria) to a northern Tanzanian referral hospital were enrolled in this prospective observational study. Follow-up surveys assessing mortality, medication use, and rehospitalization were administered at 3, 6, 9, and 12 months following initial presentation, by telephone or in person. Multivariate logistic regression was performed to identify baseline clinical and sociodemographic factors associated with one-year mortality.
Results
Of 152 enrolled patients with AMI, 5 were lost to one-year follow-up (96.7% retention rate). Mortality rates were 34.9% (53 of 152 participants) during the initial hospitalization, 48.7% (73 of 150 patients) at 3 months, 52.7% (78 of 148 patients) at 6 months, 55.4% (82 of 148 patients) at 9 months, and 59.9% (88 of 147 patients) at one year. Of 59 patients surviving to one-year follow-up, 43 (72.9%) reported persistent anginal symptoms, 5 (8.5%) were taking an antiplatelet, 8 (13.6%) were taking an antihypertensive, 30 (50.8%) had been rehospitalized, and 7 (11.9%) had ever undergone cardiac catheterization. On multivariate analysis, one-year mortality was associated with lack of secondary education (odds ratio, 0.26 [95% CI, 0.11-0.58]; P=0.001), lower body mass index (odds ratio, 0.90 [95% CI, 0.82-0.98]; P=0.015), and higher initial troponin (odds ratio, 1.30 [95% CI, 1.05-1.80]; P=0.052).
Conclusions
In northern Tanzania, AMI is associated with high all-cause one-year mortality and use of evidence-based secondary preventative therapies among AMI survivors is low. Interventions are needed to improve AMI care and outcomes.



Circ Cardiovasc Qual Outcomes: 18 Mar 2022:CIRCOUTCOMES121008528; epub ahead of print
Hertz JT, Sakita FM, Kweka GL, Tarimo TG, ... Thielman NM, Bloomfield GS
Circ Cardiovasc Qual Outcomes: 18 Mar 2022:CIRCOUTCOMES121008528; epub ahead of print | PMID: 35300504
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Evidence-Based Process Performance Measures and Clinical Outcomes in Patients With Incident Heart Failure With Reduced Ejection Fraction: A Danish Nationwide Cohort Study.

Schjødt I, Johnsen SP, Strömberg A, DeVore AD, Valentin JB, Løgstrup BB
Background
Data on the association between quality of heart failure (HF) care and outcomes among patients with incident HF are sparse. We examined the association between process performance measures and clinical outcomes in patients with incident HF with reduced ejection fraction.
Methods
Patients with incident HF with reduced ejection fraction (n=10 966) between January 2008 and October 2015 were identified from the Danish HF Registry. Data from public registries were linked. Multivariable regression analyses were used to assess the association between 6 guideline-recommended HF care processes (New York Heart Association assessment, use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists, exercise training, and patient education) and all-cause and HF readmission, all-cause and HF hospital days, and mortality within 3 to 12 months after HF diagnosis. The associations were analyzed according to the percentages of all relevant performance measures fulfilled for the individual patient (0%-50% [reference group], >50%-75%, and >75%-100%) and for the individual performance measures.
Results
Fulfilling >75% to 100% of the performance measures (n=5341 [48.7%]) was associated with lower risk of all-cause readmission (adjusted hazard ratio, 0.78 [95% CI, 0.68-0.89]) and HF readmission (adjusted hazard ratio, 0.71 [95% CI, 0.54-0.92]), lower use of all-cause hospital days (adjusted mean ratio, 0.73 [95% CI, 0.70-0.76]) and HF hospital days (adjusted mean ratio, 0.79 [95% CI, 0.70-0.89]), and lower mortality (adjusted hazard ratio, 0.42 [95% CI, 0.32-0.53]). A dose-response relationship was observed between fulfilling more performance measures and mortality (adjusted hazard ratio, 0.62 [95% CI, 0.49-0.77] fulfilling >50%-75% of the measures). Fulfilling individual performance measures, except mineralocorticoid receptor antagonist therapy, was associated with lower adjusted all-cause readmission, lower adjusted use of all-cause and HF hospital days, and lower adjusted mortality.
Conclusions
Fulfilling more process performance measures was associated with better clinical outcomes in patients with incident HF with reduced ejection fraction.



Circ Cardiovasc Qual Outcomes: 10 Mar 2022:CIRCOUTCOMES121007973; epub ahead of print
Schjødt I, Johnsen SP, Strömberg A, DeVore AD, Valentin JB, Løgstrup BB
Circ Cardiovasc Qual Outcomes: 10 Mar 2022:CIRCOUTCOMES121007973; epub ahead of print | PMID: 35272503
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011-2018.

Doll JA, Beaver K, Naranjo D, Waldo SW, ... Helfrich CD, Rao SV
Background
Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox.
Methods
In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test.
Results
Among 253 179 diagnostic angiograms and 93 614 PCIs, radial access rates increased over time for both diagnostic (17.5%-60.4%; P<0.01)) and PCI procedures (14.0%-51.8%; P<0.01). Existing operators and new operators increased their use at similar rates, but new operators entered practice with higher baseline rates. Nearly all operators used radial access at least once in 2018. Overall adjusted rates of bleeding declined, a trend that was significant for diagnostic angiography (2.4%-1.4%, P=0.02) but not PCI (3.4%-2.5%, P=0.20). Femoral access patients had a higher predicted risk for bleeding.
Conclusions
A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.



Circ Cardiovasc Qual Outcomes: 10 Mar 2022:CIRCOUTCOMES121008359; epub ahead of print
Doll JA, Beaver K, Naranjo D, Waldo SW, ... Helfrich CD, Rao SV
Circ Cardiovasc Qual Outcomes: 10 Mar 2022:CIRCOUTCOMES121008359; epub ahead of print | PMID: 35272504
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Reducing Cardiovascular Risk in the Medicare Million Hearts Risk Reduction Model: Insights From the National Cardiovascular Data Registry PINNACLE Registry.

Borden WB, Wang J, Jones P, Tang Y, ... Wasfy JH, Maddox TM
Background
The Million Hearts Cardiovascular Disease Risk Reduction Model provides financial incentives for practices to lower 10-year atherosclerotic cardiovascular disease (ASCVD) risk for high-risk (ASCVD ≥30%) Medicare patients. To estimate average practice-level ASCVD risk reduction, we applied optimal trial outcomes to a real-world population with high ASCVD risk.
Methods
This study uses observational registry data from the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence Registry from January 2013 to June 2016. We modeled ASCVD risk reductions using historical clinical trial data (reducing cholesterol by 26.5%, reducing systolic blood pressure by 10.9%, reducing smoking rates by 21.8%) the average reduction in ASCVD risk associated with individual and combined risk factor modifications, and then percentage of practices achieving the various incentive thresholds for the Million Hearts Model.
Results
The final study population included 135 166 patients, with 16 248 (12.0%) with 10-year ASCVD risk of ≥30%, but without existing ASCVD. The mean 10-year ASCVD risk was 41.9% (±1 SD of 11.6). Using risk factor reductions from clinical trials, lowering cholesterol, blood pressure, and smoking rates reduced 10-year ASCVD risk by 3.3% (±3.1), 6.3% (±1.1) and 0.5% (±1.3), respectively. Combining all 3 reductions resulted in a 9.7% (±3.6) reduction, with 67 (27.0%) of practices achieving a patient-level average 10-year ASCVD risk reduction of ≥10%, 181 (73.0%) achieving a 2 to 10% reduction, and no practice achieving <2% reduction.
Conclusions
In cardiology practices, about 1 out of 8 patients have a 10-year ASCVD risk ≥30% and qualify as high risk in the Million Hearts Model. If practices target the three main modifiable risk factors and achieve reductions similar to clinical trial results, ASCVD risk could be substantially lowered and all practices could receive incentive payments. These findings support the potential benefit of the Million Hearts Model and provide guidance to participating practices.



Circ Cardiovasc Qual Outcomes: 10 Mar 2022:CIRCOUTCOMES121007908; epub ahead of print
Borden WB, Wang J, Jones P, Tang Y, ... Wasfy JH, Maddox TM
Circ Cardiovasc Qual Outcomes: 10 Mar 2022:CIRCOUTCOMES121007908; epub ahead of print | PMID: 35272505
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association.

Kini V, Breathett K, Groeneveld PW, Ho PM, ... Borden WB, American Heart Association Council on Quality of Care and Outcomes Research
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.



Circ Cardiovasc Qual Outcomes: 21 Feb 2022:HCQ0000000000000105; epub ahead of print
Kini V, Breathett K, Groeneveld PW, Ho PM, ... Borden WB, American Heart Association Council on Quality of Care and Outcomes Research
Circ Cardiovasc Qual Outcomes: 21 Feb 2022:HCQ0000000000000105; epub ahead of print | PMID: 35189687
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:

This program is still in alpha version.