Journal: Circ Cardiovasc Qual Outcomes

Sorted by: date / impact
Abstract

Early Increased Physical Activity, Cardiac Rehabilitation, and Survival After Implantable Cardioverter-Defibrillator Implantation.

Atwater BD, Li Z, Pritchard J, Greiner MA, Nabutovsky Y, Hammill BG
Background
Increased physical activity (PA) through cardiac rehabilitation (CR) improves outcomes in patients with heart failure and coronary disease, but CR referral remains infrequent. Implantable cardioverter-defibrillators (ICDs) can provide daily PA measurements to patients that may motivate them to increase PA, but it remains unclear if increased ICD measured PA is associated with improved outcomes with and without CR.
Methods
This is a retrospective observational study of 41 731 Medicare beneficiaries with ICD implantation between January 1, 2014 and December 31, 2016. We linked daily ICD PA measurements and Medicare claims data to determine if increased PA is associated with a reduction in the likelihood of death or heart failure hospitalization. To determine if CR participation altered the effect of PA on outcomes, we performed two additional analyses matching CR participants and nonparticipants using propensity scores. The first match included demographics, comorbidities, and baseline PA measurements. The second match also included the change in PA measured during CR or the same time frame after ICD implant among nonparticipants.
Results
The mean age was 75 (SD, 10) years, 30 182 beneficiaries (72.3%) were male, and 1324 (3%) participated in CR. Increased ICD detected PA was associated with improved survival. CR participants had a mean PA change of +9.7 (SD, 57.8) min/d, whereas nonparticipants had a mean change of -1.0 (SD, 59.7) min/d (P<0.001). After matching for demographics, comorbidities and baseline PA, CR participants had significantly lower 1- to 3-year mortality (hazard ratio, 0.76 [95% CI, 0.69-0.85], P=0.03). After additionally matching for the ICD measured change in PA during CR there were no differences in mortality with and without CR (hazard ratio, 1.00 [95% CI, 0.82-1.21], P=0.87). Every 10 minutes of increased daily PA was associated with a 1.1% reduction in all-cause mortality in both groups.
Conclusions
Among Medicare beneficiaries with ICDs, small increases in PA were associated with significant reductions in all-cause mortality.



Circ Cardiovasc Qual Outcomes: 20 Jul 2021:CIRCOUTCOMES120007580; epub ahead of print
Atwater BD, Li Z, Pritchard J, Greiner MA, Nabutovsky Y, Hammill BG
Circ Cardiovasc Qual Outcomes: 20 Jul 2021:CIRCOUTCOMES120007580; epub ahead of print | PMID: 34284598
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Spouse\'s Cardiovascular Disease As a Risk Factor for Cardiovascular Disease in Middle-Aged Adults: A Matched-Pair Cohort Study.

Ohbe H, Yasunaga H
Background
Little is known about the risk of subsequent cardiovascular events in individuals whose spouse has a history of cardiovascular diseases. We assessed whether the spouse\'s history of cardiovascular disease is associated with a greater risk of cardiovascular events.
Methods
Using data on married couples from the Japan Medical Data Center database (April 2008-August 2018), we conducted a matched-pair cohort study by matching individuals who had no history of cardiovascular disease and whose spouse had a history of cardiovascular disease at their first health check-up (exposure group) with up to 4 individuals who had no history of cardiovascular disease and whose spouse had no history of cardiovascular disease at their first health check-up (nonexposure group) matched for birth year, sex, and first health check-up year. We compared severe cardiovascular events after the first health check-up between the 2 groups.
Results
Among 236 527 eligible married couples (473 054 spouses), we identified 13 759 individuals in the exposure group who were matched with 55 027 individuals in the nonexposure group. During the mean 95-month observational period from the first health check-up, the percentage of individuals with severe cardiovascular events was higher in the exposure group than in the nonexposure group (0.6% [82/13 759] versus 0.4% [224/55 027], respectively), with a hazard ratio of 1.48 (95% CI, 1.15-1.90). Analyses stratified by sex showed that the hazard ratios of the exposure to the spouse\'s history of cardiovascular disease for severe cardiovascular events in women and men were 1.22 (95% CI, 0.82-1.83) and 1.68 (95% CI, 1.22-2.32), respectively.
Conclusions
This study suggests that a spouse\'s history of cardiovascular disease can be a risk factor for subsequent cardiovascular events in men but not in women. Further studies are needed to confirm our findings and to explore effective primary prevention strategies for these individuals.



Circ Cardiovasc Qual Outcomes: 08 Jul 2021:CIRCOUTCOMES120007649; epub ahead of print
Ohbe H, Yasunaga H
Circ Cardiovasc Qual Outcomes: 08 Jul 2021:CIRCOUTCOMES120007649; epub ahead of print | PMID: 34238013
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial.

Kline JA, Adler DH, Alanis N, Bledsoe JR, ... Stubblefield WB, Willoughby CB
Background
The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial.
Methods
This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes.
Results
We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%-1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%-1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%-0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%-9.5%) and was associated with a risk ratio of 6.0 (2.3-15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled.
Conclusions
Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03404635.



Circ Cardiovasc Qual Outcomes: 29 Jun 2021; 14:e007600
Kline JA, Adler DH, Alanis N, Bledsoe JR, ... Stubblefield WB, Willoughby CB
Circ Cardiovasc Qual Outcomes: 29 Jun 2021; 14:e007600 | PMID: 34148351
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Safer Stroke-Dx Instrument: Identifying Stroke Misdiagnosis in the Emergency Department.

Saleh Velez FG, Alvarado-Dyer R, Pinto CB, Ortiz García JG, ... Liberman AL, Prabhakaran S
Background
Missed or delayed diagnosis of acute stroke, or false-negative stroke (FNS), at initial emergency department (ED) presentation occurs in ≈9% of confirmed stroke patients. Failure to rapidly diagnose stroke can preclude time-sensitive treatments, resulting in higher risks of severe sequelae and disability. In this study, we developed and tested a modified version of a structured medical record review tool, the Safer Dx Instrument, to identify FNS in a subgroup of hospitalized patients with stroke to gain insight into sources of ED stroke misdiagnosis.
Methods
We conducted a retrospective cohort study at 2 unaffiliated comprehensive stroke centers. In the development and confirmatory cohorts, we applied the Safer Stroke-Dx Instrument to report the prevalence and documented sources of ED diagnostic error in FNS cases among confirmed stroke patients upon whom an acute stroke was suspected by the inpatient team, as evidenced by stroke code activation or urgent neurological consultation, but not by the ED team. Inter-rater reliability and agreement were assessed using interclass coefficient and kappa values (κ).
Results
Among 183 cases in the development cohort, the prevalence of FNS was 20.2% (95% CI, 15.0-26.7). Too narrow a differential diagnosis and limited neurological examination were common potential sources of error. The interclass coefficient for the Safer Stroke-Dx Instrument items ranged from 0.42 to 0.91, and items were highly correlated with each other. The κ for diagnostic error identification was 0.90 (95% CI, 0.821-0.978) using the Safer Stroke-Dx Instrument. In the confirmatory cohort of 99 cases, the prevalence of FNS was 21.2% (95% CI, 14.2-30.3) with similar sources of diagnostic error identified.
Conclusions
Hospitalized patients identified by stroke codes and requests for urgent neurological consultation represent an enriched population for the study of diagnostic error in the ED. The Safer Stroke-Dx Instrument is a reliable tool for identifying FNS and sources of diagnostic error.



Circ Cardiovasc Qual Outcomes: 29 Jun 2021; 14:e007758
Saleh Velez FG, Alvarado-Dyer R, Pinto CB, Ortiz García JG, ... Liberman AL, Prabhakaran S
Circ Cardiovasc Qual Outcomes: 29 Jun 2021; 14:e007758 | PMID: 34162221
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Socioeconomic Burden of Rising Methamphetamine-Associated Heart Failure Hospitalizations in California From 2008 to 2018.

Zhao SX, Deluna A, Kelsey K, Wang C, ... Staniec A, Crawford MH
Background
Methamphetamine-associated cardiomyopathy/heart failure (MethHF) is an increasingly recognized disease entity in the context of a rising methamphetamine (meth) epidemic that most severely impacts the western United States. Using heart failure (HF) hospitalization data from the Office of Statewide Health Planning and Development, this study aimed to assess trend and disease burden of MethHF in California.
Methods
Adult patients (≥18 years old) with HF as primary hospitalization diagnosis between 2008 and 2018 were included in this study. The association with Meth (MethHF) and those without (non-MethHF) were determined by meth-related International Classification of Diseases-based secondary diagnoses. Statistical significance of trends in age-adjusted rates of hospitalization per 100 000 adults were evaluated using nonparametric analysis.
Results
Between 2008 and 2018, 1 033 076 HF hospitalizations were identified: 42 565 were MethHF (4.12%) and 990 511 (95.88%) were non-MethHF. Age-adjusted MethHF hospitalizations per 100 000 increased by 585% from 4.1 in 2008 to 28.1 in 2018, while non-MethHF hospitalizations decreased by 6.0% from 342.3 in 2008 to 321.6 in 2018. The rate of MethHF hospitalization increase more than doubled that of a negative control group with urinary tract infection and meth-related secondary diagnoses (7.82-fold versus 3.48-fold, P<0.001). Annual inflation-adjusted hospitalization charges because of MethHF increased by 840% from $41.5 million in 2008 to $390.2 million in 2018, as compared with an 82% increase for all HF hospitalization from $3.503 billion to $6.376 billion. Patients with MethHF were significantly younger (49.64±10.06 versus 72.20±14.97 years old, P<0.001), predominantly male (79.1% versus 52.4%, P<0.001), with lower Charlson Comorbidity Index, yet they had longer length of stay, more hospitalizations per patient, and more procedures performed during their stays.
Conclusions
MethHF hospitalizations increased sharply during the study period and contributed significantly to the HF hospitalization burden in California. This emerging HF phenotype, which engenders considerable financial and societal costs, calls for an urgent and concerted public health response to contain its spread.



Circ Cardiovasc Qual Outcomes: 29 Jun 2021; 14:e007638
Zhao SX, Deluna A, Kelsey K, Wang C, ... Staniec A, Crawford MH
Circ Cardiovasc Qual Outcomes: 29 Jun 2021; 14:e007638 | PMID: 34256572
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Digital Health Intervention in Acute Myocardial Infarction.

Marvel FA, Spaulding EM, Lee MA, Yang WE, ... Allen JK, Martin SS
Background
Thirty-day readmissions among patients with acute myocardial infarction (AMI) contribute to the US health care burden of preventable complications and costs. Digital health interventions (DHIs) may improve patient health care self-management and outcomes. We aimed to determine if patients with AMI using a DHI have lower 30-day unplanned all-cause readmissions than a historical control.
Methods
This nonrandomized controlled trial with a historical control, conducted at 4 US hospitals from 2015 to 2019, included 1064 patients with AMI (DHI n=200, control n=864). The DHI integrated a smartphone application, smartwatch, and blood pressure monitor to support guideline-directed care during hospitalization and through 30-days post-discharge via (1) medication reminders, (2) vital sign and activity tracking, (3) education, and (4) outpatient care coordination. The Patient Activation Measure assessed patient knowledge, skills, and confidence for health care self-management. All-cause 30-day readmissions were measured through administrative databases. Propensity score-adjusted Cox proportional hazard models estimated hazard ratios of readmission for the DHI group relative to the control group.
Results
Following propensity score adjustment, baseline characteristics were well-balanced between the DHI versus control patients (standardized differences <0.07), including a mean age of 59.3 versus 60.1 years, 30% versus 29% Women, 70% versus 70% White, 54% versus 54% with private insurance, 61% versus 60% patients with a non ST-elevation myocardial infarction, and 15% versus 15% with high comorbidity burden. DHI patients were predominantly in the highest levels of patient activation for health care self-management (mean score 71.7±16.6 at 30 days). The DHI group had fewer all-cause 30-day readmissions than the control group (6.5% versus 16.8%, respectively). Adjusting for hospital site and a propensity score inclusive of age, sex, race, AMI type, comorbidities, and 6 additional confounding factors, the DHI group had a 52% lower risk for all-cause 30-day readmissions (hazard ratio, 0.48 [95% CI, 0.26-0.88]). Similar results were obtained in a sensitivity analysis employing propensity matching.
Conclusions
Our results suggest that in patients with AMI, the DHI may be associated with high patient activation for health care self-management and lower risk of all-cause unplanned 30-day readmissions. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03760796.



Circ Cardiovasc Qual Outcomes: 29 Jun 2021; 14:e007741
Marvel FA, Spaulding EM, Lee MA, Yang WE, ... Allen JK, Martin SS
Circ Cardiovasc Qual Outcomes: 29 Jun 2021; 14:e007741 | PMID: 34261332
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Toward Dynamic Risk Prediction of Outcomes After Coronary Artery Bypass Graft: Improving Risk Prediction With Intraoperative Events Using Gradient Boosting.

Mori M, Durant TJS, Huang C, Mortazavi BJ, ... Schulz WL, Krumholz HM
Background
Intraoperative data may improve models predicting postoperative events. We evaluated the effect of incorporating intraoperative variables to the existing preoperative model on the predictive performance of the model for coronary artery bypass graft.
Methods
We analyzed 378 572 isolated coronary artery bypass graft cases performed across 1083 centers, using the national Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2014 and 2016. Outcomes were operative mortality, 5 postoperative complications, and composite representation of all events. We fitted models by logistic regression or extreme gradient boosting (XGBoost). For each modeling approach, we used preoperative only, intraoperative only, or pre+intraoperative variables. We developed 84 models with unique combinations of the 3 variable sets, 2 variable selection methods, 2 modeling approaches, and 7 outcomes. Each model was tested in 20 iterations of 70:30 stratified random splitting into development/testing samples. Model performances were evaluated on the testing dataset using the C statistic, area under the precision-recall curve, and calibration metrics, including the Brier score.
Results
The mean patient age was 65.3 years, and 24.7% were women. Operative mortality, excluding intraoperative death, occurred in 1.9%. In all outcomes, models that considered pre+intraoperative variables demonstrated significantly improved Brier score and area under the precision-recall curve compared with models considering pre or intraoperative variables alone. XGBoost without external variable selection had the best C statistics, Brier score, and area under the precision-recall curve values in 4 of the 7 outcomes (mortality, renal failure, prolonged ventilation, and composite) compared with logistic regression models with or without variable selection. Based on the calibration plots, risk restratification for mortality showed that the logistic regression model underestimated the risk in 11 114 patients (9.8%) and overestimated in 12 005 patients (10.6%). In contrast, the XGBoost model underestimated the risk in 7218 patients (6.4%) and overestimated in 0 patients (0%).
Conclusions
In isolated coronary artery bypass graft, adding intraoperative variables to preoperative variables resulted in improved predictions of all 7 outcomes. Risk models based on XGBoost may provide a better prediction of adverse events to guide clinical care.



Circ Cardiovasc Qual Outcomes: 30 May 2021; 14:e007363
Mori M, Durant TJS, Huang C, Mortazavi BJ, ... Schulz WL, Krumholz HM
Circ Cardiovasc Qual Outcomes: 30 May 2021; 14:e007363 | PMID: 34078100
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Reclassification, Thromboembolic, and Major Bleeding Outcomes Using Different Estimates of Renal Function in Anticoagulated Patients With Atrial Fibrillation: Insights From the PREFER-in-AF and PREFER-in-AF Prolongation Registries.

Rohla M, Pecen L, Cemin R, Patti G, ... Kirchhof P, De Caterina R
Background
The Cockcroft-Gault formula is recommended to determine a renal indication for dose reduction of dabigatran, edoxaban, and rivaroxaban. Nephrology guidelines now recommend the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulae as more accurate estimates of glomerular filtration rate.
Methods
We analyzed anticoagulated patients with atrial fibrillation who were enrolled in the Prevention of Thromboembolic Events - European Registry in Atrial Fibrillation (PREFER in AF). The proportion of patients with dissimilar renal dosing indications was assessed when applying Cockcroft-Gault, MDRD, or CKD-EPI. Thromboembolic and major bleeding events at 1 year were compared in patients in whom Cockcroft-Gault and CKD-EPI provided concordant or discordant results around a threshold of 50 mL/minute.
Results
Out of 1288 patients with atrial fibrillation with chronic kidney disease in whom Cockcroft-Gault suggested a dose reduction of dabigatran, edoxaban, or rivaroxaban (creatinine clearance ≤50 mL/minutes), 19% and 16% were reclassified to the respective higher doses, and 24% and 23% to the respective lower doses by applying the MDRD and CKD-EPI formulae, respectively. In patients potentially receiving a different dose of dabigatran, edoxaban, or rivaroxaban when using CKD-EPI, we observed an excess of thromboembolic events (4.1% versus 0.8%; odds ratio, 5.5 [95% CI, 1.5-20.8]; P=0.01). Major bleeding rates were nonsignificantly different in the discordance versus concordance group (5.7% versus 2.7%; odds ratio, 2.2 [95% CI, 0.9-5.6]; P=0.09).
Conclusions
The MDRD and CKD-EPI formulae suggest a different dosing in up to a quarter of anticoagulated patients with atrial fibrillation. This seems to impact hard outcomes.



Circ Cardiovasc Qual Outcomes: 30 May 2021; 14:e006852
Rohla M, Pecen L, Cemin R, Patti G, ... Kirchhof P, De Caterina R
Circ Cardiovasc Qual Outcomes: 30 May 2021; 14:e006852 | PMID: 34078099
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Health-Related Quality of Life and Angina in Fractional Flow Reserve- Versus Angiography-Guided Coronary Artery Bypass Grafting: FARGO Trial (Fractional Flow Reserve Versus Angiography Randomization for Graft Optimization).

Thuesen AL, Riber LP, Veien KT, Christiansen EH, ... Mortensen PE, Jensen LO
Background
In coronary artery bypass grafting (CABG), the use of fractional flow reserve (FFR) is insufficiently investigated. Stenosis assessment usually relies on visual estimates of lesion severity. This study evaluated health-related quality of life (HRQoL) and angina after FFR- versus angiography-guided CABG.
Methods
One hundred patients referred for CABG were randomized to FFR- or angiography-guided CABG. In the FFR group, lesions with FFR>0.80 were deferred, while the surgeon was blinded to the FFR values in the angiography group. Before and 6 months after CABG, HRQoL was assessed by the health state classifier EQ-5D of the EuroQoL 5-level instrument and angina status based on the Canadian Cardiovascular Society classification system were registered.
Results
Six-month angiography included FFR evaluations of deferred lesions. In total, completed EQ-5D of the EuroQoL 5-level instrument questionnaires were available in 86 patients (43 in the FFR versus 43 in the angiography-guided group). HRQoL was significantly improved and angina significantly decreased from baseline to 6 months after CABG with no difference between the randomization groups. Graft failure rates and clinical outcomes were similar in both groups. Patients with graft failure or FFR<0.80 of the previous deferred lesions had significantly lower visual analogue scale scores (78.7±14.2 versus 86.8±14.7, P=0.004) and more angina compared with patients without graft failure or FFR≥0.80 at 6-month follow-up.
Conclusions
FFR- versus angiography-guided CABG demonstrated similar improvements in HRQoL and angina 6 months after CABG. Graft failure or low FFR in deferred lesions were associated with low HRQoL and angina. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02477371.



Circ Cardiovasc Qual Outcomes: 30 May 2021; 14:e007302
Thuesen AL, Riber LP, Veien KT, Christiansen EH, ... Mortensen PE, Jensen LO
Circ Cardiovasc Qual Outcomes: 30 May 2021; 14:e007302 | PMID: 34078097
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Personalized, Electronic Health Record-Integrated Decision Aid for Stroke Prevention in Atrial Fibrillation: A Small Cluster Randomized Trial and Qualitative Analysis of Efficacy and Acceptability.

Schott SL, Berkowitz J, Dodge SE, Petersen CL, ... Xu K, Coylewright M
Background
Shared decision-making in cardiology is increasingly recommended to improve patient-centeredness of care. Decision aids can improve patient knowledge and decisional quality but are infrequently used in real-world practice. This mixed-methods study tests the efficacy and acceptability of a decision aid integrated into the electronic health record (Integrated Decision Aid [IDeA]) and delivered by clinicians for patients with atrial fibrillation considering options to reduce stroke risk. We aimed to determine whether the IDeA improves patient knowledge, reduces decisional conflict, and is seen as acceptable by clinicians and patients.
Methods
A small cluster randomized trial included 6 cardiovascular clinicians and 66 patients randomized either to the IDeA (HealthDecision) or usual care (clinician discretion) during a clinical encounter when stroke prevention treatment options were discussed. The primary outcome was patient knowledge of personalized stroke risk. Exploratory outcomes included decisional conflict, values concordance, trust, the presence of a shared decision-making process, and patient knowledge related to time spent using the IDeA. Additionally, we conducted semistructured interviews with clinicians and patients who used the IDeA were conducted to assess acceptability and predictions of future use.
Results
The IDeA significantly increased patients\' knowledge of their stroke risk (odds ratio, 3.88 [95% CI, 1.39-10.78]; P<0.01]). Patients had less uncertainty about their final decision (P=0.04). There were no significant differences in values concordance, trust in clinician or shared decision-making. Despite training, each clinician used the IDeA differently. Qualitative analysis revealed patients prefer using the IDeA earlier in their diagnosis. Clinicians were satisfied with the IDeA, yet varied in the contexts in which they planned to use it in the future.
Conclusions
Using an Integrated Decision Aid, or IDeA, increases patient knowledge and lessens uncertainty for decision-making around stroke prevention in atrial fibrillation. Qualitative data provide insight into potential implementation strategies in real-world practice.



Circ Cardiovasc Qual Outcomes: 30 May 2021; 14:e007329
Schott SL, Berkowitz J, Dodge SE, Petersen CL, ... Xu K, Coylewright M
Circ Cardiovasc Qual Outcomes: 30 May 2021; 14:e007329 | PMID: 34107740
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Obesity Prevalence and Risks Among Chinese Adults: Findings From the China PEACE Million Persons Project, 2014-2018.

Mu L, Liu J, Zhou G, Wu C, ... Krumholz HM, Zheng X
Background
China has seen a burgeoning epidemic of obesity in recent decades, but few studies reported nationally on obesity across socio-demographic subgroups. We sought to assess the prevalence and socio-demographic associations of obesity nationwide.
Methods
We assessed the prevalence of overall obesity (body mass index ≥28 kg/m2) and abdominal obesity (waist circumference ≥85/90 cm for women/men) among 2.7 million community-dwelling adults aged 35 to 75 years in the China PEACE Million Persons Project from 2014 to 2018 and quantified the socio-demographic associations of obesity using multivariable mixed models.
Results
Age-standardized rates of overall and abdominal obesity were 14.4% (95% CI, 14.3%-14.4%) and 32.7% (32.6%-32.8%) in women and 16.0% (15.9%-16.1%) and 36.6% (36.5%-36.8%) in men. Obesity varied considerably across socio-demographic subgroups. Older women were at higher risk for obesity (eg, adjusted relative risk [95% CI] of women aged 65-75 versus 35-44 years: 1.29 [1.27-1.31] for overall obesity, 1.76 [1.74-1.77] for abdominal obesity) while older men were not. Higher education was associated with lower risk in women (eg, adjusted relative risk [95% CI] of those with college or university education versus below primary school: 0.47 [0.46-0.48] for overall obesity, 0.61 [0.60-0.62] for abdominal obesity) but higher risk in men (1.07 [1.05-1.10], 1.17 [1.16-1.19]).
Conclusions
In China, over 1 in 7 individuals meet criteria for overall obesity, and 1 in 3 for abdominal obesity. Wide variation exists across socio-demographic subgroups. The associations of age and education with obesity are significant and differ by sex. Understanding obesity in contemporary China has broad domestic policy implications and provides a valuable international reference.



Circ Cardiovasc Qual Outcomes: 30 May 2021; 14:e007292
Mu L, Liu J, Zhou G, Wu C, ... Krumholz HM, Zheng X
Circ Cardiovasc Qual Outcomes: 30 May 2021; 14:e007292 | PMID: 34107739
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Harnessing Mobile Health Technology for Secondary Cardiovascular Disease Prevention in Older Adults: A Scientific Statement From the American Heart Association.

Schorr EN, Gepner AD, Dolansky MA, Forman DE, ... American Heart Association Cardiovascular Disease in Older Populations Committee of the Council on Clinical Cardiology and Council on Cardiovascular and Stroke Nursing; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Lifestyle and Cardiometabolic Health
Secondary prevention of cardiovascular disease (CVD), the leading cause of morbidity and mortality, is critical to improving health outcomes and quality of life in our aging population. As mobile health (mHealth) technology gains universal leverage and popularity, it is becoming more user-friendly for older adults and an adjunct to manage CVD risk and improve overall cardiovascular health. With the rapid advances in mHealth technology and increasing technological engagement of older adults, a comprehensive understanding of the current literature and knowledge of gaps and barriers surrounding the impact of mHealth on secondary CVD prevention is essential. After a systematic review of the literature, 26 studies that used mHealth for secondary CVD prevention focusing on lifestyle behavior change and medication adherence in cohorts with a mean age of ≥60 years were identified. Improvements in health behaviors and medication adherence were observed, particularly when there was a short message service (ie, texting) component involved. Although mobile technologies are becoming more mainstream and are starting to blend more seamlessly with standard health care, there are still distinct barriers that limit implementation particularly in older adults, including affordability, usability, privacy, and security issues. Furthermore, studies on the type of mHealth that is the most effective for older adults with longer study duration are essential as the field continues to grow. As our population ages, identifying and implementing effective, widely accepted, cost-effective, and time-efficient mHealth interventions to improve CVD health in a vulnerable demographic group should be a top health priority.



Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e000103
Schorr EN, Gepner AD, Dolansky MA, Forman DE, ... American Heart Association Cardiovascular Disease in Older Populations Committee of the Council on Clinical Cardiology and Council on Cardiovascular and Stroke Nursing; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Lifestyle and Cardiometabolic Health
Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e000103 | PMID: 33793309
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Provider Care Team Segregation and Operative Mortality Following Coronary Artery Bypass Grafting.

Hollingsworth JM, Yu X, Yan PL, Yoo H, ... Waljee AK, Nallamothu BK
Background
Studies have shown that Black patients die more frequently following coronary artery bypass grafting than their White counterparts for reasons not fully explained by disease severity or comorbidity. To examine whether provider care team segregation within hospitals contributes to this inequity, we analyzed national Medicare data.
Methods
Using national Medicare data, we identified beneficiaries who underwent coronary artery bypass grafting at hospitals where this procedure was performed on at least 10 Black and 10 White patients between 2008 and 2014 (n=12 646). After determining the providers who participated in their perioperative care, we examined the extent to which Black and White patients were cared for by unique networks of provider care teams within the same hospital. We then evaluated whether a lack of overlap in composition of the provider care teams treating Black versus White patients (ie, high segregation) was associated with higher 90-day operative mortality among Black patients.
Results
The median level of provider care team segregation was high (0.89) but varied across hospitals (interquartile range, 0.85-0.90). On multivariable analysis, after controlling for patient-, hospital-, and community-level differences, mortality rates for White patients were comparable at hospitals with high and low levels of provider care segregation (5.4% [95% CI, 4.7%-6.1%] versus 5.8% [95% CI, 4.7%-7.0%], respectively; P=0.601), while Black patients treated at high-segregation hospitals had significantly higher mortality than those treated at low-segregation hospitals (8.3% [95% CI, 5.4%-12.4%] versus 3.3% [95% CI, 2.0%-5.4%], respectively; P=0.017). The difference in mortality rates for Black and White patients treated at low-segregation hospitals was nonsignificant (-2.5%; P=0.098).
Conclusions
Black patients who undergo coronary artery bypass grafting at a hospital with a higher level of provider care team segregation die more frequently after surgery than Black patients treated at a hospital with a lower level.



Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007778
Hollingsworth JM, Yu X, Yan PL, Yoo H, ... Waljee AK, Nallamothu BK
Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007778 | PMID: 33926210
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Establishing Thresholds for Minimal Clinically Important Differences for the Peripheral Artery Disease Questionnaire.

Peri-Okonny PA, Wang J, Gosch KL, Patel MR, ... Spertus JA, Smolderen KG
Background
Understanding minimum clinically important differences (MCID) in patient-reported outcomes is essential in interpreting the magnitude of changes in these measures. No MCID from patients\' perspectives has ever been published for peripheral artery disease-specific health status assessment tools. The Peripheral Artery Questionnaire (PAQ) is a commonly used, validated peripheral artery disease-specific health status instrument for which we sought to prospectively establish its MCID from patients\' perspectives.
Methods and results
Patients presenting to vascular clinics with new or worsened claudication in the US cohort of the PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry who completed baseline and follow-up PAQ assessments along with the Global Assessment of Functioning scale were included. Mean change in PAQ summary scores from 3- to 6-month follow-up was calculated according to Global Assessment of Functioning category. MCID was defined as the mean difference in scores between those with small improvement or deterioration and those with no change. Multivariable linear regression was used to provide an MCID estimate after adjusting for patients\' 3-month PAQ score. Of the 483 patients who completed the Global Assessment of Functioning score at 6 months and who had available 3- and 6-month PAQ assessments, the mean age was 69 years, 42% were female, and 71% were White. The MCIDs for PAQ summary scale improvement and worsening were 8.7 (2.9-14.5) and -11.0 (-18.6 to -3.3), respectively. After multivariable adjustment, these were 8.9 (3.0-14.8) and -11.2 (-18.2 to -4.2), respectively. There was no significant interaction between treatment (invasive versus noninvasive) and Global Assessment of Functioning response (P=0.75).
Conclusions
In patients with new or worsened claudication, a 10-point change in PAQ summary score represents an MCID. This estimate needs external validation and may inform the interpretation of PAQ scores when used as outcomes in clinical trials or in routine clinical care. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01419080.



Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007232
Peri-Okonny PA, Wang J, Gosch KL, Patel MR, ... Spertus JA, Smolderen KG
Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007232 | PMID: 33947205
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Progression of Preclinical Heart Failure: A Description of Stage A and B Heart Failure in a Community Population.

Young KA, Scott CG, Rodeheffer RJ, Chen HH
Background
The aims of this study are to evaluate the rate of progression of preclinical (Stage A and B) heart failure, identify associated characteristics, and evaluate long-term outcomes.
Methods
Retrospective review of the Olmsted County Heart Function Study. Individuals categorized as Stage A or B heart failure at initial visit that returned for a second visit 4 years later were included. Logistic regression analyses evaluated group differences with adjustment for age and sex.
Results
At visit 1, 413 (32%) individuals were classified as Stage A and 413 (32%) as Stage B. By visit 2, 146 (35%) individuals from Stage A progressed with the vast majority (n=142) progressing to Stage B. In comparison, a total of 23 (6%) individuals progressed from Stage B. A greater rate of progression was seen for Stage A compared with Stage B (8.7 per 100 person-years [95% CI, 7.4-10.2] versus 1.4 per 100 person-years [95% CI, 0.9-2.1]; P<0.001). NT-proBNP correlated with progression for Stage B (P=0.01), but not for Stage A (P=0.39). A multivariate model found female sex (odds ratio, 1.65 [95% CI, 1.05-2.58]; P=0.03), increased E/e\' (odds ratio, 1.13 [95% CI, 1.02-1.26], P=0.02), and beta blocker use (odds ratio, 2.19 [95% CI, 1.25-3.82], P=0.006) were associated with progression for Stage A. There was a signal that cardiovascular mortality was higher in individuals who progressed, although not statistically significant (P=0.06 for Stage A and P=0.05 for Stage B).
Conclusions
There is significant progression of preclinical heart failure in a community population, with progression rates higher for Stage A. NT-proBNP correlated with progression for Stage B, but not for Stage A. No statistically significant differences in long-term outcomes were seen. Study results have clinical implications important to help guide future heart failure screening and prevention strategies.



Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007216
Young KA, Scott CG, Rodeheffer RJ, Chen HH
Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007216 | PMID: 33951931
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Association Between Industry Marketing Payments and Prescriptions for PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) Inhibitors in the United States.

Inoue K, Figueroa JF, DeJong C, Tsugawa Y, ... Shen C, Kazi DS
Background
Marketing payments from the pharmaceutical industry to physicians have come under scrutiny due to their potential to influence clinical decision-making. Two proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) were approved by the US Food and Drug Administration in 2015 for reducing low-density lipoprotein cholesterol in high-risk patients, but their initial uptake was limited due to their high-cost and stringent prior authorization requirements. We sought to investigate the association between industry marketing and early adoption of PCSK9i among US physicians.
Methods
We used nationwide databases of primary care physicians, cardiologists, and endocrinologists treating Medicare beneficiaries to examine the association between PCSK9i-related marketing payments in 2016 and the number of filled PCSK9i prescriptions in 2017, after adjusting for physician characteristics. In subgroup analyses, we stratified our analyses by physician specialty and prior experience with prescribing PCSK9i.
Results
Among 209 840 physicians included in this analysis, 49 341 (24%) physicians received 292 941 PCSK9i-related marketing payments in 2016. The total value of these payments was $19 million, with a median payment of $61 per physician (interquartile range, $25-$132). Most payments (95%) were for meals, with a median of $14 per meal. The receipt of PCSK9i-related payments in 2016 was associated with increased PCSK9i prescription in 2017 (adjusted risk ratio, 3.18 [95% CI, 2.95-3.42]). This association was larger among primary care physicians (adjusted risk ratio, 6.67 [95% CI, 5.87-7.57]) than cardiologists (adjusted risk ratio, 2.00 [95% CI, 1.84-2.16]) and endocrinologists (adjusted risk ratio, 4.06 [95% CI, 2.95-5.59]). The association was observed across all types of payments.
Conclusions
At a time when few physicians had experience with prescribing PCSK9i under strict prior authorization requirements, industry marketing payments to physicians for PCSK9i, predominantly in the form of meals, were associated with increased PCSK9i prescription in the subsequent year.



Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007521
Inoue K, Figueroa JF, DeJong C, Tsugawa Y, ... Shen C, Kazi DS
Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007521 | PMID: 33966446
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Intravascular Ultrasound Versus Angiography-Guided Drug-Eluting Stent Implantation: A Health Economic Analysis.

Zhou J, Liew D, Duffy SJ, Shaw J, ... Gerber R, Stub D
Background
There is increasing evidence that use of intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes compared with angiography guidance alone. However, concern regarding the cost-effectiveness of IVUS has limited use of this technology worldwide. In this study, we aimed to evaluate the cost-effectiveness of IVUS-guided PCI compared with angiography-guided PCI in patients undergoing drug-eluting stent implantation.
Methods
A decision-analytic Markov model was constructed to compare the cost-effectiveness of IVUS to angiography guidance from the Australian healthcare system perspective. Procedure-related morbidity and mortality were estimated from the literature. Costs were obtained from Australian sources. The population of interest was all-comers undergoing PCI with drug-eluting stent. Outcomes of interest included costs, life-expectancy, and quality-adjusted life years (QALYs) for both treatment groups.
Results
In the base case, IVUS guidance was cost-effective compared with angiography guidance alone. With 5% annual discounting, IVUS was associated with increased lifetime costs of Australian dollars (AUD) $823 (USD $597) per person and benefits of 0.04 life years and 0.05 QALYs compared with angiography, yielding an incremental cost-effectiveness ratio of AUD $17 539 (USD $12 730) per QALY gained. Results were robust to sensitivity analyses, with IVUS being cost-effective in 99% of 10 000 Monte Carlo iterations assuming a willingness-to-pay threshold of AUD $50 000 per QALY gained. In a worst-case scenario analysis, IVUS remained the cost-effective option, with an ICER of AUD $36 651 (USD $26 601) per QALY gained. Exploratory subgroup analysis revealed that cost-effectiveness may be greatest among patients with left main and complex coronary lesions.
Conclusions
Use of IVUS guidance during PCI is likely to be cost-effective compared with angiography guidance alone among patients undergoing drug-eluting stent implantation.



Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e006789
Zhou J, Liew D, Duffy SJ, Shaw J, ... Gerber R, Stub D
Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e006789 | PMID: 34003686
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Accuracy of Cardiovascular Trial Outcome Ascertainment and Treatment Effect Estimates from Routine Health Data: A Systematic Review and Meta-Analysis.

Rodrigues C, Odutayo A, Patel S, Agarwal A, ... Farkouh ME, Udell JA
Background
Registry-based randomized controlled trials allow for outcome ascertainment using routine health data (RHD). While this method provides a potential solution to the rising cost and complexity of clinical trials, comparative analyses of outcome ascertainment by clinical end point committee (CEC) adjudication compared with RHD sources are sparse. Among cardiovascular trials, we set out to systematically compare the incidence of cardiovascular events and estimated randomized treatment effects ascertained from RHD versus traditional clinical evaluation and adjudication.
Methods
We searched MEDLINE (1976 to August 2020) for studies where outcome ascertainment was performed by both RHD and CEC adjudication to compare the incidence of cardiovascular events and treatment effects. We derived ratios of hazard ratios to compare treatment effects from RHD and CEC adjudication. We pooled ratios of hazard ratios using an inverse variance random-effects meta-analysis.
Results
Nine studies (1988-2020; 32 156 patients) involving 10 randomized control trials compared outcome ascertainment with RHD and CEC in patients with or at risk of cardiovascular disease. There was a high degree of agreement and interrater reliability between CEC and RHD outcome determination for all-cause mortality (agreement percentage: 98.4%-100% and κ: 0.95-1.0) and cardiovascular mortality (agreement percentage: 97.8%-99.9% and κ: 0.66-0.99). For myocardial infarction, the κ values ranged from 0.67-0.98, and for stroke the values ranged from 0.52-0.89. In contrast, the κ value for peripheral artery disease was low (κ: 0.27). There was little difference in the randomized treatment effect derived from CEC and RHD ascertainment of events based on the ratios of hazard ratio, with pooled ratios of hazard ratios ranging from 0.93 (95% CI, 0.63-1.39) for cardiovascular mortality to 1.27 (95% CI, 0.67-2.41) for stroke.
Conclusions
Clinical outcome ascertainment using retrospectively acquired RHD displayed high levels of agreement with CEC adjudication for identifying all-cause mortality and cardiovascular outcomes. Importantly, cardiovascular treatment effects in randomized control trials determined from RHD and CEC resulted in similar point estimates. Overall, our review supports the use of RHD as a potential alternative source for clinical outcome ascertainment in cardiovascular trials. Validation studies with prospectively planned linkage are warranted.



Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007903
Rodrigues C, Odutayo A, Patel S, Agarwal A, ... Farkouh ME, Udell JA
Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007903 | PMID: 33993728
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Text Message Medication Adherence Reminders Automated and Delivered at Scale Across Two Institutions: Testing the Nudge System: Pilot Study.

Luong P, Glorioso TJ, Grunwald GK, Peterson P, ... Ho PM, Bull S
Background
Medication refill behavior in patients with cardiovascular diseases is suboptimal. Brief behavioral interventions called Nudges may impact medication refill behavior and can be delivered at scale to patients using text messaging.
Methods
Patients who were prescribed and filled at least one medication for hypertension, hyperlipidemia, diabetes, atrial fibrillation, and coronary artery disease were identified for the pilot study. Patients eligible for the pilot (N=400) were enrolled with an opportunity to opt out. In phase I of the pilot, we tested text message delivery to 60 patients. In phase II, we tested intervention feasibility by identifying those with refill gap of ≥7 days and randomized them to intervention or control arms. Patients were texted Nudges and assessed whether they refilled their medications.
Results
Of 400 patients sent study invitations, 56 (14%) opted out. In phase I, we successfully delivered text messages to 58 of 60 patients and captured patient responses via text. In phase II, 207 of 286 (72.4%) patients had a medication gap ≥7 days for one or more cardiovascular medications and were randomized to intervention or control. Enrolled patients averaged 61.7 years old, were primarily male (69.1%) and White (72.5%) with hypertension being the most prevalent qualifying condition (78.7%). There was a trend towards intervention patients being more likely to refill at least 1 gapping medication (30.6% versus 18.0%; P=0.12) and all gapping medications (17.8% versus 10.0%; P=0.27).
Conclusions
It is possible to set up automated processes within health care delivery systems to identify patients with gaps in medication adherence and send Nudges to facilitate medication refills. Text message Nudges could potentially be a feasible and effective method to facilitate medication refills. A large multi-site randomized trial to determine the impact of text-based Nudges on overall CVD morbidity and mortality is now underway to explore this further. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03973931.



Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007015
Luong P, Glorioso TJ, Grunwald GK, Peterson P, ... Ho PM, Bull S
Circ Cardiovasc Qual Outcomes: 29 Apr 2021; 14:e007015 | PMID: 33993727
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:

This program is still in alpha version.