Pub Date : 2024-04-10DOI: 10.1161/circoutcomes.123.010090
Rishi K. Wadhera, Eric A. Secemsky, Jiaman Xu, Robert W. Yeh, Yang Song, Samuel Z. Goldhaber
BACKGROUND:Socioeconomically disadvantaged communities in the United States disproportionately experience poor cardiovascular outcomes. Little is known about how hospitalizations and mortality for acute cardiovascular conditions have changed among Medicare beneficiaries in socioeconomically disadvantaged and nondisadvantaged communities over the past 2 decades.METHODS:Medicare files were linked with the Centers for Disease Control and Prevention’s social vulnerability index to examine age-sex standardized hospitalizations for myocardial infarction, heart failure, ischemic stroke, and pulmonary embolism among Medicare fee-for-service beneficiaries ≥65 years of age residing in socioeconomically disadvantaged communities (highest social vulnerability index quintile nationally) and nondisadvantaged communities (all other quintiles) from 2003 to 2019, as well as risk-adjusted 30-day mortality among hospitalized beneficiaries.RESULTS:A total of 10 942 483 Medicare beneficiaries ≥65 years of age were hospitalized for myocardial infarction, heart failure, stroke, or pulmonary embolism (mean age, 79.2 [SD, 8.7] years; 53.9% female). Although age-sex standardized myocardial infarction hospitalizations declined in socioeconomically disadvantaged (990–650 per 100 000) and nondisadvantaged communities (950–570 per 100 000) from 2003 to 2019, the gap in hospitalizations between these groups significantly widened (adjusted odds ratio 2003, 1.03 [95% CI, 1.02–1.04]; adjusted odds ratio 2019, 1.14 [95% CI, 1.13–1.16]). There was a similar decline in hospitalizations for heart failure in socioeconomically disadvantaged (2063–1559 per 100 000) and nondisadvantaged communities (1767–1385 per 100 000), as well as for ischemic stroke, but the relative gap did not change for both conditions. In contrast, pulmonary embolism hospitalizations increased in both disadvantaged (146–184 per 100 000) and nondisadvantaged communities (153–184 per 100 000). By 2019, risk-adjusted 30-day mortality was similar between hospitalized beneficiaries from socioeconomically disadvantaged and nondisadvantaged communities for myocardial infarction, heart failure, and ischemic stroke but was higher for pulmonary embolism (odds ratio, 1.10 [95% CI, 1.01–1.20]).CONCLUSIONS:Over the past 2 decades, hospitalizations for most acute cardiovascular conditions decreased in both socioeconomically disadvantaged and nondisadvantaged communities, although significant disparities remain, while 30-day mortality is now similar across most conditions.
{"title":"Community Socioeconomic Status, Acute Cardiovascular Hospitalizations, and Mortality in Medicare, 2003 to 2019","authors":"Rishi K. Wadhera, Eric A. Secemsky, Jiaman Xu, Robert W. Yeh, Yang Song, Samuel Z. Goldhaber","doi":"10.1161/circoutcomes.123.010090","DOIUrl":"https://doi.org/10.1161/circoutcomes.123.010090","url":null,"abstract":"BACKGROUND:Socioeconomically disadvantaged communities in the United States disproportionately experience poor cardiovascular outcomes. Little is known about how hospitalizations and mortality for acute cardiovascular conditions have changed among Medicare beneficiaries in socioeconomically disadvantaged and nondisadvantaged communities over the past 2 decades.METHODS:Medicare files were linked with the Centers for Disease Control and Prevention’s social vulnerability index to examine age-sex standardized hospitalizations for myocardial infarction, heart failure, ischemic stroke, and pulmonary embolism among Medicare fee-for-service beneficiaries ≥65 years of age residing in socioeconomically disadvantaged communities (highest social vulnerability index quintile nationally) and nondisadvantaged communities (all other quintiles) from 2003 to 2019, as well as risk-adjusted 30-day mortality among hospitalized beneficiaries.RESULTS:A total of 10 942 483 Medicare beneficiaries ≥65 years of age were hospitalized for myocardial infarction, heart failure, stroke, or pulmonary embolism (mean age, 79.2 [SD, 8.7] years; 53.9% female). Although age-sex standardized myocardial infarction hospitalizations declined in socioeconomically disadvantaged (990–650 per 100 000) and nondisadvantaged communities (950–570 per 100 000) from 2003 to 2019, the gap in hospitalizations between these groups significantly widened (adjusted odds ratio 2003, 1.03 [95% CI, 1.02–1.04]; adjusted odds ratio 2019, 1.14 [95% CI, 1.13–1.16]). There was a similar decline in hospitalizations for heart failure in socioeconomically disadvantaged (2063–1559 per 100 000) and nondisadvantaged communities (1767–1385 per 100 000), as well as for ischemic stroke, but the relative gap did not change for both conditions. In contrast, pulmonary embolism hospitalizations increased in both disadvantaged (146–184 per 100 000) and nondisadvantaged communities (153–184 per 100 000). By 2019, risk-adjusted 30-day mortality was similar between hospitalized beneficiaries from socioeconomically disadvantaged and nondisadvantaged communities for myocardial infarction, heart failure, and ischemic stroke but was higher for pulmonary embolism (odds ratio, 1.10 [95% CI, 1.01–1.20]).CONCLUSIONS:Over the past 2 decades, hospitalizations for most acute cardiovascular conditions decreased in both socioeconomically disadvantaged and nondisadvantaged communities, although significant disparities remain, while 30-day mortality is now similar across most conditions.","PeriodicalId":10239,"journal":{"name":"Circulation: Cardiovascular Quality and Outcomes","volume":"90 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140585444","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-03DOI: 10.1161/circoutcomes.123.010111
Nicholas K. Brownell, Boback Ziaeian, Nicholas J. Jackson, Adam K. Richards
BACKGROUND:Mean cardiovascular health has improved over the past several decades in the United States, but it is unclear whether the benefit is shared equitably. This study examined 30-year trends in cardiovascular health using a suite of income equity metrics to provide a comprehensive picture of cardiovascular income equity.METHODS:The study evaluated data from the 1988–2018 National Health and Nutrition Examination Survey. Survey groupings were stratified by poverty-to-income ratio (PIR) category, and the mean predicted 10-year risk of a major cardiovascular event or death based on the pooled cohort equations (PCE) was calculated (10-year PCE risk). Equity metrics including the relative and absolute concentration indices and the achievement index—metrics that assess both the prevalence and the distribution of a health measure across different socioeconomic categories—were calculated.RESULTS:A total of 26 633 participants aged 40 to 75 years were included (mean age, 53.0–55.5 years; women, 51.9%–53.0%). From 1988–1994 to 2015–2018, the mean 10-year PCE risk improved from 7.8% to 6.4% (P<0.05). The improvement was limited to the 2 highest income categories (10-year PCE risk for PIR 5: 7.7%–5.1%, P<0.05; PIR 3–4.99: 7.6%–6.1%, P<0.05). The 10-year PCE risk for the lowest income category (PIR <1) did not significantly change (8.1%–8.7%). In 1988–1994, the 10-year PCE risk for PIR <1 was 6% higher than PIR 5; by 2015–2018, this relative inequity increased to 70% (P<0.05). When using metrics that account for all income categories, the achievement index improved (8.0%–7.1%, P<0.05); however, the achievement index was consistently higher than the mean 10-year PCE risk, indicating the poor persistently had a greater share of adverse health.CONCLUSIONS:In this serial cross-sectional survey of US adults spanning 30 years, the population’s mean 10-year PCE risk improved, but the improvement was not felt equally across the income spectrum.
{"title":"Trends in Income Inequities in Cardiovascular Health Among US Adults, 1988–2018","authors":"Nicholas K. Brownell, Boback Ziaeian, Nicholas J. Jackson, Adam K. Richards","doi":"10.1161/circoutcomes.123.010111","DOIUrl":"https://doi.org/10.1161/circoutcomes.123.010111","url":null,"abstract":"BACKGROUND:Mean cardiovascular health has improved over the past several decades in the United States, but it is unclear whether the benefit is shared equitably. This study examined 30-year trends in cardiovascular health using a suite of income equity metrics to provide a comprehensive picture of cardiovascular income equity.METHODS:The study evaluated data from the 1988–2018 National Health and Nutrition Examination Survey. Survey groupings were stratified by poverty-to-income ratio (PIR) category, and the mean predicted 10-year risk of a major cardiovascular event or death based on the pooled cohort equations (PCE) was calculated (10-year PCE risk). Equity metrics including the relative and absolute concentration indices and the achievement index—metrics that assess both the prevalence and the distribution of a health measure across different socioeconomic categories—were calculated.RESULTS:A total of 26 633 participants aged 40 to 75 years were included (mean age, 53.0–55.5 years; women, 51.9%–53.0%). From 1988–1994 to 2015–2018, the mean 10-year PCE risk improved from 7.8% to 6.4% (<i>P</i><0.05). The improvement was limited to the 2 highest income categories (10-year PCE risk for PIR 5: 7.7%–5.1%, <i>P</i><0.05; PIR 3–4.99: 7.6%–6.1%, <i>P</i><0.05). The 10-year PCE risk for the lowest income category (PIR <1) did not significantly change (8.1%–8.7%). In 1988–1994, the 10-year PCE risk for PIR <1 was 6% higher than PIR 5; by 2015–2018, this relative inequity increased to 70% (<i>P</i><0.05). When using metrics that account for all income categories, the achievement index improved (8.0%–7.1%, <i>P</i><0.05); however, the achievement index was consistently higher than the mean 10-year PCE risk, indicating the poor persistently had a greater share of adverse health.CONCLUSIONS:In this serial cross-sectional survey of US adults spanning 30 years, the population’s mean 10-year PCE risk improved, but the improvement was not felt equally across the income spectrum.","PeriodicalId":10239,"journal":{"name":"Circulation: Cardiovascular Quality and Outcomes","volume":"7 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140585242","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-03DOI: 10.1161/circoutcomes.123.010477
Kathleen E. McKee, Andrew J. Knighton, Kristy Veale, Julie Martinez, Cory McCann, Jonathan W. Anderson, Doug Wolfe, Robert Blackburn, Marilyn McKasson, Tyler Bardsley, Blessing Ofori-Atta, Tom H. Greene, Robert Hoesch, H. Adrian Püttgen, Rajendu Srivastava
BACKGROUND:Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system.METHODS:Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized stepped-wedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers.RESULTS:A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56–79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40–2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58–80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47–7.78]; stroke centers (77.4%–90.0%); nonstroke centers [59.3%–72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, −9.68 [95% CI, −17.17 to −2.20]; stroke centers [41–35 minutes]; nonstroke centers [55–52 minutes]). No differences were observed in clinical effectiveness outcomes.CONCLUSIONS:A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers.
{"title":"Impact of Local Tailoring on Acute Stroke Care in 21 Disparate Emergency Departments: A Prospective Stepped Wedge Type III Hybrid Effectiveness-Implementation Study","authors":"Kathleen E. McKee, Andrew J. Knighton, Kristy Veale, Julie Martinez, Cory McCann, Jonathan W. Anderson, Doug Wolfe, Robert Blackburn, Marilyn McKasson, Tyler Bardsley, Blessing Ofori-Atta, Tom H. Greene, Robert Hoesch, H. Adrian Püttgen, Rajendu Srivastava","doi":"10.1161/circoutcomes.123.010477","DOIUrl":"https://doi.org/10.1161/circoutcomes.123.010477","url":null,"abstract":"BACKGROUND:Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system.METHODS:Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized stepped-wedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers.RESULTS:A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56–79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40–2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58–80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47–7.78]; stroke centers (77.4%–90.0%); nonstroke centers [59.3%–72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, −9.68 [95% CI, −17.17 to −2.20]; stroke centers [41–35 minutes]; nonstroke centers [55–52 minutes]). No differences were observed in clinical effectiveness outcomes.CONCLUSIONS:A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers.","PeriodicalId":10239,"journal":{"name":"Circulation: Cardiovascular Quality and Outcomes","volume":"8 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140585238","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-03DOI: 10.1161/circoutcomes.123.010560
Pishoy Gouda, Sarah Rathwell, Eloisa Colin-Ramirez, G. Michael Felker, Heather Ross, Jorge Escobedo, Peter Macdonald, Richard W. Troughton, Christopher M. O’Connor, Justin A. Ezekowitz
BACKGROUND:In heart failure (HF) trials, there has been an emphasis on utilizing more patient-centered outcomes, including quality of life (QoL) and days alive and out of hospital. We aimed to explore the impact of QoL adjusted days alive and out of hospital as an outcome in 2 HF clinical trials.METHODS:Using data from 2 trials in HF (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure [GUIDE-IT] and Study of Dietary Intervention under 100 mmol in Heart Failure [SODIUM-HF]), we determined treatment differences using percentage days alive and out of hospital (%DAOH) adjusted for QoL at 18 months as the primary outcome. For each participant, %DAOH was calculated as a ratio between days alive and out of hospital/total follow-up. Using a regression model, %DAOH was subsequently adjusted for QoL measured by the Kansas City Cardiomyopathy Questionnaire Overall Summary Score.RESULTS:In the GUIDE-IT trial, 847 participants had a median baseline Kansas City Cardiomyopathy Questionnaire Overall Summary Score of 59.0 (interquartile range, 40.8–74.3), which did not change over 18 months. %DAOH was 90.76%±22.09% in the biomarker-guided arm and 88.56%±25.27% in the usual care arm. No significant difference in QoL adjusted %DAOH was observed (1.09% [95% CI, −1.57% to 3.97%]). In the SODIUM-HF trial, 796 participants had a median baseline Kansas City Cardiomyopathy Questionnaire Overall Summary Score of 69.8 (interquartile range, 49.3–84.3), which did not change over 18 months. %DAOH was 95.69%±16.31% in the low-sodium arm and 95.95%±14.76% in the usual care arm. No significant difference was observed (1.91% [95% CI, −0.85% to 4.77%]).CONCLUSIONs:In 2 large HF clinical trials, adjusting %DAOH for QoL was feasible and may provide complementary information on treatment effects in clinical trials.
背景：在心力衰竭（HF）试验中，人们一直在强调使用更多的以患者为中心的结果，包括生活质量（QoL）、存活天数和出院天数。方法：我们利用两项心力衰竭试验（心力衰竭生物标记物强化治疗指导循证疗法[GUIDE-IT]和心力衰竭100毫摩尔以下饮食干预研究[SODIUM-HF]）的数据，以18个月时根据QoL调整的存活和出院天数百分比（%DAOH）作为主要结果，确定治疗差异。每位参与者的存活和出院天数百分比计算为存活和出院天数与总随访天数之比。结果：在 GUIDE-IT 试验中，847 名参与者的基线堪萨斯城心肌病问卷总分中位数为 59.0（四分位间范围为 40.8-74.3），在 18 个月内没有变化。生物标志物指导组的DAOH%为90.76%±22.09%，常规治疗组为88.56%±25.27%。调整后的 QoL %DAOH 无明显差异（1.09% [95% CI, -1.57% to 3.97%]）。在 SODIUM-HF 试验中，796 名参与者的基线堪萨斯城心肌病问卷总体汇总得分中位数为 69.8（四分位间范围为 49.3-84.3），18 个月内没有变化。低钠治疗组的脱氧血症发生率为 95.69%±16.31%，常规治疗组的脱氧血症发生率为 95.95%±14.76%。结论：在两项大型 HF 临床试验中，根据 QoL 调整 %DAOH 是可行的，可为临床试验中的治疗效果提供补充信息。
{"title":"Utilizing Quality of Life Adjusted Days Alive and Out of Hospital in Heart Failure Clinical Trials","authors":"Pishoy Gouda, Sarah Rathwell, Eloisa Colin-Ramirez, G. Michael Felker, Heather Ross, Jorge Escobedo, Peter Macdonald, Richard W. Troughton, Christopher M. O’Connor, Justin A. Ezekowitz","doi":"10.1161/circoutcomes.123.010560","DOIUrl":"https://doi.org/10.1161/circoutcomes.123.010560","url":null,"abstract":"BACKGROUND:In heart failure (HF) trials, there has been an emphasis on utilizing more patient-centered outcomes, including quality of life (QoL) and days alive and out of hospital. We aimed to explore the impact of QoL adjusted days alive and out of hospital as an outcome in 2 HF clinical trials.METHODS:Using data from 2 trials in HF (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure [GUIDE-IT] and Study of Dietary Intervention under 100 mmol in Heart Failure [SODIUM-HF]), we determined treatment differences using percentage days alive and out of hospital (%DAOH) adjusted for QoL at 18 months as the primary outcome. For each participant, %DAOH was calculated as a ratio between days alive and out of hospital/total follow-up. Using a regression model, %DAOH was subsequently adjusted for QoL measured by the Kansas City Cardiomyopathy Questionnaire Overall Summary Score.RESULTS:In the GUIDE-IT trial, 847 participants had a median baseline Kansas City Cardiomyopathy Questionnaire Overall Summary Score of 59.0 (interquartile range, 40.8–74.3), which did not change over 18 months. %DAOH was 90.76%±22.09% in the biomarker-guided arm and 88.56%±25.27% in the usual care arm. No significant difference in QoL adjusted %DAOH was observed (1.09% [95% CI, −1.57% to 3.97%]). In the SODIUM-HF trial, 796 participants had a median baseline Kansas City Cardiomyopathy Questionnaire Overall Summary Score of 69.8 (interquartile range, 49.3–84.3), which did not change over 18 months. %DAOH was 95.69%±16.31% in the low-sodium arm and 95.95%±14.76% in the usual care arm. No significant difference was observed (1.91% [95% CI, −0.85% to 4.77%]).CONCLUSIONs:In 2 large HF clinical trials, adjusting %DAOH for QoL was feasible and may provide complementary information on treatment effects in clinical trials.","PeriodicalId":10239,"journal":{"name":"Circulation: Cardiovascular Quality and Outcomes","volume":"87 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140585245","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-01DOI: 10.1161/CIRCOUTCOMES.123.010007
H. Krumholz
{"title":"Transformational Journey of Outcomes Research: Looking Back From the Future","authors":"H. Krumholz","doi":"10.1161/CIRCOUTCOMES.123.010007","DOIUrl":"https://doi.org/10.1161/CIRCOUTCOMES.123.010007","url":null,"abstract":"","PeriodicalId":10239,"journal":{"name":"Circulation: Cardiovascular Quality and Outcomes","volume":"105 1","pages":"e010007"},"PeriodicalIF":0.0,"publicationDate":"2024-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139454049","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-05-01DOI: 10.1161/hcq.13.suppl_1.261
S. Anand, Yeriko Santillan, Ameesh Isaath, T. Goldberg, Dipal Patel
Needs and Objectives: Poorly-controlled hypertension is associated with increased risk of adverse cardiovascular outcomes and thus is an important healthcare quality metric for primary care practices. Yet achieving blood pressure goals among socially-complex, economically-disadvantaged patient populations can be challenging due to cost-related non-adherence, poor health literacy and other social determinant barriers. Indeed, by early 2019, only 59% of hypertensive patients at our inner-city community health clinic had a blood pressure less than 140/90. The goal of this resident-driven quality improvement (QI) project was to increase blood pressure control among our hypertensive patients to a network target of 75% over 6 months. Setting and Participants: Our project was implemented at the Ryan Adair Center, a Federally Qualified Health Center located in Central Harlem that serves as a primary care practice site for Internal Medicine residents. The patient population consists predominantly of Black and Latino patients, most of whom are on Medicaid and live well below the federal poverty line. Our target population was hypertensive patients. Intervention: We used the Plan-Do-Study-Act method to carry out our clinic-based project. PGY1’s at the site served as the QI project leaders with faculty oversight. Cycle 1 focused on nurse education regarding proper blood pressure measurement. Cycle 2 focused on home blood pressure monitoring including patient education on proper technique and the importance of maintaining a daily log. Cycle 3 focused on assessment of health literacy via a patient questionnaire. Cycle 4 focused on provider education by ensuring that our patients were prescribed an appropriate medication regimen based on ACC/AHA Guidelines. Cycle 5 focused on referring patients with continued poor control to community health coaches to identify barriers like nutrition, medication access, and health literacy. Evaluation: Using our clinic’s online hypertensive registry (DRVS), we tracked on a monthly basis the percentage of hypertensive patients who had controlled blood pressure (<140/90). Percent of patients at goal went from 59% in February 2019 to 73% in July 2019. Discussion/lessons learned: Through this project, we demonstrated a meaningful improvement in hypertensive control among an economically-disadvantaged, racially diverse urban patient population. Accurate nurse measurements, engagement of patients in self-management, and resident education on evidence-based medication standards have all contributed to this success. Future directions will explore the impact of community health coaches in hypertension control and use of standard questionnaire to assess health literacy.
{"title":"Abstract 261: Improving Hypertension Control Among an Underserved Urban Patient Population","authors":"S. Anand, Yeriko Santillan, Ameesh Isaath, T. Goldberg, Dipal Patel","doi":"10.1161/hcq.13.suppl_1.261","DOIUrl":"https://doi.org/10.1161/hcq.13.suppl_1.261","url":null,"abstract":"\u0000 Needs and Objectives:\u0000 Poorly-controlled hypertension is associated with increased risk of adverse cardiovascular outcomes and thus is an important healthcare quality metric for primary care practices. Yet achieving blood pressure goals among socially-complex, economically-disadvantaged patient populations can be challenging due to cost-related non-adherence, poor health literacy and other social determinant barriers. Indeed, by early 2019, only 59% of hypertensive patients at our inner-city community health clinic had a blood pressure less than 140/90. The goal of this resident-driven quality improvement (QI) project was to increase blood pressure control among our hypertensive patients to a network target of 75% over 6 months.\u0000 \u0000 \u0000 Setting and Participants:\u0000 Our project was implemented at the Ryan Adair Center, a Federally Qualified Health Center located in Central Harlem that serves as a primary care practice site for Internal Medicine residents. The patient population consists predominantly of Black and Latino patients, most of whom are on Medicaid and live well below the federal poverty line. Our target population was hypertensive patients.\u0000 \u0000 \u0000 Intervention:\u0000 We used the Plan-Do-Study-Act method to carry out our clinic-based project. PGY1’s at the site served as the QI project leaders with faculty oversight. Cycle 1 focused on nurse education regarding proper blood pressure measurement. Cycle 2 focused on home blood pressure monitoring including patient education on proper technique and the importance of maintaining a daily log. Cycle 3 focused on assessment of health literacy via a patient questionnaire. Cycle 4 focused on provider education by ensuring that our patients were prescribed an appropriate medication regimen based on ACC/AHA Guidelines. Cycle 5 focused on referring patients with continued poor control to community health coaches to identify barriers like nutrition, medication access, and health literacy.\u0000 \u0000 \u0000 Evaluation:\u0000 Using our clinic’s online hypertensive registry (DRVS), we tracked on a monthly basis the percentage of hypertensive patients who had controlled blood pressure (<140/90). Percent of patients at goal went from 59% in February 2019 to 73% in July 2019.\u0000 \u0000 \u0000 Discussion/lessons learned:\u0000 Through this project, we demonstrated a meaningful improvement in hypertensive control among an economically-disadvantaged, racially diverse urban patient population. Accurate nurse measurements, engagement of patients in self-management, and resident education on evidence-based medication standards have all contributed to this success. Future directions will explore the impact of community health coaches in hypertension control and use of standard questionnaire to assess health literacy.\u0000","PeriodicalId":10239,"journal":{"name":"Circulation: Cardiovascular Quality and Outcomes","volume":"41 9","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141207318","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-05-01DOI: 10.1161/hcq.13.suppl_1.241
D. Lin, A. Klein, D. Cella, A. Beutler, F. Fang, M. Magestro, P. Cremer, M. LeWinter, S. Luis, A. Abbate, A. Ertel, L. Litcher-Kelly, B. Klooster, J. Paolini
Background: Recurrent pericarditis (RP) episodes and conventional treatments result in morbidity, but the impact on patient health-related quality of life (HRQoL) has not been quantified. The Phase 2 trial NCT03980522 of rilonacept (IL-1α/IL-1β inhibitor) evaluated HRQoL. Methods: Patients with active RP who were symptomatic at Baseline (A-RP, n=16) and RP patients who were not currently experiencing a recurrence but were corticosteroid-dependent at Baseline (CSD-RP, n=9) were enrolled. All received rilonacept weekly for 6 weeks to end of base treatment period (TP) plus an optional 18-week extension treatment period (EP). Corticosteroid tapering occurred in the EP. Physical and mental HRQoL (PROMIS Global Health v1.2 Physical and Mental Component Scores [PCS/MCS]) were assessed at baseline and follow-up. Results: Figure 1 presents the PROMIS PCS/MCS and pain scale scores (both patient-reported) as well as C-reactive protein levels over time. Mean PCS/MCS scores at baseline were 39.9/44.5 and 43.3/46.5 for A-RP and CSD-RP groups respectively (versus the norm mean of 50). In A-RP, PCS/MCS scores improved by 11.4/5.6 points by end of base TP, and this improvement was sustained throughout the EP (increase of 11.4/6.0 points from baseline at end of EP). In CSD-RP, PCS/MCS scores increased by 1.8/1.4 points by end of TP and improved by 3.5/4.2 points at end of study, after tapering or discontinuation of corticosteroid without disease recurrence. Conclusion: Impaired baseline HRQoL suggests negative impact of RP. For A-RP, rilonacept rapidly improved pericarditis signs and symptoms which was associated with HRQoL improvements. For CSD-RP, rilonacept supported tapering/withdrawal of corticosteroids without recurrence, with maintained/improved HRQoL. These results suggest rilonacept can improve RP patient HRQoL while providing an alternative to corticosteroids.
背景：复发性心包炎（RP）发作和常规治疗会导致发病，但对患者健康相关生活质量（HRQoL）的影响尚未量化。利龙赛普（IL-1α/IL-1β抑制剂）的 2 期试验 NCT03980522 对 HRQoL 进行了评估。 研究方法纳入基线时有症状的活动性 RP 患者（A-RP，16 人）和目前未复发但基线时依赖皮质类固醇的 RP 患者（CSD-RP，9 人）。所有患者每周接受利龙赛普治疗 6 周，直至基础治疗期（TP）结束，并可选择接受为期 18 周的延长治疗期（EP）。在延长治疗期，皮质类固醇逐渐减少。在基线和随访期间对患者的身体和心理 HRQoL（PROMIS Global Health v1.2 身体和心理成分评分 [PCS/MCS]）进行评估。 结果图 1 显示了随时间变化的 PROMIS PCS/MCS 和疼痛量表评分（均由患者报告）以及 C 反应蛋白水平。A-RP 组和 CSD-RP 组基线时的 PCS/MCS 平均分分别为 39.9/44.5 和 43.3/46.5（标准平均分为 50）。在 A-RP 组中，PCS/MCS 分数在基础 TP 结束时提高了 11.4/5.6 分，而且这种提高在整个 EP 中一直持续（EP 结束时比基线提高了 11.4/6.0 分）。在 CSD-RP 中，PCS/MCS 评分在 TP 结束时提高了 1.8/1.4 分，在研究结束时提高了 3.5/4.2 分，在减量或停用皮质类固醇后疾病没有复发。 结论基线 HRQoL 受损表明 RP 有负面影响。对于A型RP，利隆钠肽能迅速改善心包炎的体征和症状，这与心率质生活改善有关。对于 CSD-RP，利隆塞普支持皮质类固醇的减量/停药，且不会复发，同时还能维持/改善 HRQoL。这些结果表明，利龙赛普可以改善RP患者的HRQoL，同时提供皮质类固醇的替代品。
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