Pub Date : 2023-03-01DOI: 10.1161/CIRCOUTCOMES.122.009453
Yuan Lu, Cindy Xinxin Du, Hazar Khidir, César Caraballo, Shiwani Mahajan, Erica S Spatz, Leslie A Curry, Harlan M Krumholz
Background: The digital transformation of medical data presents opportunities for novel approaches to manage patients with persistent hypertension. We sought to develop an actionable taxonomy of patients with persistent hypertension (defined as 5 or more consecutive measurements of blood pressure ≥160/100 mmHg over time) based on data from the electronic health records.
Methods: This qualitative study was a content analysis of clinician notes in the electronic health records of patients in the Yale New Haven Health System. Eligible patients were 18 to 85 years and had blood pressure ≥160/100 mmHg at 5 or more consecutive outpatient visits between January 1, 2013 and October 31, 2018. A total of 1664 patients met criteria, of which 200 records were randomly selected for chart review. Through a systematic, inductive approach, we developed a rubric to abstract data from the electronic health records and then analyzed the abstracted data qualitatively using conventional content analysis until saturation was reached.
Results: We reached saturation with 115 patients, who had a mean age of 66.0 (SD, 11.6) years; 54.8% were female; 52.2%, 30.4%, and 13.9% were White, Black, and Hispanic patients. We identified 3 content domains related to persistence of hypertension: (1) non-intensification of pharmacological treatment, defined as absence of antihypertensive treatment intensification in response to persistent severely elevated blood pressure; (2) non-implementation of prescribed treatment, defined as a documentation of provider recommending a specified treatment plan to address hypertension but treatment plan not being implemented; and (3) non-response to prescribed treatment, defined as clinician-acknowledged persistent hypertension despite documented effort to escalate existing pharmacologic agents and addition of additional pharmacologic agents with presumption of adherence.
Conclusions: This study presents a novel actionable taxonomy for classifying patients with persistent hypertension by their contributing causes based on electronic health record data. These categories can be automated and linked to specific types of actions to address them.
{"title":"Developing an Actionable Taxonomy of Persistent Hypertension Using Electronic Health Records.","authors":"Yuan Lu, Cindy Xinxin Du, Hazar Khidir, César Caraballo, Shiwani Mahajan, Erica S Spatz, Leslie A Curry, Harlan M Krumholz","doi":"10.1161/CIRCOUTCOMES.122.009453","DOIUrl":"https://doi.org/10.1161/CIRCOUTCOMES.122.009453","url":null,"abstract":"<p><strong>Background: </strong>The digital transformation of medical data presents opportunities for novel approaches to manage patients with persistent hypertension. We sought to develop an actionable taxonomy of patients with persistent hypertension (defined as 5 or more consecutive measurements of blood pressure ≥160/100 mmHg over time) based on data from the electronic health records.</p><p><strong>Methods: </strong>This qualitative study was a content analysis of clinician notes in the electronic health records of patients in the Yale New Haven Health System. Eligible patients were 18 to 85 years and had blood pressure ≥160/100 mmHg at 5 or more consecutive outpatient visits between January 1, 2013 and October 31, 2018. A total of 1664 patients met criteria, of which 200 records were randomly selected for chart review. Through a systematic, inductive approach, we developed a rubric to abstract data from the electronic health records and then analyzed the abstracted data qualitatively using conventional content analysis until saturation was reached.</p><p><strong>Results: </strong>We reached saturation with 115 patients, who had a mean age of 66.0 (SD, 11.6) years; 54.8% were female; 52.2%, 30.4%, and 13.9% were White, Black, and Hispanic patients. We identified 3 content domains related to persistence of hypertension: (1) non-intensification of pharmacological treatment, defined as absence of antihypertensive treatment intensification in response to persistent severely elevated blood pressure; (2) non-implementation of prescribed treatment, defined as a documentation of provider recommending a specified treatment plan to address hypertension but treatment plan not being implemented; and (3) non-response to prescribed treatment, defined as clinician-acknowledged persistent hypertension despite documented effort to escalate existing pharmacologic agents and addition of additional pharmacologic agents with presumption of adherence.</p><p><strong>Conclusions: </strong>This study presents a novel actionable taxonomy for classifying patients with persistent hypertension by their contributing causes based on electronic health record data. These categories can be automated and linked to specific types of actions to address them.</p>","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 3","pages":"e009453"},"PeriodicalIF":6.9,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9484038","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01Epub Date: 2023-03-02DOI: 10.1161/CIRCOUTCOMES.122.009215
Hooman Kamel, Ava L Liberman, Alexander E Merkler, Neal S Parikh, Saad A Mir, Alan Z Segal, Cenai Zhang, Iván Díaz, Babak B Navi
Background: Administrative data can be useful for stroke research but have historically lacked data on stroke severity. Hospitals increasingly report the National Institutes of Health Stroke Scale (NIHSS) score using an International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code, but this code's validity remains unclear.
Methods: We examined the concordance of ICD-10 NIHSS scores versus NIHSS scores recorded in CAESAR (Cornell Acute Stroke Academic Registry). We included all patients with acute ischemic stroke from October 1, 2015, when US hospitals transitioned to ICD-10, through 2018, the latest year in our registry. The NIHSS score (range, 0-42) recorded in our registry served as the reference gold standard. ICD-10 NIHSS scores were derived from hospital discharge diagnosis code R29.7xx, with the latter 2 digits representing the NIHSS score. Multiple logistic regression was used to explore factors associated with availability of ICD-10 NIHSS scores. We used ANOVA to examine the proportion of variation (R2) in the true (registry) NIHSS score that was explained by the ICD-10 NIHSS score.
Results: Among 1357 patients, 395 (29.1%) had an ICD-10 NIHSS score recorded. This proportion increased from 0% in 2015 to 46.5% in 2018. In a logistic regression model, only higher registry NIHSS score (odds ratio per point, 1.05 [95% CI, 1.03-1.07]) and cardioembolic stroke (odds ratio, 1.4 [95% CI, 1.0-2.0]) were associated with availability of the ICD-10 NIHSS score. In an ANOVA model, the ICD-10 NIHSS score explained almost all the variation in the registry NIHSS score (R2=0.88). Fewer than 10% of patients had a large discordance (≥4 points) between their ICD-10 and registry NIHSS scores.
Conclusions: When present, ICD-10 codes representing NIHSS scores had excellent agreement with NIHSS scores recorded in our stroke registry. However, ICD-10 NIHSS scores were often missing, especially in less severe strokes, limiting the reliability of these codes for risk adjustment.
{"title":"Validation of the <i>International Classification of Diseases, Tenth Revision</i> Code for the National Institutes of Health Stroke Scale Score.","authors":"Hooman Kamel, Ava L Liberman, Alexander E Merkler, Neal S Parikh, Saad A Mir, Alan Z Segal, Cenai Zhang, Iván Díaz, Babak B Navi","doi":"10.1161/CIRCOUTCOMES.122.009215","DOIUrl":"10.1161/CIRCOUTCOMES.122.009215","url":null,"abstract":"<p><strong>Background: </strong>Administrative data can be useful for stroke research but have historically lacked data on stroke severity. Hospitals increasingly report the National Institutes of Health Stroke Scale (NIHSS) score using an <i>International Classification of Diseases</i>, <i>Tenth Revision</i> (<i>ICD-10</i>) diagnosis code, but this code's validity remains unclear.</p><p><strong>Methods: </strong>We examined the concordance of <i>ICD-10</i> NIHSS scores versus NIHSS scores recorded in CAESAR (Cornell Acute Stroke Academic Registry). We included all patients with acute ischemic stroke from October 1, 2015, when US hospitals transitioned to <i>ICD-10</i>, through 2018, the latest year in our registry. The NIHSS score (range, 0-42) recorded in our registry served as the reference gold standard. <i>ICD-10</i> NIHSS scores were derived from hospital discharge diagnosis code R29.7xx, with the latter 2 digits representing the NIHSS score. Multiple logistic regression was used to explore factors associated with availability of <i>ICD-10</i> NIHSS scores. We used ANOVA to examine the proportion of variation (<i>R<sup>2</sup></i>) in the true (registry) NIHSS score that was explained by the <i>ICD-10</i> NIHSS score.</p><p><strong>Results: </strong>Among 1357 patients, 395 (29.1%) had an <i>ICD-10</i> NIHSS score recorded. This proportion increased from 0% in 2015 to 46.5% in 2018. In a logistic regression model, only higher registry NIHSS score (odds ratio per point, 1.05 [95% CI, 1.03-1.07]) and cardioembolic stroke (odds ratio, 1.4 [95% CI, 1.0-2.0]) were associated with availability of the <i>ICD-10</i> NIHSS score. In an ANOVA model, the <i>ICD-10</i> NIHSS score explained almost all the variation in the registry NIHSS score (<i>R</i><sup>2</sup>=0.88). Fewer than 10% of patients had a large discordance (≥4 points) between their <i>ICD-10</i> and registry NIHSS scores.</p><p><strong>Conclusions: </strong>When present, <i>ICD-10</i> codes representing NIHSS scores had excellent agreement with NIHSS scores recorded in our stroke registry. However, <i>ICD-10</i> NIHSS scores were often missing, especially in less severe strokes, limiting the reliability of these codes for risk adjustment.</p>","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 3","pages":"e009215"},"PeriodicalIF":6.9,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10237010/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9570643","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01Epub Date: 2023-02-28DOI: 10.1161/CIRCOUTCOMES.122.009494
Allan J Walkey, Laura C Myers, Khanh K Thai, Patricia Kipnis, Manisha Desai, Alan S Go, Yun Lu, Heather Clancy, Ycar Devis, Romain Neugebauer, Vincent X Liu
Background: Practice patterns and outcomes associated with the use of oral anticoagulation for arterial thromboembolism prevention following a hospitalization with new-onset atrial fibrillation (AF) during sepsis are unclear.
Methods: Retrospective, observational cohort study of patients ≥40 years of age discharged alive following hospitalization with new-onset AF during sepsis across 21 hospitals in the Kaiser Permanente Northern California health care delivery system, years 2011 to 2018. Primary outcomes were ischemic stroke/transient ischemic attack (TIA), with a safety outcome of major bleeding events, both within 1 year of discharge alive from sepsis hospitalization. Adjusted risk differences for outcomes between patients who did and did not receive oral anticoagulation within 30 days of discharge were estimated using marginal structural models fitted by inverse probability weighting using Super Learning within a target trial emulation framework.
Results: Among 82 748 patients hospitalized with sepsis, 3992 (4.8%) had new-onset AF and survived to hospital discharge; mean age was 78±11 years, 53% were men, and 70% were White. Patients with new-onset AF during sepsis averaged 45±33% of telemetry monitoring entries with AF, and 27% had AF present on the day of hospital discharge. Within 1 year of hospital discharge, 89 (2.2%) patients experienced stroke/TIA, 225 (5.6%) had major bleeding, and 1011 (25%) died. Within 30 days of discharge, 807 (20%) patients filled oral anticoagulation prescriptions, which were associated with higher 1-year adjusted risks of ischemic stroke/TIA (5.69% versus 2.32%; risk difference, 3.37% [95% CI, 0.36-6.38]) and no significant difference in 1-year adjusted risks of major bleeding (6.51% versus 7.10%; risk difference, -0.59% [95% CI, -3.09 to 1.91]). Sensitivity analysis of ischemic stroke-only outcomes showed a risk difference of 0.15% (95% CI, -1.72 to 2.03).
Conclusions: After hospitalization with new-onset AF during sepsis, oral anticoagulation use was uncommon and associated with potentially higher stroke/TIA risk. Further research to inform mechanisms of stroke and TIA and management of new-onset AF after sepsis is needed.
{"title":"Practice Patterns and Outcomes Associated With Anticoagulation Use Following Sepsis Hospitalizations With New-Onset Atrial Fibrillation.","authors":"Allan J Walkey, Laura C Myers, Khanh K Thai, Patricia Kipnis, Manisha Desai, Alan S Go, Yun Lu, Heather Clancy, Ycar Devis, Romain Neugebauer, Vincent X Liu","doi":"10.1161/CIRCOUTCOMES.122.009494","DOIUrl":"10.1161/CIRCOUTCOMES.122.009494","url":null,"abstract":"<p><strong>Background: </strong>Practice patterns and outcomes associated with the use of oral anticoagulation for arterial thromboembolism prevention following a hospitalization with new-onset atrial fibrillation (AF) during sepsis are unclear.</p><p><strong>Methods: </strong>Retrospective, observational cohort study of patients ≥40 years of age discharged alive following hospitalization with new-onset AF during sepsis across 21 hospitals in the Kaiser Permanente Northern California health care delivery system, years 2011 to 2018. Primary outcomes were ischemic stroke/transient ischemic attack (TIA), with a safety outcome of major bleeding events, both within 1 year of discharge alive from sepsis hospitalization. Adjusted risk differences for outcomes between patients who did and did not receive oral anticoagulation within 30 days of discharge were estimated using marginal structural models fitted by inverse probability weighting using Super Learning within a target trial emulation framework.</p><p><strong>Results: </strong>Among 82 748 patients hospitalized with sepsis, 3992 (4.8%) had new-onset AF and survived to hospital discharge; mean age was 78±11 years, 53% were men, and 70% were White. Patients with new-onset AF during sepsis averaged 45±33% of telemetry monitoring entries with AF, and 27% had AF present on the day of hospital discharge. Within 1 year of hospital discharge, 89 (2.2%) patients experienced stroke/TIA, 225 (5.6%) had major bleeding, and 1011 (25%) died. Within 30 days of discharge, 807 (20%) patients filled oral anticoagulation prescriptions, which were associated with higher 1-year adjusted risks of ischemic stroke/TIA (5.69% versus 2.32%; risk difference, 3.37% [95% CI, 0.36-6.38]) and no significant difference in 1-year adjusted risks of major bleeding (6.51% versus 7.10%; risk difference, -0.59% [95% CI, -3.09 to 1.91]). Sensitivity analysis of ischemic stroke-only outcomes showed a risk difference of 0.15% (95% CI, -1.72 to 2.03).</p><p><strong>Conclusions: </strong>After hospitalization with new-onset AF during sepsis, oral anticoagulation use was uncommon and associated with potentially higher stroke/TIA risk. Further research to inform mechanisms of stroke and TIA and management of new-onset AF after sepsis is needed.</p>","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 3","pages":"e009494"},"PeriodicalIF":6.9,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10033425/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9487184","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/CIRCOUTCOMES.122.008961
Daniel Santos, Luke Maillie, Mandip S Dhamoon
Background: Up to 20% of acute ischemic stroke (AIS) patients may benefit from intensive care unit (ICU)-level care; however, there are few studies evaluating ICU availability for AIS. We aim to summarize the proportion of elderly AIS patients in the United States who are admitted to an ICU and assess the national availability of ICU-level care in AIS.
Methods: We performed a retrospective cohort study using de-identified Medicare inpatient datasets from January 1, 2016 through December 31, 2019 for US individuals aged ≥65 years. We used validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify AIS admission and interventions. ICU-level care was identified by revenue center code. AIS patient characteristics and interventions were stratified by receipt of ICU-level care, comparing differences through calculated standardized mean difference score due to large sample sizes.
Results: From 2016 through 2019, a total of 952 400 admissions by 850 055 individuals met criteria for hospital admission for AIS with 19.9% involving ICU-level care. Individuals were predominantly >75 years of age (58.5%) and identified as white (80.0%). Hospitals on average admitted 11.4% (SD 14.6) of AIS patients to the ICU, with the median hospital admitting 7.7% of AIS patients to the ICU. The ICU admissions were younger and more likely to receive reperfusion therapy but had more comorbid conditions and neurologic complications. Of the 5084 hospitals included, 1971 (38.8%) reported no ICU-level AIS care. Teaching hospitals (36.9% versus 1.6%, P<0.0001) with larger AIS volume (P<0.0001) or in larger metropolitan areas (P<0.0001) were more likely to have an ICU available.
Conclusions: We found evidence of national variation in the availability of ICU-level care for AIS admissions. Since ICUs may provide comprehensive care for the most severe AIS patients, continued effort is needed to examine ICU accessibility and utility among AIS.
背景:高达20%的急性缺血性卒中(AIS)患者可能受益于重症监护病房(ICU)级别的护理;然而,很少有研究评估ICU对AIS的可用性。我们的目的是总结美国老年AIS患者入住ICU的比例,并评估全国AIS ICU级别护理的可得性。方法:我们使用2016年1月1日至2019年12月31日期间未识别的医疗保险住院患者数据集对年龄≥65岁的美国个体进行了回顾性队列研究。我们使用经过验证的国际疾病分类第十版临床修改代码来识别AIS的入院和干预措施。icu级别的护理由收入中心代码标识。通过接受icu级护理对AIS患者的特征和干预措施进行分层,由于样本量大,通过计算的标准化平均差异评分比较差异。结果:从2016年到2019年,共有952 400例患者入院,850 055例患者符合AIS住院标准,其中19.9%涉及icu级别的护理。个体以75岁以上为主(58.5%),以白人为主(80.0%)。医院平均将11.4% (SD 14.6)的AIS患者送入ICU,中位数为7.7%的AIS患者送入ICU。ICU入院患者年龄更小,更有可能接受再灌注治疗,但有更多的合并症和神经系统并发症。在纳入的5084家医院中,1971家(38.8%)报告没有icu级别的AIS护理。教学医院(36.9% vs . 1.6%, ppp)结论:我们发现了AIS入院患者在icu级别护理可得性方面存在国家差异的证据。由于ICU可以为最严重的AIS患者提供全面的护理,因此需要继续努力检查ICU在AIS中的可及性和实用性。
{"title":"Patterns and Outcomes of Intensive Care on Acute Ischemic Stroke Patients in the US.","authors":"Daniel Santos, Luke Maillie, Mandip S Dhamoon","doi":"10.1161/CIRCOUTCOMES.122.008961","DOIUrl":"https://doi.org/10.1161/CIRCOUTCOMES.122.008961","url":null,"abstract":"<p><strong>Background: </strong>Up to 20% of acute ischemic stroke (AIS) patients may benefit from intensive care unit (ICU)-level care; however, there are few studies evaluating ICU availability for AIS. We aim to summarize the proportion of elderly AIS patients in the United States who are admitted to an ICU and assess the national availability of ICU-level care in AIS.</p><p><strong>Methods: </strong>We performed a retrospective cohort study using de-identified Medicare inpatient datasets from January 1, 2016 through December 31, 2019 for US individuals aged ≥65 years. We used validated <i>International Classification of Diseases, Tenth Revision</i>, Clinical Modification codes to identify AIS admission and interventions. ICU-level care was identified by revenue center code. AIS patient characteristics and interventions were stratified by receipt of ICU-level care, comparing differences through calculated standardized mean difference score due to large sample sizes.</p><p><strong>Results: </strong>From 2016 through 2019, a total of 952 400 admissions by 850 055 individuals met criteria for hospital admission for AIS with 19.9% involving ICU-level care. Individuals were predominantly >75 years of age (58.5%) and identified as white (80.0%). Hospitals on average admitted 11.4% (SD 14.6) of AIS patients to the ICU, with the median hospital admitting 7.7% of AIS patients to the ICU. The ICU admissions were younger and more likely to receive reperfusion therapy but had more comorbid conditions and neurologic complications. Of the 5084 hospitals included, 1971 (38.8%) reported no ICU-level AIS care. Teaching hospitals (36.9% versus 1.6%, <i>P</i><0.0001) with larger AIS volume (<i>P</i><0.0001) or in larger metropolitan areas (<i>P</i><0.0001) were more likely to have an ICU available.</p><p><strong>Conclusions: </strong>We found evidence of national variation in the availability of ICU-level care for AIS admissions. Since ICUs may provide comprehensive care for the most severe AIS patients, continued effort is needed to examine ICU accessibility and utility among AIS.</p>","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 3","pages":"e008961"},"PeriodicalIF":6.9,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9482267","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/CIRCOUTCOMES.122.009491
Ioannis Milioglou, Issam Motairek, Salil Deo, Ravi Ramani, Ian J Neeland, Sanjay Rajagopalan, Sadeer G Al-Kindi
{"title":"Time-Varying Cardiovascular Outcomes of Sodium-Glucose Cotransporter Inhibitors in Patients With Type 2 Diabetes: A Post Hoc Analysis of Pivotal Trials Using Restricted Mean Survival Time.","authors":"Ioannis Milioglou, Issam Motairek, Salil Deo, Ravi Ramani, Ian J Neeland, Sanjay Rajagopalan, Sadeer G Al-Kindi","doi":"10.1161/CIRCOUTCOMES.122.009491","DOIUrl":"https://doi.org/10.1161/CIRCOUTCOMES.122.009491","url":null,"abstract":"","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 3","pages":"e009491"},"PeriodicalIF":6.9,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9475439","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/CIRCOUTCOMES.123.009805
Mathew J Reeves
{"title":"In Search of Reliable and Complete Data on Stroke Severity: The Unfulfilled Promise of R29.7xx.","authors":"Mathew J Reeves","doi":"10.1161/CIRCOUTCOMES.123.009805","DOIUrl":"https://doi.org/10.1161/CIRCOUTCOMES.123.009805","url":null,"abstract":"","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 3","pages":"e009805"},"PeriodicalIF":6.9,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9836757","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01Epub Date: 2023-02-01DOI: 10.1161/CIRCOUTCOMES.122.008949
Stanley A Swat, Annika Hebbe, Mary E Plomondon, Ki E Park, Rory S Bricker, Stephen W Waldo, Javier A Valle
Background: Guidelines recommend maximal antianginal medical therapy before attempted coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The degree to which this occurs in contemporary practice is unknown. We aimed to characterize the frequency and variability of preprocedural use of antianginal therapy and stress testing within 3 months before PCI of CTO (CTO PCI) across a nationally integrated health care system.
Methods: We identified patients who underwent attempted CTO PCI from January 2012 to September 2018 within the Veterans Affairs Healthcare System. Patients were categorized by management before CTO PCI: presence of ≥2 antianginals, stress testing, and ≥2 antianginals and stress testing within 3 months of PCI attempt. Multivariable logistic regression and inverse propensity weighting were used for adjustment before trimming, with median odds ratios calculated for variability estimates.
Results: Among 4250 patients undergoing attempted CTO PCI, 40% received ≥2 antianginal medications and 24% underwent preprocedural stress testing. The odds of antianginal therapy with more than one medication before CTO PCI did not change over the years of the study (odds ratio [OR], 1.0 [95% CI, 0.97-1.04]), whereas the odds of undergoing preprocedural stress testing decreased (OR, 0.97 [95% CI, 0.93-0.99]), and the odds of antianginal therapy with ≥2 antianginals and stress testing did not change (OR, 0.98 [95% CI, 0.93-1.04]). Median odds ratios (MOR) showed substantial variability in antianginal therapy across hospital sites (MOR, 1.3 [95% CI, 1.26-1.42]) and operators (MOR, 1.35 [95% CI, 1.26-1.63]). Similarly, preprocedural stress testing varied significantly by site (MOR, 1.68 [95% CI, 1.58-1.81]) and operator (MOR, 1.80 [95% CI, 1.56-2.38]).
Conclusions: Just under half of patients received guideline-recommended management before CTO PCI, with significant site and operator variability. These findings suggest an opportunity to reduce variability in management before CTO PCI.
{"title":"Contemporary Management Before Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.","authors":"Stanley A Swat, Annika Hebbe, Mary E Plomondon, Ki E Park, Rory S Bricker, Stephen W Waldo, Javier A Valle","doi":"10.1161/CIRCOUTCOMES.122.008949","DOIUrl":"10.1161/CIRCOUTCOMES.122.008949","url":null,"abstract":"<p><strong>Background: </strong>Guidelines recommend maximal antianginal medical therapy before attempted coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The degree to which this occurs in contemporary practice is unknown. We aimed to characterize the frequency and variability of preprocedural use of antianginal therapy and stress testing within 3 months before PCI of CTO (CTO PCI) across a nationally integrated health care system.</p><p><strong>Methods: </strong>We identified patients who underwent attempted CTO PCI from January 2012 to September 2018 within the Veterans Affairs Healthcare System. Patients were categorized by management before CTO PCI: presence of ≥2 antianginals, stress testing, and ≥2 antianginals and stress testing within 3 months of PCI attempt. Multivariable logistic regression and inverse propensity weighting were used for adjustment before trimming, with median odds ratios calculated for variability estimates.</p><p><strong>Results: </strong>Among 4250 patients undergoing attempted CTO PCI, 40% received ≥2 antianginal medications and 24% underwent preprocedural stress testing. The odds of antianginal therapy with more than one medication before CTO PCI did not change over the years of the study (odds ratio [OR], 1.0 [95% CI, 0.97-1.04]), whereas the odds of undergoing preprocedural stress testing decreased (OR, 0.97 [95% CI, 0.93-0.99]), and the odds of antianginal therapy with ≥2 antianginals and stress testing did not change (OR, 0.98 [95% CI, 0.93-1.04]). Median odds ratios (MOR) showed substantial variability in antianginal therapy across hospital sites (MOR, 1.3 [95% CI, 1.26-1.42]) and operators (MOR, 1.35 [95% CI, 1.26-1.63]). Similarly, preprocedural stress testing varied significantly by site (MOR, 1.68 [95% CI, 1.58-1.81]) and operator (MOR, 1.80 [95% CI, 1.56-2.38]).</p><p><strong>Conclusions: </strong>Just under half of patients received guideline-recommended management before CTO PCI, with significant site and operator variability. These findings suggest an opportunity to reduce variability in management before CTO PCI.</p>","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 3","pages":"e008949"},"PeriodicalIF":6.9,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10033351/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9536959","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01Epub Date: 2023-02-23DOI: 10.1161/CIRCOUTCOMES.122.009321
Nadia S Islam, Laura C Wyatt, Shahmir H Ali, Jennifer M Zanowiak, Sadia Mohaimin, Keith Goldfeld, Priscilla Lopez, Rashi Kumar, Susan Beane, Lorna E Thorpe, Chau Trinh-Shevrin
Background: Blood pressure (BP) control is suboptimal in minority communities, including Asian populations. We evaluate the feasibility, adoption, and effectiveness of an integrated CHW-led health coaching and practice-level intervention to improve hypertension control among South Asian patients in New York City, Project IMPACT (Integrating Million Hearts for Provider and Community Transformation). The primary outcome was BP control, and secondary outcomes were systolic BP and diastolic BP at 6-month follow-up.
Methods: A randomized-controlled trial took place within community-based primary care practices that primarily serve South Asian patients in New York City between 2017 and 2019. A total of 303 South Asian patients aged 18-85 with diagnosed hypertension and uncontrolled BP (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg) within the previous 6 months at 14 clinic sites consented to participate. After completing 1 education session, individuals were randomized into treatment (n=159) or control (n=144) groups. Treatment participants received 4 additional group education sessions and individualized health coaching over a 6-month period. A mixed effect generalized linear model with a logit link function was used to assess intervention effectiveness for controlled hypertension (Yes/No), adjusting for practice level random effect, age, sex, baseline systolic BP, and days between BP measurements.
Results: Among the total enrolled population, mean age was 56.8±11.2 years, and 54.1% were women. At 6 months among individuals with follow-up BP data (treatment, n=154; control, n=137), 68.2% of the treatment group and 41.6% of the control group had controlled BP (P<0.001). In final adjusted analysis, treatment group participants had 3.7 [95% CI, 2.1-6.5] times the odds of achieving BP control at follow-up compared with the control group.
Conclusions: A CHW-led health coaching intervention was effective in achieving BP control among South Asian Americans in New York City primary care practices. Findings can guide translation and dissemination of this model across other communities experiencing hypertension disparities.
背景:包括亚裔人口在内的少数族裔社区的血压(BP)控制并不理想。为了改善纽约市南亚病人的高血压控制情况,我们评估了由社区保健员牵头的健康指导和实践层面的综合干预的可行性、采用情况和效果,即 IMPACT 项目(Integrating Million Hearts for Provider and Community Transformation)。主要结果是血压控制,次要结果是随访 6 个月时的收缩压和舒张压:随机对照试验于 2017 年至 2019 年期间在纽约市主要为南亚病人服务的社区初级保健诊所内进行。14个诊所共有303名年龄在18-85岁、确诊为高血压且在过去6个月内血压未得到控制(收缩压≥140毫米汞柱或舒张压≥90毫米汞柱)的南亚患者同意参与。在完成一次教育课程后,参与者被随机分为治疗组(159 人)或对照组(144 人)。在 6 个月的时间里,治疗组的参与者还接受了 4 次额外的小组教育课程和个性化健康指导。采用具有对数连接功能的混合效应广义线性模型评估干预对控制高血压(是/否)的效果,并对实践水平随机效应、年龄、性别、基线收缩压和两次血压测量之间的间隔天数进行调整:在所有参与人群中,平均年龄为(56.8±11.2)岁,54.1%为女性。6个月后,在有随访血压数据的人(治疗组,n=154;对照组,n=137)中,68.2%的治疗组和41.6%的对照组血压得到控制(PC结论:由CHW主导的健康指导是一种有效的健康管理方法:由社区保健工作者主导的健康指导干预措施对纽约市初级保健实践中的南亚裔美国人实现血压控制很有效。研究结果可指导这一模式在其他存在高血压差异的社区的转化和推广:URL: https://www.Clinicaltrials: gov; Unique identifier:NCT03159533。
{"title":"Integrating Community Health Workers into Community-Based Primary Care Practice Settings to Improve Blood Pressure Control Among South Asian Immigrants in New York City: Results from a Randomized Control Trial.","authors":"Nadia S Islam, Laura C Wyatt, Shahmir H Ali, Jennifer M Zanowiak, Sadia Mohaimin, Keith Goldfeld, Priscilla Lopez, Rashi Kumar, Susan Beane, Lorna E Thorpe, Chau Trinh-Shevrin","doi":"10.1161/CIRCOUTCOMES.122.009321","DOIUrl":"10.1161/CIRCOUTCOMES.122.009321","url":null,"abstract":"<p><strong>Background: </strong>Blood pressure (BP) control is suboptimal in minority communities, including Asian populations. We evaluate the feasibility, adoption, and effectiveness of an integrated CHW-led health coaching and practice-level intervention to improve hypertension control among South Asian patients in New York City, Project IMPACT (Integrating Million Hearts for Provider and Community Transformation). The primary outcome was BP control, and secondary outcomes were systolic BP and diastolic BP at 6-month follow-up.</p><p><strong>Methods: </strong>A randomized-controlled trial took place within community-based primary care practices that primarily serve South Asian patients in New York City between 2017 and 2019. A total of 303 South Asian patients aged 18-85 with diagnosed hypertension and uncontrolled BP (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg) within the previous 6 months at 14 clinic sites consented to participate. After completing 1 education session, individuals were randomized into treatment (n=159) or control (n=144) groups. Treatment participants received 4 additional group education sessions and individualized health coaching over a 6-month period. A mixed effect generalized linear model with a logit link function was used to assess intervention effectiveness for controlled hypertension (Yes/No), adjusting for practice level random effect, age, sex, baseline systolic BP, and days between BP measurements.</p><p><strong>Results: </strong>Among the total enrolled population, mean age was 56.8±11.2 years, and 54.1% were women. At 6 months among individuals with follow-up BP data (treatment, n=154; control, n=137), 68.2% of the treatment group and 41.6% of the control group had controlled BP (<i>P</i><0.001). In final adjusted analysis, treatment group participants had 3.7 [95% CI, 2.1-6.5] times the odds of achieving BP control at follow-up compared with the control group.</p><p><strong>Conclusions: </strong>A CHW-led health coaching intervention was effective in achieving BP control among South Asian Americans in New York City primary care practices. Findings can guide translation and dissemination of this model across other communities experiencing hypertension disparities.</p><p><strong>Registration: </strong>URL: https://www.</p><p><strong>Clinicaltrials: </strong>gov; Unique identifier: NCT03159533.</p>","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 3","pages":"e009321"},"PeriodicalIF":6.9,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10033337/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9487173","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01Epub Date: 2023-02-23DOI: 10.1161/CIRCOUTCOMES.123.009900
Robert D Brook, Phillip D Levy, Alec J Brook, Ijeoma N Opara
{"title":"Community Health Workers as Key Allies in the Global Battle Against Hypertension: Current Roles and Future Possibilities.","authors":"Robert D Brook, Phillip D Levy, Alec J Brook, Ijeoma N Opara","doi":"10.1161/CIRCOUTCOMES.123.009900","DOIUrl":"10.1161/CIRCOUTCOMES.123.009900","url":null,"abstract":"","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 3","pages":"e009900"},"PeriodicalIF":6.9,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11200125/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9481821","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-02-01Epub Date: 2023-01-12DOI: 10.1161/HCQ.0000000000000114
Elizabeth D Blume, Roxanne Kirsch, Melissa K Cousino, Jennifer K Walter, Jill M Steiner, Thomas A Miller, Desiree Machado, Christine Peyton, Emile Bacha, Emily Morell
Aim: This summary from the American Heart Association provides guidance for the provision of primary and subspecialty palliative care in pediatric congenital and acquired heart disease.
Methods: A comprehensive literature search was conducted from January 2010 to December 2021. Seminal articles published before January 2010 were also included in the review. Human subject studies and systematic reviews published in English in PubMed, ClinicalTrials.gov, and the Cochrane Collaboration were included. Structure: Although survival for pediatric congenital and acquired heart disease has tremendously improved in recent decades, morbidity and mortality risks remain for a subset of young people with heart disease, necessitating a role for palliative care. This scientific statement provides an evidence-based approach to the provision of primary and specialty palliative care for children with heart disease. Primary and specialty palliative care specific to pediatric heart disease is defined, and triggers for palliative care are outlined. Palliative care training in pediatric cardiology; diversity, equity, and inclusion considerations; and future research directions are discussed.
{"title":"Palliative Care Across the Life Span for Children With Heart Disease: A Scientific Statement From the American Heart Association.","authors":"Elizabeth D Blume, Roxanne Kirsch, Melissa K Cousino, Jennifer K Walter, Jill M Steiner, Thomas A Miller, Desiree Machado, Christine Peyton, Emile Bacha, Emily Morell","doi":"10.1161/HCQ.0000000000000114","DOIUrl":"10.1161/HCQ.0000000000000114","url":null,"abstract":"<p><strong>Aim: </strong>This summary from the American Heart Association provides guidance for the provision of primary and subspecialty palliative care in pediatric congenital and acquired heart disease.</p><p><strong>Methods: </strong>A comprehensive literature search was conducted from January 2010 to December 2021. Seminal articles published before January 2010 were also included in the review. Human subject studies and systematic reviews published in English in PubMed, ClinicalTrials.gov, and the Cochrane Collaboration were included. Structure: Although survival for pediatric congenital and acquired heart disease has tremendously improved in recent decades, morbidity and mortality risks remain for a subset of young people with heart disease, necessitating a role for palliative care. This scientific statement provides an evidence-based approach to the provision of primary and specialty palliative care for children with heart disease. Primary and specialty palliative care specific to pediatric heart disease is defined, and triggers for palliative care are outlined. Palliative care training in pediatric cardiology; diversity, equity, and inclusion considerations; and future research directions are discussed.</p>","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 2","pages":"e000114"},"PeriodicalIF":6.9,"publicationDate":"2023-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10472747/pdf/nihms-1922836.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10141982","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}