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Developing an Actionable Taxonomy of Persistent Hypertension Using Electronic Health Records. 利用电子健康记录开发可操作的持续性高血压分类。
IF 6.9 2区 医学 Pub Date : 2023-03-01 DOI: 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.

背景:医疗数据的数字化转型为管理持续性高血压患者提供了新方法。我们试图根据电子健康记录的数据,为持续性高血压患者(定义为连续5次或更多次血压≥160/100 mmHg)制定一种可操作的分类方法。方法:本定性研究对耶鲁大学纽黑文医疗系统患者电子病历中的临床医师笔记进行内容分析。符合条件的患者年龄为18至85岁,在2013年1月1日至2018年10月31日期间连续5次或以上门诊就诊血压≥160/100 mmHg。符合标准的患者共1664例,随机抽取200例进行病历回顾。通过系统的归纳方法,我们开发了一个从电子健康记录中抽象数据的规则,然后使用常规的内容分析对抽象数据进行定性分析,直到达到饱和。结果:115例患者达到饱和,平均年龄66.0岁(SD, 11.6);女性占54.8%;白人、黑人和西班牙裔患者分别占52.2%、30.4%和13.9%。我们确定了与高血压持续性相关的3个内容域:(1)药物治疗未强化,定义为在持续严重血压升高时没有加强降压治疗;(2)未执行规定治疗,定义为提供者推荐特定治疗计划以解决高血压,但治疗计划未被执行的文件;(3)对处方治疗无反应,定义为临床医生承认的持续性高血压,尽管有文献记载的努力升级现有的药物和增加额外的药物,并假定坚持服用。结论:本研究提出了一种新的可操作的分类法,可根据电子健康记录数据根据病因对持续性高血压患者进行分类。这些分类可以自动化,并链接到特定类型的操作来处理它们。
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引用次数: 0
Validation of the International Classification of Diseases, Tenth Revision Code for the National Institutes of Health Stroke Scale Score. 验证美国国立卫生研究院中风量表评分的国际疾病分类第十次修订版代码。
IF 6.9 2区 医学 Pub Date : 2023-03-01 Epub Date: 2023-03-02 DOI: 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.

背景:管理数据可用于卒中研究,但历来缺乏卒中严重程度的数据。医院越来越多地使用国际疾病分类第十版(ICD-10)诊断代码报告美国国立卫生研究院卒中量表(NIHSS)评分,但该代码的有效性仍不明确:我们研究了 ICD-10 NIHSS 评分与 CAESAR(康奈尔大学急性卒中学术登记处)记录的 NIHSS 评分的一致性。我们纳入了所有急性缺血性卒中患者,时间从 2015 年 10 月 1 日美国医院过渡到 ICD-10 到 2018 年,也就是我们注册表中最近的一年。我们登记处记录的 NIHSS 评分(范围为 0-42)作为参考金标准。ICD-10 NIHSS 评分来自医院出院诊断代码 R29.7xx,后两位数字代表 NIHSS 评分。我们采用多元逻辑回归法来探讨与ICD-10 NIHSS评分可用性相关的因素。我们使用方差分析来检验 ICD-10 NIHSS 评分所能解释的真实(登记处)NIHSS 评分的变化比例(R2):在1357名患者中,395人(29.1%)记录了ICD-10 NIHSS评分。这一比例从 2015 年的 0% 增加到 2018 年的 46.5%。在逻辑回归模型中,只有较高的登记 NIHSS 评分(每点的几率比为 1.05 [95% CI, 1.03-1.07])和心肌栓塞性卒中(几率比为 1.4 [95% CI, 1.0-2.0])与 ICD-10 NIHSS 评分的可用性相关。在方差分析模型中,ICD-10 NIHSS 评分几乎可以解释登记的 NIHSS 评分的所有变化(R2=0.88)。ICD-10和登记处NIHSS评分之间存在较大差异(≥4分)的患者不到10%:结论:代表 NIHSS 评分的 ICD-10 编码与卒中登记处记录的 NIHSS 评分非常一致。然而,ICD-10 NIHSS 评分经常缺失,尤其是在不太严重的卒中中,这限制了这些代码用于风险调整的可靠性。
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引用次数: 0
Practice Patterns and Outcomes Associated With Anticoagulation Use Following Sepsis Hospitalizations With New-Onset Atrial Fibrillation. 新发心房颤动脓毒症患者住院后使用抗凝药的实践模式和结果。
IF 6.9 2区 医学 Pub Date : 2023-03-01 Epub Date: 2023-02-28 DOI: 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.

背景:脓毒症期间新发房颤(AF)患者住院后使用口服抗凝药预防动脉血栓栓塞的实践模式和结果尚不清楚:回顾性观察队列研究:2011 年至 2018 年,北加州凯撒医疗保健服务系统的 21 家医院对脓毒症期间新发房颤住院后存活出院的年龄≥40 岁的患者进行观察。主要结局为缺血性中风/短暂性脑缺血发作(TIA),安全结局为大出血事件,均在脓毒症住院患者出院后 1 年内发生。在目标试验仿真框架内,使用超级学习法通过反概率加权拟合边际结构模型,对出院后30天内接受和未接受口服抗凝治疗的患者之间的调整后风险差异进行了估计:在82 748名因脓毒症住院的患者中,有3 992人(4.8%)患有新发房颤并存活至出院;平均年龄为78±11岁,53%为男性,70%为白人。脓毒症期间新发房颤患者平均占遥测监测房颤患者的 45±33%,27% 的患者在出院当天出现房颤。出院 1 年内,89 名患者(2.2%)发生中风/TIA,225 名患者(5.6%)大出血,1011 名患者(25%)死亡。出院 30 天内,807 名(20%)患者开具了口服抗凝处方,这与较高的 1 年调整后缺血性中风/TIA 风险相关(5.69% 对 2.32%;风险差异为 3.37% [95% CI,0.36-6.38]),而 1 年调整后大出血风险无显著差异(6.51% 对 7.10%;风险差异为-0.59% [95% CI,-3.09 至 1.91])。仅对缺血性卒中结果进行的敏感性分析显示,风险差异为 0.15%(95% CI,-1.72 至 2.03):结论:脓毒症期间新发房颤患者住院后,口服抗凝药物并不常见,但可能与更高的卒中/TIA 风险相关。需要进一步开展研究,以了解中风和 TIA 的机制以及脓毒症后新发房颤的管理。
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引用次数: 0
Patterns and Outcomes of Intensive Care on Acute Ischemic Stroke Patients in the US. 美国急性缺血性脑卒中患者重症监护模式和结果
IF 6.9 2区 医学 Pub Date : 2023-03-01 DOI: 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,&nbsp;Luke Maillie,&nbsp;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}
引用次数: 1
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. 2型糖尿病患者钠-葡萄糖共转运蛋白抑制剂的时变心血管结局:限制平均生存时间的关键试验的事后分析
IF 6.9 2区 医学 Pub Date : 2023-03-01 DOI: 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,&nbsp;Issam Motairek,&nbsp;Salil Deo,&nbsp;Ravi Ramani,&nbsp;Ian J Neeland,&nbsp;Sanjay Rajagopalan,&nbsp;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}
引用次数: 0
In Search of Reliable and Complete Data on Stroke Severity: The Unfulfilled Promise of R29.7xx. 寻找中风严重程度的可靠和完整的数据:R29.7xx未实现的承诺。
IF 6.9 2区 医学 Pub Date : 2023-03-01 DOI: 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}
引用次数: 0
Contemporary Management Before Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. 慢性全闭塞经皮冠状动脉介入治疗前的当代管理:退伍军人事务临床评估、报告和跟踪计划的启示》。
IF 6.9 2区 医学 Pub Date : 2023-03-01 Epub Date: 2023-02-01 DOI: 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.

背景:指南建议,在尝试冠状动脉慢性全闭塞(CTO)经皮冠状动脉介入治疗(PCI)之前,应最大限度地使用抗心绞痛药物治疗。但在当代实践中的应用程度尚不清楚。我们的目的是描述一个全国性综合医疗系统在 CTO PCI(CTO PCI)术前 3 个月内使用抗心绞痛治疗和压力测试的频率和变异性:我们确定了退伍军人事务医疗保健系统内 2012 年 1 月至 2018 年 9 月期间尝试进行 CTO PCI 的患者。患者按 CTO PCI 前的管理进行分类:存在≥2 个反向血管、进行过压力测试,以及在尝试 PCI 后 3 个月内存在≥2 个反向血管并进行过压力测试。采用多变量逻辑回归和反倾向加权法进行调整后再进行裁剪,并计算中位赔率以估计变异性:在 4250 例尝试进行 CTO PCI 的患者中,40% 的患者接受了≥2 种抗心绞痛药物治疗,24% 的患者接受了术前压力测试。在研究期间,CTO PCI 前接受一种以上抗心绞痛药物治疗的几率没有变化(几率比 [OR],1.0 [95% CI,0.97-1.04]),而接受术前压力测试的几率有所下降(OR,0.97 [95% CI,0.93-0.99]),接受≥2 种抗心绞痛药物治疗和压力测试的几率没有变化(OR,0.98 [95% CI,0.93-1.04])。中位几率比(MOR)显示,不同医院(MOR,1.3 [95% CI,1.26-1.42])和不同操作者(MOR,1.35 [95% CI,1.26-1.63])在抗心绞痛治疗方面存在很大差异。同样,不同医院(MOR,1.68[95% CI,1.58-1.81])和不同操作者(MOR,1.80[95% CI,1.56-2.38])的术前压力测试差异也很大:结论:仅有不到一半的患者在进行CTO PCI前接受了指南推荐的治疗,而治疗部位和操作者存在显著差异。这些研究结果表明,有机会减少CTO PCI术前管理的变异性。
{"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}
引用次数: 0
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. 将社区健康工作者纳入社区初级保健实践设置,以改善纽约市南亚移民的血压控制:随机对照试验的结果。
IF 6.9 2区 医学 Pub Date : 2023-03-01 Epub Date: 2023-02-23 DOI: 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.

Registration: URL: https://www.

Clinicaltrials: gov; Unique identifier: NCT03159533.

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}
引用次数: 0
Community Health Workers as Key Allies in the Global Battle Against Hypertension: Current Roles and Future Possibilities. 社区卫生工作者是全球抗击高血压的重要盟友:当前的作用和未来的可能性》。
IF 6.9 2区 医学 Pub Date : 2023-03-01 Epub Date: 2023-02-23 DOI: 10.1161/CIRCOUTCOMES.123.009900
Robert D Brook, Phillip D Levy, Alec J Brook, Ijeoma N Opara
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引用次数: 0
Palliative Care Across the Life Span for Children With Heart Disease: A Scientific Statement From the American Heart Association. 心脏病儿童终身姑息治疗:美国心脏协会的科学声明。
IF 6.9 2区 医学 Pub Date : 2023-02-01 Epub Date: 2023-01-12 DOI: 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.

目的:美国心脏协会的这篇综述为儿童先天性和获得性心脏病的初级和亚专业姑息治疗提供了指导。方法:对2010年1月至2021年12月的文献进行综合检索。2010年1月之前发表的研讨会文章也包括在评论中。包括PubMed、ClinicalTrials.gov和Cochrane Collaboration上以英语发表的人类受试者研究和系统综述。结构:尽管近几十年来,儿童先天性和获得性心脏病的存活率大幅提高,但一部分患有心脏病的年轻人的发病率和死亡率风险仍然存在,因此需要发挥姑息治疗的作用。这一科学声明为心脏病儿童提供初级和专业姑息治疗提供了一种循证方法。定义了针对儿童心脏病的初级和专业姑息治疗,并概述了姑息治疗的触发因素。儿科心脏病学姑息治疗培训;多样性、公平性和包容性考虑;并对未来的研究方向进行了展望。
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Circulation. Cardiovascular Quality and Outcomes
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