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Oesterle A, Dhruva SS, Pellegrini CN, Liem B, Raitt MH. Ventricular arrhythmia detection for contemporary Biotronik and Abbott implantable cardioverter defibrillators with markedly prolonged detection in Biotronik devices. J Interv Card Electrophysiol 2023; 66:1679-1691. [PMID: 36737506 DOI: 10.1007/s10840-023-01498-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Implantable cardioverter defibrillators (ICDs) are typically programed with both ventricular tachycardia (VT) and ventricular fibrillation (VF) treatment zones. Biotronik and Abbott ICDs do not increment the VT counter when the tachycardia accelerates to the VF zone, which could result in a prolonged delay in tachycardia detection. METHODS Patients with Biotronik and Abbott ICDs receiving care at Veterans Affairs facilities in Northern California were identified. Patient information and device tracings for patients with any ICD therapies were examined to assess for possible delayed tachycardia detection. RESULTS Among 52 patients with Biotronik ICDs, 8 (15%) experienced appropriate ICD therapy over a median follow-up of 29 months. Among 68 patients with Abbott ICDs, 26 (38%) experienced appropriate ICD therapy over a median follow-up of 83 months. Three of the patients with Biotronik ICDs who received appropriate therapy experienced a delay in VT/VF detection due to the tachycardia rate oscillating between the VT and VF treatment zones (longest 31.2 s on detection), compared with four of the patients with Abbott ICDs (longest 4.1 s on the detection and 8 s on redetect). One of the patients with a Biotronik ICD experienced recurrent syncope associated with delayed detection and another died on the day of delayed detection. One of the patients with an Abbott ICD experienced syncope. CONCLUSIONS Because contemporary Biotronik and Abbott ICDs freeze the VT counters when tachycardia is in the VF zone, ICD therapies can be markedly delayed when the tachycardia oscillates between the VT and VF zone.
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Hurley NC, Dhruva SS, Desai NR, Ross JR, Ngufor CG, Masoudi F, Krumholz HM, Mortazavi BJ. Clinical Phenotyping with an Outcomes-driven Mixture of Experts for Patient Matching and Risk Estimation. ACM TRANSACTIONS ON COMPUTING FOR HEALTHCARE 2023; 4:1-18. [PMID: 37908872 PMCID: PMC10613929 DOI: 10.1145/3616021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/02/2023] [Indexed: 11/02/2023]
Abstract
Observational medical data present unique opportunities for analysis of medical outcomes and treatment decision making. However, because these datasets do not contain the strict pairing of randomized control trials, matching techniques are to draw comparisons among patients. A key limitation to such techniques is verification that the variables used to model treatment decision making are also relevant in identifying the risk of major adverse events. This article explores a deep mixture of experts approach to jointly learn how to match patients and model the risk of major adverse events in patients. Although trained with information regarding treatment and outcomes, after training, the proposed model is decomposable into a network that clusters patients into phenotypes from information available before treatment. This model is validated on a dataset of patients with acute myocardial infarction complicated by cardiogenic shock. The mixture of experts approach can predict the outcome of mortality with an area under the receiver operating characteristic curve of 0.85 ± 0.01 while jointly discovering five potential phenotypes of interest. The technique and interpretation allow for identifying clinically relevant phenotypes that may be used both for outcomes modeling as well as potentially evaluating individualized treatment effects.
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Dhruva SS, Smith-Bindman R, Redberg RF. The Need for Randomized Clinical Trials Demonstrating Reduction in All-Cause Mortality With Blood Tests for Cancer Screening. JAMA Intern Med 2023; 183:1051-1053. [PMID: 37639263 DOI: 10.1001/jamainternmed.2023.3610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
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Mooghali M, Rathi VK, Kadakia KT, Ross JS, Dhruva SS. Medical device risk (re)classification: lessons from the FDA's 515 Program Initiative. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2023; 5:e000186. [PMID: 38033980 PMCID: PMC10687393 DOI: 10.1136/bmjsit-2023-000186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/22/2023] [Indexed: 12/02/2023] Open
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Lu A, Ji RZ, Ge AY, Ross JS, Ramachandran R, Redberg RF, Dhruva SS. Financial Conflicts of Interest in Public Comments on Medicare National Coverage Determinations of Medical Devices. JAMA 2023; 330:1094-1096. [PMID: 37589985 PMCID: PMC10436180 DOI: 10.1001/jama.2023.14414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/13/2023] [Indexed: 08/18/2023]
Abstract
This study reviewed public comments for all Medicare National Coverage Determinations between June 2019 and 2022 on select pulmonary and cardiac devices to determine whether financial conflicts of interest were disclosed.
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Dhruva SS, Kesselheim AS, Woloshin S, Ji RZ, Lu Z, Darrow JJ, Redberg RF. Physician Perspectives on the Food and Drug Administration's Decision to Grant Accelerated Approval to Aducanumab for Alzheimer's Disease. Clin Pharmacol Ther 2023; 114:614-617. [PMID: 37218658 PMCID: PMC10869173 DOI: 10.1002/cpt.2954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/04/2023] [Indexed: 05/24/2023]
Abstract
In June 2021, the US Food and Drug Administration (FDA) granted accelerated approval to aducanumab, a monoclonal antibody indicated for the treatment of Alzheimer's disease. The accelerated approval decision was controversial due to concerns about the use of an unvalidated surrogate measure, beta-amyloid, as the basis for approval and a lack of clinical outcome benefit. Between October 2021 and September 2022, we conducted a survey of a nationally representative group of internists, medical oncologists, and cardiologists to understand perspectives around aducanumab's approval and how this FDA decision may influence trust in other drugs approved through the accelerated approval program. Among 214 physician respondents familiar with the accelerated approval of aducanumab, 184 (86%) would not prescribe or recommend aducanumab. Further, 143 (67%) physicians reported losing trust in other drugs approved through the accelerated approval program due to the FDA's decision with aducanumab. As a growing number of similar novel Alzheimer's disease treatments are on the horizon, the first of which, lecanemab, already has received accelerated approval in January 2023, our survey findings provide insight into the impact of the FDA's regulatory decisions on the perspectives and prescribing behavior of physicians concerning these novel drug treatments.
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Oesterle A, Liem LB, Dhruva SS, Friday G, Raitt MH, Pellegrini CN. Reply: The Challenge of Minimizing Unnecessary ICD Shocks While Also Preventing Syncope. JACC Clin Electrophysiol 2023; 9:2005. [PMID: 37758373 DOI: 10.1016/j.jacep.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 10/03/2023]
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Gupta K, Gupta R, Xiao R, Rathi VK, Miller PE, Ross JS, Dhruva SS. Payer-Negotiated Prices for Cardiac Electrophysiology Procedures at 2022-2023 Top 100 US News & World Report for Cardiology and Heart Surgery Hospitals. Circ Arrhythm Electrophysiol 2023; 16:e012159. [PMID: 37622312 DOI: 10.1161/circep.123.012159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
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Demkowicz PC, Dhruva SS, Spatz ES, Beatty AL, Ross JS, Khera R. Physician responses to apple watch-detected irregular rhythm alerts. Am Heart J 2023; 262:29-37. [PMID: 37084933 PMCID: PMC10988207 DOI: 10.1016/j.ahj.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND While the US Food and Drug Administration (FDA) has cleared smartwatch software for detecting atrial fibrillation (AF), there is lack of guidance on management by physicians. We sought to evaluate the approach to management of Apple Watch alerts for AF by physicians and assess whether respondent and case characteristics were associated with their approach. METHODS We conducted a case-based survey of physicians practicing primary care, emergency medicine, and cardiology at 2 large academic centers (Yale and University of California San Francisco) between September and December 2021. Cases described asymptomatic patients receiving Apple Watch AF alerts; cases varied in sex, race, medical history, and notification frequency. We evaluated physician responses among prespecified diagnostic testing, referral, and treatment options. RESULTS We emailed 636 physicians, of whom 95 (14.9%) completed the survey, including 39 primary care, 25 emergency medicine, and 31 cardiology physicians. Among a total of 192 cases (16 unique scenarios), physicians selected at least one diagnostic test in 191 (99.5%) cases and medications in 48 (25.0%). Physicians in primary care, emergency medicine, and cardiology reported varying preference for patient referral (14%, 30%, and 16%, respectively; P=.048), rhythm monitoring (84%, 46%, and 94%, respectively; P<.001), measurement of BNP (8%, 20%, and 2%; P=.003), and use of antiarrhythmics (16%, 4%, and 23%; P=.023). There were few physician differences in reported practices across patient demographics (sex and race), clinical complexity, and alert frequency of the clinical case. CONCLUSIONS In hypothetical cases of patients presenting without clinical symptoms, physicians opted for further diagnostic testing and often to medical intervention based on Apple Watch irregular rhythm notifications. There was also considerable variation across physician specialties, suggesting a need for uniform clinical practice guidelines. Additional study is required before irregular rhythm notifications should be used in clinical settings.
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Lu Y, Keeley EC, Barrette E, Cooper-DeHoff RM, Dhruva SS, Gaffney J, Gamble G, Handke B, Huang C, Krumholz HM, McDonough Rowe CW, Schulz W, Shaw K, Smith M, Woodard J, Young P, Ervin K, Ross JS. Use of Electronic Health Records to Characterize Patients with Uncontrolled Hypertension in Two Large Health System Networks. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.26.23293225. [PMID: 37546792 PMCID: PMC10402222 DOI: 10.1101/2023.07.26.23293225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Background Improving hypertension control is a public health priority. However, uncertainty remains regarding the optimal way to identify patients with uncontrolled hypertension using electronic health records (EHR) data. Methods In this retrospective cohort study, we applied computable definitions to the EHR data to identify patients with controlled and uncontrolled hypertension and to evaluate differences in characteristics, treatment, and clinical outcomes between these patient populations. We included adult patients (≥18 years) with hypertension receiving ambulatory care within Yale-New Haven Health System (YNHHS; a large US health system) and OneFlorida Clinical Research Consortium (OneFlorida; a Clinical Research Network comprised of 16 health systems) between October 2015 and December 2018. We identified patients with controlled and uncontrolled hypertension based on either a single blood pressure (BP) measurement from a randomly selected visit or all BP measurements recorded between hypertension identification and the randomly selected visit). Results Overall, 253,207 and 182,827 adults at YNHHS and OneFlorida were identified as having hypertension. Of these patients, 83.1% at YNHHS and 76.8% at OneFlorida were identified using ICD-10-CM codes, whereas 16.9% and 23.2%, respectively, were identified using elevated BP measurements (≥ 140/90 mmHg). Uncontrolled hypertension was observed among 32.5% and 43.7% of patients at YNHHS and OneFlorida, respectively. Uncontrolled hypertension was disproportionately higher among Black patients when compared with White patients (38.9% versus 31.5% in YNHHS; p<0.001; 49.7% versus 41.2% in OneFlorida; p<0.001). Medication prescription for hypertension management was more common in patients with uncontrolled hypertension when compared with those with controlled hypertension (overall treatment rate: 39.3% versus 37.3% in YNHHS; p=0.04; 42.2% versus 34.8% in OneFlorida; p<0.001). Patients with controlled and uncontrolled hypertension had similar rates of short-term (at 3 and 6 months) and long-term (at 12 and 24 months) clinical outcomes. The two computable definitions generated consistent results. Conclusions Computable definitions can be successfully applied to health system EHR data to conduct population surveillance for hypertension and identify patients with uncontrolled hypertension who may benefit from additional treatment.
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Mooghali M, Ross JS, Kadakia KT, Dhruva SS. Availability of Unique Device Identifiers for Class I Medical Device Recalls From 2018 to 2022. JAMA Intern Med 2023; 183:735-737. [PMID: 37184854 PMCID: PMC10186206 DOI: 10.1001/jamainternmed.2023.0727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/15/2023] [Indexed: 05/16/2023]
Abstract
This cross-sectional study describes the inclusion of unique device identifier in recall notices for moderate- and high-risk medical devices in the US.
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Ngufor C, Yao X, Inselman JW, Ross JS, Dhruva SS, Graham DJ, Lee JY, Siontis KC, Desai NR, Polley E, Shah ND, Noseworthy PA. Identifying treatment heterogeneity in atrial fibrillation using a novel causal machine learning method. Am Heart J 2023; 260:124-140. [PMID: 36893934 PMCID: PMC10615250 DOI: 10.1016/j.ahj.2023.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/02/2023] [Accepted: 02/25/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Lifelong oral anticoagulation is recommended in patients with atrial fibrillation (AF) to prevent stroke. Over the last decade, multiple new oral anticoagulants (OACs) have expanded the number of treatment options for these patients. While population-level effectiveness of OACs has been compared, it is unclear if there is variability in benefit and risk across patient subgroups. METHODS We analyzed claims and medical data for 34,569 patients who initiated a nonvitamin K antagonist oral anticoagulant (non-vitamin K antagonist oral anticoagulant (NOAC); apixaban, dabigatran, and rivaroxaban) or warfarin for nonvalvular AF between 08/01/2010 and 11/29/2017 from the OptumLabs Data Warehouse. A machine learning (ML) method was applied to match different OAC groups on several baseline variables including, age, sex, race, renal function, and CHA2DS2 -VASC score. A causal ML method was then used to discover patient subgroups characterizing the head-to-head treatment effects of the OACs on a primary composite outcome of ischemic stroke, intracranial hemorrhage, and all-cause mortality. RESULTS The mean age, number of females and white race in the entire cohort of 34,569 patients were 71.2 (SD, 10.7) years, 14,916 (43.1%), and 25,051 (72.5%) respectively. During a mean follow-up of 8.3 (SD, 9.0) months, 2,110 (6.1%) of patients experienced the composite outcome, of whom 1,675 (4.8%) died. The causal ML method identified 5 subgroups with variables favoring apixaban over dabigatran; 2 subgroups favoring apixaban over rivaroxaban; 1 subgroup favoring dabigatran over rivaroxaban; and 1 subgroup favoring rivaroxaban over dabigatran in terms of risk reduction of the primary endpoint. No subgroup favored warfarin and most dabigatran vs warfarin users favored neither drug. The variables that most influenced favoring one subgroup over another included Age, history of ischemic stroke, thromboembolism, estimated glomerular filtration rate, Race, and myocardial infarction. CONCLUSIONS Among patients with AF treated with a NOAC or warfarin, a causal ML method identified patient subgroups with differences in outcomes associated with OAC use. The findings suggest that the effects of OACs are heterogeneous across subgroups of AF patients, which could help personalize the choice of OAC. Future prospective studies are needed to better understand the clinical impact of the subgroups with respect to OAC selection.
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Mooghali M, Ross JS, Kadakia KT, Dhruva SS. Characterization of US Food and Drug Administration Class I Recalls from 2018 to 2022 for Moderate- and High-Risk Medical Devices: A Cross-Sectional Study. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2023; 16:111-122. [PMID: 37229515 PMCID: PMC10204764 DOI: 10.2147/mder.s412802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Abstract
Background Medical device recalls are initiated in response to safety concerns. Class I (highest severity) recalls imply a reasonable likelihood of serious adverse events or death associated with device use. Recalled devices must be identified, assessed, and corrected or removed, upon which a recall can be terminated. Objective To characterize Class I medical device recalls and corresponding recalled devices. Methods This was a cross-sectional study of Class I recalls posted on the Food and Drug Administration's annual log from January 1, 2018 to June 30, 2022 for moderate-risk and high-risk medical devices. Devices were categorized by therapeutic use, need for implantation, and life-sustaining designation; recalls were categorized by reason, status, and time elapsed. Results There were 189 unique Class I medical device recalls, including 151 (79.9%) for moderate-risk and 34 (18.0%) for high-risk devices. Sixty-five (34.4%) recalls were for cardiovascular devices, 36 (19.0%) for implanted devices, and 37 (19.6%) for life-sustaining devices. The median number of device units recalled in the US per recall notice was 4620 (interquartile range [IQR], 578-42,591), with 11 (5.8%) recalls associated with more than 1 million device units. Overall, 125 (66.1%) devices had multiple recalls, with a median of 4 (IQR, 3-11) recalls issued per recalled device. As of September 15, 2022, 50 (26.5%) recalls were terminated, with a median of 24 (IQR, 17.3-30.8) months elapsed between recall initiation and termination. Recalls were terminated more commonly among devices recalled once compared to those recalled multiple times (36.2% vs 19.2%; p=0.02) and for recalls that recommended discontinuing further use of affected devices compared to those that recommended device assessment and/or education of affected population (31.8% vs 18.2%; p=0.04). Conclusion High-severity medical device recalls are common and affect millions of device units annually in the US. Recall termination takes a significant amount of time, putting patients at risk for serious safety concerns.
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Kadakia KT, Rathi VK, Ramachandran R, Johnston JL, Ross JS, Dhruva SS. Challenges and solutions to advancing health equity with medical devices. Nat Biotechnol 2023; 41:607-609. [PMID: 37037905 DOI: 10.1038/s41587-023-01746-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
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Essa M, Ross JS, Dhruva SS, Desai NR, Yeh RW, Faridi KF. Trends in Spending and Claims for P2Y12 Inhibitors by Medicare and Medicaid From 2015 to 2020. J Am Heart Assoc 2023; 12:e028869. [PMID: 37042289 PMCID: PMC10227267 DOI: 10.1161/jaha.122.028869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/15/2023] [Indexed: 04/13/2023]
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Caughron H, Dhruva SS. Medical Device Modifications Through Premarket Approval Supplements-Ensuring Patient Safety. JAMA Netw Open 2023; 6:e237704. [PMID: 37043206 DOI: 10.1001/jamanetworkopen.2023.7704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
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Caughron H, Bowman H, Raitt MH, Whooley MA, Tarasovsky G, Shen H, Matheny ME, Selzman KA, Wang L, Major J, Odobasic H, Dhruva SS. Cardiovascular implantable electronic device lead safety: Harnessing real-world remote monitoring data for medical device evaluation. Heart Rhythm 2023; 20:512-519. [PMID: 36586706 DOI: 10.1016/j.hrthm.2022.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Current methods to identify cardiovascular implantable electronic device lead failure include postapproval studies, which may be limited in scope, participant numbers, and attrition; studies relying on administrative codes, which lack specificity; and voluntary adverse event reporting, which cannot determine incidence or attribution to the lead. OBJECTIVE The purpose of this study was to determine whether adjudicated remote monitoring (RM) data can address these limitations and augment lead safety evaluation. METHODS Among 48,191 actively monitored patients with a cardiovascular implantable electronic device, we identified RM transmissions signifying incident lead abnormalities and, separately, identified all leads abandoned or extracted between April 1, 2019, and April 1, 2021. We queried electronic health record and Medicare fee-for-service claims data to determine whether patients had administrative codes for lead failure. We verified lead failure through manual electronic health record review. RESULTS Of the 48,191 patients, 1170 (2.4%) had incident lead abnormalities detected by RM. Of these, 409 patients had administrative codes for lead failure, and 233 of these 409 patients (57.0%) had structural lead failure verified through chart review. Of the 761 patients without administrative codes, 167 (21.9%) had structural lead failure verified through chart review. Thus, 400 patients with RM transmissions suggestive of lead abnormalities (34.2%) had structural lead failure. In addition, 200 patients without preceding abnormal RM transmissions had leads abandoned or extracted for structural failure, making the total lead failure cohort 600 patients (66.7% with RM abnormalities, 33.3% without). Patients with isolated right atrial or left ventricular lead failure were less likely to have lead replacement and administrative codes reflective of lead failure. CONCLUSION RM may strengthen real-world assessment of lead failure, particularly for leads where patients do not undergo replacement.
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Yu Y, Jiang G, Brandt E, Forsyth T, Dhruva SS, Zhang S, Chen J, Noseworthy PA, Doshi AA, Collison-Farr K, Kim D, Ross JS, Coplan PM, Drozda JP. Integrating real-world data to assess cardiac ablation device outcomes in a multicenter study using the OMOP common data model for regulatory decisions: implementation and evaluation. JAMIA Open 2023; 6:ooac108. [PMID: 36632328 PMCID: PMC9831049 DOI: 10.1093/jamiaopen/ooac108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/10/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
The objective of this study is to describe application of the Observational Medical Outcomes Partnership (OMOP) common data model (CDM) to support medical device real-world evaluation in a National Evaluation System for health Technology Coordinating Center (NESTcc) Test-Case involving 2 healthcare systems, Mercy Health and Mayo Clinic. CDM implementation was coordinated across 2 healthcare systems with multiple hospitals to aggregate both medical device data from supply chain databases and patient outcomes and covariates from electronic health record data. Several data quality assurance (QA) analyses were implemented on the OMOP CDM to validate the data extraction, transformation, and load (ETL) process. OMOP CDM-based data of relevant patient encounters were successfully established to support studies for FDA regulatory submissions. QA analyses verified that the data transformation was robust between data sources and OMOP CDM. Our efforts provided useful insights in real-world data integration using OMOP CDM for medical device evaluation coordinated across multiple healthcare systems.
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Warren RE, Dhruva SS, Kinard M, Neuhaus JM, Redberg RF. Trends in FDA Adverse Events Reporting for Inferior Vena Cava Filters and Estimated Insertions in the US, 2016 to 2020. JAMA Intern Med 2023; 183:271-272. [PMID: 36689213 PMCID: PMC9871941 DOI: 10.1001/jamainternmed.2022.6161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/10/2022] [Indexed: 01/24/2023]
Abstract
This quality improvement study identifies adverse events for inferior vena cava filters and reports changes in adverse event reporting and estimated insertions between 2016 and 2020 in the US.
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Oesterle A, Liem LB, Dhruva SS, Friday G, Raitt MH, Pellegrini CN. Traumatic Syncope Caused by Prolonged Ventricular Arrhythmias With a Defibrillator Programmed to 2019 Consensus Recommendations. JACC Clin Electrophysiol 2023; 9:442-443. [PMID: 36702697 DOI: 10.1016/j.jacep.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/02/2022] [Accepted: 11/09/2022] [Indexed: 01/20/2023]
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Kadakia KT, Dhruva SS, Ross JS, Krumholz HM. Adding device identifiers to claims forms-a key step to advance medical device safety. BMJ 2023; 380:82. [PMID: 36631149 DOI: 10.1136/bmj.p82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Kadakia KT, Dhruva SS, Caraballo C, Ross JS, Krumholz HM. Use of Recalled Devices in New Device Authorizations Under the US Food and Drug Administration's 510(k) Pathway and Risk of Subsequent Recalls. JAMA 2023; 329:136-143. [PMID: 36625810 PMCID: PMC9857464 DOI: 10.1001/jama.2022.23279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE In the US, nearly all medical devices progress to market under the 510(k) pathway, which uses previously authorized devices (predicates) to support new authorizations. Current regulations permit manufacturers to use devices subject to a Class I recall-the FDA's most serious designation indicating a high probability of adverse health consequences or death-as predicates for new devices. The consequences for patient safety are not known. OBJECTIVE To determine the risk of a future Class I recall associated with using a recalled device as a predicate device in the 510(k) pathway. DESIGN AND SETTING In this cross-sectional study, all 510(k) devices subject to Class I recalls from January 2017 through December 2021 (index devices) were identified from the FDA's annual recall listings. Information about predicate devices was extracted from the Devices@FDA database. Devices authorized using index devices as predicates (descendants) were identified using a regulatory intelligence platform. A matched cohort of predicates was constructed to assess the future recall risk from using a predicate device with a Class I recall. MAIN OUTCOMES AND MEASURES Devices were characterized by their regulatory history and recall history. Risk ratios (RRs) were calculated to compare the risk of future Class I recalls between devices descended from predicates with matched controls. RESULTS Of 156 index devices subject to Class I recall from 2017 through 2021, 44 (28.2%) had prior Class I recalls. Predicates were identified for 127 index devices, with 56 (44.1%) using predicates with a Class I recall. One hundred four index devices were also used as predicates to support the authorization of 265 descendant devices, with 50 index devices (48.1%) authorizing a descendant with a Class I recall. Compared with matched controls, devices authorized using predicates with Class I recalls had a higher risk of subsequent Class I recall (6.40 [95% CI, 3.59-11.40]; P<.001). CONCLUSIONS AND RELEVANCE Many 510(k) devices subjected to Class I recalls in the US use predicates with a known history of Class I recalls. These devices have substantially higher risk of a subsequent Class I recall. Safeguards for the 510(k) pathway are needed to prevent problematic predicate selection and ensure patient safety.
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Dhruva SS, Murillo J, Ameli O, Morin PE, Spencer DL, Redberg RF, Cohen K. Long-term Outcomes in Use of Opioids, Nonpharmacologic Pain Interventions, and Total Costs of Spinal Cord Stimulators Compared With Conventional Medical Therapy for Chronic Pain. JAMA Neurol 2023; 80:18-29. [PMID: 36441532 PMCID: PMC9706399 DOI: 10.1001/jamaneurol.2022.4166] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022]
Abstract
Importance Spinal cord stimulators (SCSs) are increasingly used for the treatment of chronic pain. There is a need for studies with long-term follow-up. Objective To determine the comparative effectiveness and costs of SCSs compared with conventional medical management (CMM) in a large cohort of patients with chronic pain. Design, Setting, and Participants This was a 1:5 propensity-matched retrospective comparative effectiveness research analysis of insured individuals from April 1, 2016, to August 31, 2018. This study used administrative claims data, including longitudinal medical and pharmacy claims, from US commercial and Medicare Advantage enrollees 18 years or older in Optum Labs Data Warehouse. Patients with incident diagnosis codes for failed back surgery syndrome, complex regional pain syndrome, chronic pain syndrome, and other chronic postsurgical back and extremity pain were included in this study. Data were analyzed from February 1, 2021, to August 31, 2022. Exposures SCSs or CMM. Main Outcomes and Measures Surrogate measures for primary chronic pain treatment modalities, including pharmacologic and nonpharmacologic pain interventions (epidural and facet corticosteroid injections, radiofrequency ablation, and spine surgery), as well as total costs. Results In the propensity-matched population of 7560 patients, mean (SD) age was 63.5 (12.5) years, 3080 (40.7%) were male, and 4480 (59.3%) were female. Among matched patients, during the first 12 months, patients treated with SCSs had higher odds of chronic opioid use (adjusted odds ratio [aOR], 1.14; 95% CI, 1.01-1.29) compared with patients treated with CMM but lower odds of epidural and facet corticosteroid injections (aOR, 0.44; 95% CI, 0.39-0.51), radiofrequency ablation (aOR, 0.57; 95% CI, 0.44-0.72), and spine surgery (aOR, 0.72; 95% CI, 0.61-0.85). During months 13 to 24, there was no significant difference in chronic opioid use (aOR, 1.06; 95% CI, 0.94-1.20), epidural and facet corticosteroid injections (aOR, 1.00; 95% CI, 0.87-1.14), radiofrequency ablation (aOR, 0.84; 95% CI, 0.66-1.09), or spine surgery (aOR, 0.91; 95% CI, 0.75-1.09) with SCS use compared with CMM. Overall, 226 of 1260 patients (17.9%) treated with SCS experienced SCS-related complications within 2 years, and 279 of 1260 patients (22.1%) had device revisions and/or removals, which were not always for complications. Total costs of care in the first year were $39 000 higher with SCS than CMM and similar between SCS and CMM in the second year. Conclusions and Relevance In this large, real-world, comparative effectiveness research study comparing SCS and CMM for chronic pain, SCS placement was not associated with a reduction in opioid use or nonpharmacologic pain interventions at 2 years. SCS was associated with higher costs, and SCS-related complications were common.
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Dhruva SS, Ridgeway JL, Ross JS, Drozda, JP, Wilson NA. Exploring unique device identifier implementation and use for real-world evidence: a mixed-methods study with NESTcc health system network collaborators. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2023; 5:e000167. [PMID: 36704544 PMCID: PMC9872505 DOI: 10.1136/bmjsit-2022-000167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 12/29/2022] [Indexed: 01/25/2023] Open
Abstract
Objectives To examine the current state of unique device identifier (UDI) implementation, including barriers and facilitators, among eight health systems participating in a research network committed to real-world evidence (RWE) generation for medical devices. Design Mixed methods, including a structured survey and semistructured interviews. Setting Eight health systems participating in the National Evaluation System for health Technology research network within the USA. Participants Individuals identified as being involved in or knowledgeable about UDI implementation or medical device identification from supply chain, information technology and high-volume procedural area(s) in their health system. Main outcomes measures Interview topics were related to UDI implementation, including barriers and facilitators; UDI use; benefits of UDI adoption; and vision for UDI implementation. Data were analysed using directed content analysis, drawing on prior conceptual models of UDI implementation and the Exploration, Preparation, Implementation, Sustainment framework. A brief survey of health system characteristics and scope of UDI implementation was also conducted. Results Thirty-five individuals completed interviews. Three of eight health systems reported having implemented UDI. Themes identified about barriers and facilitators to UDI implementation included knowledge of the UDI and its benefits among decision-makers; organisational systems, culture and networks that support technology and workflow changes; and external factors such as policy mandates and technology. A final theme focused on the availability of UDIs for RWE; lack of availability significantly hindered RWE studies on medical devices. Conclusions UDI adoption within health systems requires knowledge of and impetus to achieve operational and clinical benefits. These are necessary to support UDI availability for medical device safety and effectiveness studies and RWE generation.
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Mori M, Dhruva SS, Geirsson A, Krumholz HM. Characterization of multi-domain postoperative recovery trajectories after cardiac surgery using a digital platform. NPJ Digit Med 2022; 5:192. [PMID: 36564550 PMCID: PMC9789027 DOI: 10.1038/s41746-022-00736-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/29/2022] [Indexed: 12/25/2022] Open
Abstract
Understanding postoperative recovery is critical for guiding efforts to improve post-acute phase care. How recovery evolves during the first 30 days after cardiac surgery is not well-understood. A digital platform may enable granular quantification of recovery by frequently capturing patient-reported outcome measures (PROM) that can be clinically implemented to support recovery. We conduct a prospective cohort study using a digital platform to measure recovery after cardiac surgery using a PROM sent every 3 days for 30 days after surgery to characterize recovery in multiple domains (e.g., pain, sleep, activities of daily living, anxiety) and to identify factors related to the patient's perception of overall recovery. We enroll patients who underwent cardiac surgery at a tertiary center between January 2019 and March 2020 and automatically deliver PROMs and reminders electronically. Of the 10 surveys delivered per patient, 8 (IQR 6-10) are completed. Patients who experienced postoperative complications more commonly belong to the worst overall recovery trajectory. Of the 12 domains modeled, only the worst anxiety trajectory is associated with the worse overall recovery trajectory membership, suggesting that even when patients struggle in the recovery of other domains, the patient may still feel progress in their recovery. We demonstrate that using a digital platform, automated PROM data collection, and characterization of multi-domain recovery trajectories is feasible and likely implementable in clinical practice. Overall recovery may be impacted by complications, while slow progress in constituent domains may still allow for the perception of overall recovery progression.
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