Leveraging telemedicine for management of veterans with heart failure during COVID-19

BACKGROUND

Telemedicine and telemonitoring have become invaluable tools in managing chronic diseases, such as heart failure (HF). With the recent pandemic, telemedicine has become the preferred method of providing consultative care.

LOCAL PROBLEM

This rapid paradigm shift from face-to-face (F2F) consultations to telemedicine required a collaborative approach for successful implementation while maintaining quality of care. The processes for conducting a telemedicine visit for HF patient are not well defined or outlined.

METHOD

Using a collaborative practice model and nurse practitioner led program, technology was leveraged to manage the high-risk HF population using virtual care (consultation via phone or video-to-home) with two aims: first to provide ongoing HF care using available telemedicine technologies or F2F care when necessary and, second, to evaluate and direct those needing urgent/emergent level of care to emergency department (ED).

INTERVENTION

The process was converted into an intuitive algorithm that describes essential elements and team roles necessary for execution of a successful HF consultation.

RESULTS

Following the algorithm, nurse practitioners conducted 132 visits, yielding 100% success in the conversion of F2F appointments to telemedicine, with 3 patients referred to ED for care. The information obtained through telemedicine consultation accurately informed decision for ED evaluation with resultant admission.

CONCLUSION

Collaborative team-based approach delineated in the algorithm facilitated successful virtual consultations for HF patients and accurately informed decisions for higher level of care.

National surveillance of stroke quality of care and outcomes by applying post-stratification survey weights on the Get With The Guidelines-Stroke patient registry

Background

The U.S. lacks a stroke surveillance system. This study develops a method to transform an existing registry into a nationally representative database to evaluate acute ischemic stroke care quality.

Methods

Two statistical approaches are used to develop post-stratification weights for the Get With The Guidelines-Stroke registry by anchoring population estimates to the National Inpatient Sample. Post-stratification survey weights are estimated using a raking procedure and Bayesian interpolation methods. Weighting methods are adjusted to limit the dispersion of weights and make reasonable epidemiologic estimates of patient characteristics, quality of hospital care, and clinical outcomes. Standardized differences in national estimates are reported between the two post-stratification methods for anchored and non-anchored patient characteristics to evaluate estimation quality. Primary measures evaluated are patient and hospital characteristics, stroke severity, vital and laboratory measures, disposition, and clinical outcomes at discharge.

Results

A total of 1,388,296 acute ischemic strokes occurred between 2012 and 2014. Raking and Bayesian estimates of clinical data not available in administrative data are estimated within 5 to 10% of margin for expected values. Median weight for the raking method is 1.386 and the weights at the 99th percentile is 6.881 with a maximum weight of 30.775. Median Bayesian weight is 1.329 and the 99th percentile weights is 11.201 with a maximum weight of 515.689.

Conclusions

Leveraging existing databases with patient registries to develop post-stratification weights is a reliable approach to estimate acute ischemic stroke epidemiology and monitoring for stroke quality of care nationally. These methods may be applied to other diseases or settings to better monitor population health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01214-z.

Analysis of Adverse Events Related to Impella Usage (from the Manufacturer and User Facility Device Experience and National Inpatient Sample Databases)

Impella devices are increasingly utilized for hemodynamic support in high-risk percutaneous coronary intervention or cardiogenic shock despite a lack of randomized clinical trial data showing clinical benefit and newer observational data suggesting harm. In this retrospective analysis, our aim was to determine the most common adverse events associated with Impella usage reported annually to the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database and to estimate via the National Inpatient Sample (NIS) database the number of percutaneous ventricular assist devices utilized and associated with inpatient mortality since introduction of the Impella. Among the 885 complete reports submitted to the MAUDE database from 2008 to 2019 related to Impella usage, there were 1,206 complications coded; 88.2% of reports occurred from 2016 to 2019. Among patients with adverse events reported, bleeding (32.8%), device deployment or retrieval issues (18.2%), vascular complications (15.8%), and death (12.4%) were the most common, and 7.9% of all complications were attributable to operator decision-making or technique. From 2007 to 2017 there was a >100-fold increase in percutaneous ventricular assist devices use with an increase and plateau in in-hospital mortality to 31% from 2012 to 2016 based on NIS data. In conclusion, Impella use has increased substantially over the last decade but remains associated with high inpatient mortality and serious complications based on data from the NIS and MAUDE databases. These findings emphasize the need for high quality randomized controlled trials to determine the clinical utility of Impella in high-risk percutaneous coronary intervention and cardiogenic shock.

Intraaortic Balloon Pump vs Peripheral Ventricular Assist Device Use in the United States

BACKGROUND

The objective of this study was to characterize practical use trends and outcomes for intraaortic balloon pump (IABP) and percutaneous left ventricular assist device (pVAD) use in cardiogenic shock at a national level.

METHODS

An analysis of all adult patients admitted nonelectively for cardiogenic shock from January 2008 through December 2017 was performed using the National Inpatient Sample. Trends of inpatient IABP and pVAD use were analyzed using survey-weighted estimates and the modified Cochran-Armitage test for significance. Multivariable regression models and inverse probability of treatment weights were used to perform risk-adjusted analyses of pVAD mortality, a composite of adverse events (AE), and resource use, with IABP as reference.

RESULTS

Of an estimated 774,310 patients admitted with cardiogenic shock, 143,051 received a device: IABP, 127,792 (16.5%); or pVAD, 15,259 (2.0%). IABP use decreased (23.8% to 12.7%; P for trend <.001), whereas pVAD implantation increased significantly during the study period (0.2% to 4.5%; P for trend <.001). Inverse probability of treatment weights demonstrated significantly higher odds of mortality with pVAD (odds ratio, 1.9; 95% confidence interval, 1.7 to 2.2), but not AE (odds ratio, 1.1; 95% confidence interval, 0.96 to 1.27), compared with IABP. After risk adjustment, pVAD use was associated with an additional $15,202 (P < .001) in cost for survivors and $29,643 for nonsurvivors (P < .001).

CONCLUSIONS

Over the study period, the rate of pVAD use for cardiogenic shock significantly increased. Compared with IABP, pVAD use was associated with increased mortality, higher costs, and several AEs. Multi-institutional clinical trials with rigorous inclusion criteria are warranted to evaluate the clinical utility of pVADs in the modern era.

Cardiovascular Disease in Hospitalized Patients With a Diagnosis of Coronavirus From the Pre-COVID-19 Era in United States: National Analysis From 2016-2017

OBJECTIVE

To analyze the cardiovascular disease (CVD) burden in hospitalized patients with a diagnosis of coronavirus from the pre-coronavirus disease 2019 era in the United States.

PATIENTS AND METHODS

We identified hospitalized adults with a diagnosis of coronavirus in a large US administrative database, the National (Nationwide) Inpatient Sample, from January 1, 2016, to December 3, 2017, to study patient demographic characteristics, clinical comorbidities, and outcomes (in-hospital mortality and health care resource utilization) based on the presence or absence of CVD.

RESULTS

A total of 21,300 hospitalized adults with a diagnosis of coronavirus in 2016 and 2017 from all across the United States were included in the final analysis; the mean age was 63.6 years, 11,033 (51.8%) were female, and 15,911 (74.7%) had public insurers. Among these hospitalized patients, 11,930 (56.0%) had a diagnosis of CVD. Compared with those without CVD, the patients with CVD were older (70.1 vs 55.4 years) and had higher Charlson comorbidity index scores (2.5 vs 1.6) and Elixhauser comorbidity index scores (4.3 vs 2.4) (all P<.001). After multivariable risk adjustment, patients with CVD had higher mortality than those without CVD (5.3% [632 of 11,930] vs 1.5% [140 of 9370]; adjusted odds ratio, 2.0 [95% CI, 1.2 to 3.4]; P=.008). The mean length of hospital stay (6.9 vs 6.1 days; P=.003), hospital charges ($78,377 vs $66,538; P=.002), and discharge to nursing home (24.6% [2945 of 11,930] vs 12.9% [1208 of 9370]; P<.001) were higher in those with CVD compared with the patients without CVD.

CONCLUSION

Cardiovascular disease was present in a notable proportion of hospitalized patients with coronavirus in the pre-coronavirus disease 2019 era in United States and was associated with higher risk of in-hospital mortality and health care resource utilization.

Prognostic implications of pre-existing medical comorbidity in Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is associated with significant short-term morbidity and mortality. Several risk factors for poor outcomes have been identified; however, the prognostic implications of pre-existing comorbidity in TC are poorly delineated. We sought to assess the association of aggregate pre-existing comorbidity with short-term outcomes in TC. We performed a retrospective observational study of adult subjects diagnosed with TC at two academic tertiary care hospitals between 2005 and 2018. Overall burden of medical comorbidity was estimated using the Charlson comorbidity index (CCI). Multivariable logistic regression was used to test for independent association of CCI with 30-day mortality and severe shock at index presentation. Multivariable poisson regression was performed to assess the association of CCI with duration of hospitalization. Five-hundred and thirty-eight subjects were diagnosed with TC during the study period. The median CCI score of all subjects was 2 (IQR 1-4). Among subjects with physical triggers of TC, the median CCI score was 2 (IQR 1-4) compared to a median CCI score of 1 (IQR 0-1) in subjects with non-physical triggers of TC (P < 0.001). Seventy-six (14%) subjects died within 30 days of index diagnosis and 185 (34%) subjects experienced severe shock. The median duration of hospitalization was 7 days (IQR 3-14 days). In multivariable logistic regression, CCI was not associated with 30-day mortality or severe shock. In multivariable Poisson regression, CCI (IRR 1.17, 95% CI 1.16-1.18, P < 0.001) was associated with duration of hospitalization. Increased burden of pre-existing medical comorbidity was not independently associated with 30-day mortality or severe shock at index presentation, but was associated with increased duration of hospitalization after diagnosis of TC.

Relationship of neighborhood social determinants of health on racial/ethnic mortality disparities in US veterans-Mediation and moderating effects

OBJECTIVE

To examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation.

DATA SOURCES

Electronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census.

STUDY DESIGN

Racial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions.

PRINCIPAL FINDINGS

Mortality disparities existed for AI/ANs (HR = 1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (P = .047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations.

CONCLUSIONS

Neighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention.

Association of Optimal Implementation of Sodium-Glucose Cotransporter 2 Inhibitor Therapy With Outcome for Patients With Heart Failure

Importance

Sodium-glucose cotransporter 2 inhibitor (SGLT2-i) therapy provided incremental survival benefit to patients with heart failure and reduced ejection fraction (HFrEF) who received guideline-directed medical therapy regardless of type 2 diabetes status in a recent clinical trial. To date, estimation of the potential benefits that could be gained from optimal implementation of SGLT2-i therapy at the population level has not been quantified.

Objective

To quantify the projected gains for deaths prevented or postponed with comprehensive implementation of SGLT2-i therapy for patients with HFrEF in the United States.

Design, Setting, and Participants

This decision analytical model, performed from September 25 to October 20, 2019, used published sources to estimate the US population of patients with HFrEF eligible for SGLT2-i therapy and the numbers needed to treat to prevent or postpone overt death. Sensitivity analyses were performed to account for the range of potential benefits.

Main Outcomes and Measures

All-cause mortality.

Results

Of the 3.1 million patients with HFrEF in the United States, 2 132 800 (69%) were projected to be candidates for SGLT2-i therapy. Optimal implementation of SGLT2-i therapy was empirically estimated to prevent up to 34 125 deaths per year (range 21 840-49 140 deaths per year). A secondary analysis excluding patients on the basis of N-terminal-pro brain natriuretic peptide levels and other trial entry criteria would yield a potential benefit of 25 594 deaths per year prevented (range, 16 380-36 855 deaths per year prevented).

Conclusions and Relevance

This study suggests that a substantial number of deaths in the United States could be prevented by optimal implementation of SGLT2-i therapy. These data support implementation of the current evidence into practice in a timely manner to achieve important public health benefits and to reduce the mortality burden of HFrEF.

Abstract 12: National Surveillance of Stroke Quality of Care and Outcomes Using Post-stratification Survey Weights on the Get With the Guidelines-stroke Patient Registry

Background: The U.S. lacks an appropriate stroke surveillance system. This study developed and validated post-stratification weights for an existing stroke patient registry to represent the entire U.S. population across the nine U.S. Census divisions.

Methods: Two statistical approaches were used to develop post-stratification weights for the Get With The Guidelines-Stroke registry by anchoring population estimates to the National Inpatient Sample to model the burden of acute ischemic stroke. Post-stratification survey weights were estimated using a raking procedure and Bayesian interpolation methods. Both strategies for developing weights were compared. Weighting methods were adjusted to limit dispersion of weights and make reasonable national estimates of patient characteristics, quality of hospital care, and clinical outcomes. Standardized differences in national population estimates were reported between the two post-stratification methods. Color treemaps were used to visualize the distribution of post-stratification weights across relevant sub-populations. Primary measures evaluated were patient and hospital characteristics, stroke severity, vital and laboratory measures, disposition, and clinical outcomes at discharge.

Results: There were a total of 1,388,296 acute ischemic strokes between 2012 and 2014. Raking and Bayesian estimates of clinical data not recorded in administrative databases were estimated within 5 to 10% of the margins of reference values. Median weights for the raking method were 1.366 and the weights at the 99 th percentile were 6.881 with a maximum weight of 30.775. Median Bayesian weights were 1.329 and the 99 th percentile weights were 11.201 with a maximum weight of 515.689.

Conclusions: Leveraging existing databases with patient registries to develop post-stratification weights is a reliable approach to estimate acute ischemic stroke epidemiology and monitoring for stroke quality of care nationally. Post-stratification weighting may be used as a basis for more advanced modeling relevant to understanding the burden of acute ischemic stroke and the quality of care delivered in U.S. hospitals. These methods may be applied to other diseases or settings to better monitor population health.

Heart Failure With Mid-range Ejection Fraction

PURPOSE OF REVIEW

To describe the epidemiology, pathophysiology, management, and prognosis of patients with heart failure with mid-range ejection fraction (HFmrEF).

RECENT FINDINGS

In 2013, The American Heart Association (AHA)/American College of Cardiology (ACC) assigned an ejection fraction (EF) range to heart failure with reduced ejection fraction (HFrEF, EF ≤ 40%) and heart failure with preserved ejection fraction (HFpEF, EF ≥50%). This classification created a "gray zone" of patients with EFs between 41% and 49% that ultimately came to be known as heart failure with borderline or mid-range ejection fraction. HFmrEF patients represent a group with heterogeneous clinical characteristics that at times resembles HFrEF, at others HFpEF, and at others still a unique phenotype altogether. No randomized controlled trials exist in those with HFmrEF, though HFrEF and HFpEF studies that include overlap suggest some potential benefit of beta blockers, angiotensin receptor blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors. Mortality rates among the HFmrEF population are significant, and are similar to those in patients with HFrEF and HFpEF. HFmrEF is a complex disorder that remains poorly understood. Future research is needed to better elucidate the pathophysiology, management, and prognosis of this condition.

Association of Hospital Racial Composition and Payer Mix With Mortality in Acute Coronary Syndrome

Background Patient characteristics insufficiently explain disparities in cardiovascular outcomes among hospitalized patients, suggesting a role for community or hospital-level factors. Here, we evaluate the association of hospital racial composition and payer mix with all-cause inpatient mortality for patients hospitalized with acute coronary syndrome (ACS). Methods and Results Using the National Inpatient Sample, we identified adult hospitalizations from 2014 with a primary diagnosis of ACS (n=550 005). We divided National Inpatient Sample hospitals into quartiles based on percent of minority (black, Hispanic, Asian or Pacific Islander, Native American race/ethnicity) and low-income payer (Medicaid or uninsured) discharges in 2014. We utilized logistic regression to determine whether hospital minority or low-income payer makeup associated with all-cause inpatient mortality among those admitted for ACS . In adjusted models, ACS patients admitted to hospitals with >12.4% to 25.4% (Quartile 2), >25.4% to 44.3% (Q3), and >44.3% (Q4) minority discharges experienced a 14% (OR 1.14, 95% CI 1.06-1.23), 13% (OR 1.13, 95% CI 1.04-1.23), and 15% (OR 1.15, 95% CI 1.04-1.26) increased odds of all-cause inpatient mortality compared with hospitals with ≤12.4% (Q1) minority discharges. ACS patients admitted to hospitals with >18.7% to 25.7% (Q2) and >34.0% (Q4) low-income payer discharges experienced a 9% (OR 1.09, 1.01-1.17) and 9% (OR 1.09, 1.00-1.19) increased odds of all-cause inpatient mortality when compared with hospitals with ≤18.7% (Q1) low-income payer discharges. Conclusions Hospital minority and low-income payer makeup positively associate with odds of all-cause inpatient mortality among patients admitted for acute coronary syndrome.

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life.

2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions.

3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. The presence or absence of additional risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning.

4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, processed meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss.

5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.

6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist.

7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit.

8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit.

9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.

10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.

Impact of hospital safety-net status on failure to rescue after major cardiac surgery

BACKGROUND

Hospitals with safety-net status have been associated with inferior surgical outcomes and higher costs. The mechanism of this discrepancy, however, is not well understood. We hypothesized that discrepant rates of failure to rescue after complications of routine cardiac surgery would explain the observed inferior outcomes at safety-net hospitals.

METHODS

The National Inpatient Sample was used to identify adult patients who underwent elective coronary artery bypass grafting and isolated or concomitant valve operations between January 2005 and December 2016. Hospitals were stratified into low-, medium-, or high-burden categories based on the proportion of uninsured or Medicaid patients to emulate safety-net status as defined by the Institute of Medicine. Failure to rescue was defined as mortality after occurrence of neurologic, cardiovascular, respiratory, renal, or infectious complications (major and minor complications). Multivariable regression was used to perform risk-adjusted comparisons of the rate of complications, failures to rescue, and resource use for high-burden hospitals versus low-burden and medium-burden hospitals.

RESULTS

Of an estimated 2,012,104 patients undergoing elective major cardiac operations, 2% died, whereas 36% suffered major and minor complications. Safety-net hospitals had higher odds of failure to rescue after major comorbidity (adjusted odds ratio 1.12, 95% confidence interval 1.01-1.23). Occurrence of major and minor complications at safety-net hospitals was associated with increased costs ($2,480 [95% confidence interval $1,178-$3,935]) compared with low-burden hospitals.

CONCLUSION

Safety-net hospitals were associated with higher rates of failure to rescue after occurrence of tamponade, septicemia, and respiratory complications. Implementation of care bundles to tackle cardiovascular, respiratory, and renal complications may affect the discrepancy in incidence of and rescue from complications at safety-net institutions.