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Hoagland A, Kipping S. Challenges in Promoting Health Equity and Reducing Disparities in Access Across New and Established Technologies. Can J Cardiol 2024; 40:1154-1167. [PMID: 38417572 DOI: 10.1016/j.cjca.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/01/2024] Open
Abstract
Medical innovations and novel technologies stand to improve the return on high levels of health spending in developed countries, particularly in cardiovascular care. However, cardiac innovations also disrupt the landscape of accessing care, potentially creating disparities in who has access to novel and extant technologies. These disparities might disproportionately harm vulnerable groups, including those whose nonmedical conditions-including social determinants of health-inhibit timely access to diagnoses, referrals, and interventions. We first document the barriers to access novel and existing technologies in isolation, then proceed to document their interaction. Novel cardiac technologies might affect existing available services, and change the landscape of care for vulnerable patient groups who seek access to cardiology services. There is a clear need to identify and heed lessons learned from the dissemination of past innovations in the development, funding, and dissemination of future medical technologies to promote equitable access to cardiovascular care. We conclude by highlighting and synthesizing several policy implications from recent literature.
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Affiliation(s)
- Alex Hoagland
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario Shores Centre for Mental Health Sciences, Toronto, Ontario, Canada.
| | - Sarah Kipping
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario Shores Centre for Mental Health Sciences, Toronto, Ontario, Canada
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2
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Fadous M, Tanguturi VK, Strom JB. The Value of Stress Testing in Ontario: Province or Providence? J Am Soc Echocardiogr 2024; 37:300-302. [PMID: 37972788 DOI: 10.1016/j.echo.2023.11.005] [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] [Received: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Maria Fadous
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Varsha K Tanguturi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jordan B Strom
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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Quinn AE, Chew DS, Faris P, Au F, James MT, Tonelli M, Manns BJ. Physician Variation and the Impact of Payment Model in Cardiac Imaging. J Am Heart Assoc 2023; 12:e029149. [PMID: 38084753 PMCID: PMC10863764 DOI: 10.1161/jaha.122.029149] [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: 01/09/2023] [Accepted: 10/30/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND The influence of fee-for-service reimbursement on cardiac imaging has not been compared with other payment models. Furthermore, variation in ordering practices is not well understood. METHODS AND RESULTS This retrospective, population-based cohort study using linked administrative data from Alberta, Canada included adults with chronic heart disease (atrial fibrillation, coronary artery disease, and heart failure) seen by cardiac specialists for a new outpatient consultation April 2012 to December 2018. Generalized linear mixed-effects models estimated the association of payment model (including the ability to bill to interpret imaging tests) and the use of cardiac imaging and quantified variation in cardiac imaging. Among 31 685 adults seen by 308 physicians at 136 sites, patients received an observed mean of 0.67 (95% CI, 0.67-0.68) imaging tests per consultation. After adjustment, patients seeing fee-for-service physicians had 2.07 (95% CI, 1.68-2.54) and fee-for-service physicians with ability to interpret had 2.87 (95% CI, 2.16-3.81) times the rate of receiving a test than those seeing salaried physicians. Measured patient, physician, and site effects accounted for 31% of imaging variation and, following adjustment, reduced unexplained site-level variation 40% and physician-level variation 29%. CONCLUSIONS We identified substantial variation in the use of outpatient cardiac imaging related to physician and site factors. Physician payment models have a significant association with imaging use. Our results raise concern that payment models may influence cardiac imaging practice. Similar methods could be applied to identify the source and magnitude of variation in other health care processes and outcomes.
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Affiliation(s)
- Amity E. Quinn
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Derek S. Chew
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Libin Cardiovascular Institute, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Peter Faris
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Data and Analytics, Alberta Health ServicesAlbertaCanada
| | - Flora Au
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Matthew T. James
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Braden J. Manns
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Libin Cardiovascular Institute, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
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4
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Bobrowski D, Dorovenis A, Abdel-Qadir H, McNaughton CD, Alonzo R, Fang J, Austin PC, Udell JA, Jackevicius CA, Alter DA, Atzema CL, Bhatia RS, Booth GL, Ha ACT, Johnston S, Dhalla I, Kapral MK, Krumholz HM, Roifman I, Wijeysundera HC, Ko DT, Tu K, Ross HJ, Schull MJ, Lee DS. Association of neighbourhood-level material deprivation with adverse outcomes and processes of care among patients with heart failure in a single-payer healthcare system: A population-based cohort study. Eur J Heart Fail 2023; 25:2274-2286. [PMID: 37953731 DOI: 10.1002/ejhf.3090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/10/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023] Open
Abstract
AIM We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system. METHODS AND RESULTS In a population-based retrospective study (2007-2019), we examined the association of material deprivation with 1-year all-cause mortality, cause-specific hospitalization, and 90-day processes of care. Using cause-specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age ≤65 or ≥66 years. Among 395 763 patients (median age 76 [interquartile range 66-84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p ≤ 0.001). Younger residents (age ≤65 years) of the most versus least deprived neighbourhoods had higher hazards of all-cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10-1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19-1.39]). Older individuals (≥66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08-1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09-1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter-defibrillator/cardiac resynchronization therapy-pacemaker implantation (p = 0.023), compared to the least deprived. CONCLUSION Patients with newly-diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived.
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Affiliation(s)
- David Bobrowski
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Husam Abdel-Qadir
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Candace D McNaughton
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rea Alonzo
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Jiming Fang
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Peter C Austin
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jacob A Udell
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Cynthia A Jackevicius
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Western University of Health Sciences, Pomona, CA, USA
| | - David A Alter
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Clare L Atzema
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - R Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Gillian L Booth
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
| | - Andrew C T Ha
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Sharon Johnston
- Departments of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- Institut du Savoir, Hôpital Montfort, Ottawa, ON, Canada
| | - Irfan Dhalla
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
| | - Moira K Kapral
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Idan Roifman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Harindra C Wijeysundera
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Dennis T Ko
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Karen Tu
- University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- North York General Hospital, Toronto, ON, Canada
| | - Heather J Ross
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Michael J Schull
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Douglas S Lee
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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5
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Gulati A, Gulati V, Hu R, Rajiah PS, Stojanovska J, Febbo J, Litt HI, Pavri B, Sundaram B. Mitral Annular Disjunction: Review of an Increasingly Recognized Mitral Valve Entity. Radiol Cardiothorac Imaging 2023; 5:e230131. [PMID: 38166341 PMCID: PMC11163248 DOI: 10.1148/ryct.230131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/22/2023] [Accepted: 10/30/2023] [Indexed: 01/04/2024]
Abstract
Mitral annular disjunction (MAD) refers to atrial displacement of the hinge point of the mitral valve annulus from the ventricular myocardium. MAD leads to paradoxical expansion of the annulus in systole and may often be associated with mitral valve prolapse (MVP), leaflet degeneration, myocardial and papillary muscle fibrosis, and, potentially, malignant cardiac arrhythmias. Patients with MAD and MVP may present similarly, and MAD is potentially the missing link in explaining why some patients with MVP experience adverse outcomes. Patients with a 5 mm or longer MAD distance have an elevated risk of malignant cardiac arrhythmia compared with those with a shorter MAD distance. Evaluation for MAD is an important component of cardiac imaging, especially in patients with MVP and unexplained cardiac arrhythmias. Cardiac MRI is an important diagnostic tool that aids in recognizing and quantifying MAD, MVP, and fibrosis in the papillary muscle and myocardium, which may predict and help improve outcomes following electrophysiology procedures and mitral valve surgery. This article reviews the history, pathophysiology, controversy, prevalence, clinical implications, and imaging considerations of MAD, focusing on cardiac MRI. Keywords: MR-Dynamic Contrast Enhanced, Cardiac, Mitral Valve, Mitral Annular Disjunction, Mitral Valve Prolapse, Floppy Mitral Valve, Cardiac MRI, Arrhythmia, Sudden Cardiac Death, Barlow Valve © RSNA, 2023.
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Affiliation(s)
- Aishwarya Gulati
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Vaibhav Gulati
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Ray Hu
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Prabhakar Shantha Rajiah
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Jadranka Stojanovska
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Jennifer Febbo
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Harold I. Litt
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Behzad Pavri
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Baskaran Sundaram
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
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6
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Meucci MC, Delgado V. Artificial Intelligence to Speed Up Training in Echocardiography: The Next Frontier. Circ Cardiovasc Imaging 2023; 16:e016148. [PMID: 37955173 DOI: 10.1161/circimaging.123.016148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Affiliation(s)
- Maria Chiara Meucci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (M.C.M.)
| | - Victoria Delgado
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain (V.D.)
- Center of Comparative Medicine and Bioimaging (CMCIB), Research Institute Germans Trias i Pujol, Badalona, Spain (V.D.)
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7
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Moghaddam N, Lindsay MP, Hawkins NM, Anderson K, Ducharme A, Lee DS, McKelvie R, Poon S, Desmarais O, Desbiens M, Virani S. Access to Heart Failure Services in Canada: Findings of the Heart and Stroke National Heart Failure Resources and Services Inventory. Can J Cardiol 2023; 39:1469-1479. [PMID: 37422257 DOI: 10.1016/j.cjca.2023.06.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND The rising incidence of heart failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched an HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources. METHODS A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted from 2020 to 2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, service,s and processes across acute care hospitals and related ambulatory settings. RESULTS HF-RaSIs were completed by 501 acute care hospitals and urgent care centres, representing 94.7% of all HF hospitalisations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centres with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to B-type natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present at 21.6% of sites (108), and 16.2% sites (81) had dedicated inpatient interdisciplinary HF teams. Among all of the sites, 28.1% (141) were HF clinics, and of those, 40.4% (57) had average wait times from referral to first appointment of more than 2 weeks. CONCLUSIONS Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.
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Affiliation(s)
- Nima Moghaddam
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Nathaniel M Hawkins
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kim Anderson
- Dalhousie, University QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Anique Ducharme
- Institut de Cardiologie, de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Douglas S Lee
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Robert McKelvie
- St Joseph's Health Care, Western University, London, Ontario, Canada
| | - Stephanie Poon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Sean Virani
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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8
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Siyeka N, Da Silva M, Pitcher RD. Temporal trends in ultrasound utilisation in the radiology department of a tertiary hospital. SA J Radiol 2022; 26:2449. [PMID: 36093213 PMCID: PMC9453146 DOI: 10.4102/sajr.v26i1.2449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/19/2022] [Indexed: 11/01/2022] Open
Abstract
Background: Little is known about the combined impact of increasing ultrasound usage by clinical disciplines outside radiology and technical advances in other specialised radiological modalities on the role of ultrasound in tertiary-level radiology departments.Objectives: The aim of this study was to evaluate temporal trends in ultrasound utilisation in a tertiary-level radiology department.Method: An institutional review board-approved retrospective descriptive study in the radiology department of Tygerberg Hospital (TBH). The nature and number of ultrasound performed in 2013 and 2019 were retrieved from the TBH radiology information system (RIS). These were compared, expressed as a proportion of the overall annual radiology workload and stratified by location (ultrasound suite, interventional suite, mammography suite). Ultrasound suite examinations were analysed by body part and age (0–13 years; 13 years) and interventional suite workload by procedure.Results: The overall radiology workload decreased by 8%, reflecting the interplay between decreased plain radiography (–19%) and general fluoroscopy (–0.3%) and increased computed tomography (27%), magnetic resonance (23%) and fluoroscopically guided procedures (22%).There was a 12% increase in ultrasound utilisation. Ultrasound remained the second most common specialised imaging investigation throughout, after computed tomography. Ultrasound suite services were stable (–1%) representing a balance between decreased abdominal (–22%) and arterial (–16%) scans, and increased musculoskeletal (67%), small part (65%) and neonatal brain scans (41%). There were substantial increases in interventional (90%) and mammography suite (199%) services.Conclusion: Ultrasound remains a key modality in the tertiary-level radiology department, with an evolving pattern of clinical applications.
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Affiliation(s)
- Nwabisa Siyeka
- Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Michelle Da Silva
- Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Richard D. Pitcher
- Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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9
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Guo F, Ng M, Kuling G, Wright G. Cardiac MRI segmentation with sparse annotations: Ensembling deep learning uncertainty and shape priors. Med Image Anal 2022; 81:102532. [PMID: 35872359 DOI: 10.1016/j.media.2022.102532] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 06/07/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022]
Abstract
The performance of deep learning for cardiac magnetic resonance imaging (MRI) segmentation is oftentimes degraded when using small datasets and sparse annotations for training or adapting a pre-trained model to previously unseen datasets. Here, we developed and evaluated an approach to addressing some of these issues to facilitate broader use of deep learning for short-axis cardiac MRI segmentation. We developed a globally optimal label fusion (GOLF) algorithm that enforced spatial smoothness to generate consensus segmentation from segmentation predictions provided by a deep learning ensemble algorithm. The GOLF consensus was entered into an uncertainty-guided coupled continuous kernel cut (ugCCKC) algorithm that employed normalized cut, image-grid continuous regularization, and "nesting" and circular shape priors of the left ventricular myocardium (LVM) and cavity (LVC). In addition, the uncertainty measurements derived from the segmentation predictions were used to constrain the similarity of GOLF and final segmentation. We optimized ugCCKC through upper bound relaxation, for which we developed an efficient coupled continuous max-flow algorithm implemented in an iterative manner. We showed that GOLF yielded average symmetric surface distance (ASSD) 0.2-0.8 mm lower than an averaging method with higher or similar Dice similarity coefficient (DSC). We also demonstrated that ugCCKC incorporating the shape priors improved DSC by 0.01-0.05 and reduced ASSD by 0.1-0.9 mm. In addition, we integrated GOLF and ugCCKC into a deep learning ensemble algorithm by refining the segmentation of an unannotated dataset and using the refined segmentation to update the trained models. With the proposed framework, we demonstrated the capability of using relatively small datasets (5-10 subjects) with sparse (5-25% slices labeled) annotations to train a deep learning algorithm, while achieving DSC of 0.871-0.893 for LVM and 0.933-0.959 for LVC on the LVQuan dataset, and these were 0.844-0.871 for LVM and 0.923-0.931 for LVC on the ACDC dataset. Furthermore, we showed that the proposed approach can be adapted to substantially alleviate the domain shift issue. Moreover, we calculated a number of commonly used LV function measurements using the derived segmentation and observed strong correlations (Pearson r=0.77-1.00, p<0.001) between algorithm and manual LV function analyses. These results suggest that the developed approaches can be used to facilitate broader application of deep learning in research and clinical cardiac MR imaging workflow.
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Affiliation(s)
- Fumin Guo
- Wuhan National Laboratory for Optoelectronics, Biomedical Engineering, Huazhong University of Science and Technology, Wuhan, China; Department of Medical Biophysics, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Canada.
| | - Matthew Ng
- Department of Medical Biophysics, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Canada
| | - Grey Kuling
- Department of Medical Biophysics, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Canada
| | - Graham Wright
- Department of Medical Biophysics, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Canada
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10
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Unar B, Rolak SC, Zhong C, Rokey R. Implementation of Process Improvements to Facilitate Cardiac CT Re-Credentialing in a Rural Healthcare System. Clin Med Res 2022; 20:9-15. [PMID: 35022198 PMCID: PMC9390853 DOI: 10.3121/cmr.2021.1650] [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: 12/03/2020] [Accepted: 10/04/2021] [Indexed: 11/18/2022]
Abstract
Background: Because rural providers may experience barriers in achieving the necessary components to successfully re-credential in cardiac computed tomography (Cardiac CT), we evaluated the current system for re-credentialing at our organization and implemented processes to facilitate Cardiac CT re-credentialing for our providers.Methods: Institutional opportunities for Cardiac CT quality assurance (QA) conference attendance, Cardiac CT imaging evaluation, and Cardiac CT continuing medical education (CME) acquisition were assessed in 2009 and 2013. Process improvement strategies were implemented in 2014 including adding electronic media hosting sites, a "hands-on" image interpretation course, and more options for CME acquisition. Pre- and post-educational improvements were evaluated over a 10-year period. The number and type of events hosted, attendees, image review opportunities, and CME credits awarded were assessed and compared at the provider level.Results: Attendance at Cardiac CT QA conferences increased substantially following implemented changes despite fewer certified Cardiac CT providers. Electronic attendance accounted for 26% of this increased attendance, while the "hands on" course provided 43 images for review per year. The number of Cardiac CT CME credits awarded increased substantially, paralleling increased QA and "hands-on" attendance.Conclusion: In rural healthcare systems, institutional strategies can increase provider access to components necessary for Cardiac CT level II re-credentialing. In the COVID-19 era, rural and urban health organizations may find considerable provider benefit and engagement by using similar process improvement methods to help providers meet local and national requirements for certification.
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Affiliation(s)
- Bilal Unar
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin, USA
| | - Stacey C Rolak
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA; Current affiliation: Mayo Clinic School of Graduate Medical Education, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Chuyang Zhong
- Department of Internal Medicine, Marshfield Medical Center, Marshfield, Wisconsin, USA
| | - Roxann Rokey
- Clinical Research Center, Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
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11
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Xu L, Pagano J, Chow K, Oudit GY, Haykowsky MJ, Mikami Y, Howarth AG, White JA, Howlett JG, Dyck JRB, Anderson TJ, Ezekowitz JA, Thompson RB, Paterson DI. Cardiac remodelling predicts outcome in patients with chronic heart failure. ESC Heart Fail 2021; 8:5352-5362. [PMID: 34569184 PMCID: PMC8712825 DOI: 10.1002/ehf2.13626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/25/2021] [Accepted: 09/08/2021] [Indexed: 01/14/2023] Open
Abstract
Aims Surveillance imaging is often used to detect remodelling, a change in cardiac geometry, and/or function; however, there are limited data in patients with chronic heart failure (HF). We sought to characterize cardiac remodelling in patients with chronic HF and evaluate its association with outcome. Methods and results A prospective cohort of patients at risk for HF or with chronic HF underwent cardiac magnetic resonance (CMR) at baseline and 1 year. Ventricular function, volumes, mass, left atrial volume, global longitudinal strain, and myocardial scar were measured. The primary outcome was a composite of death or cardiovascular hospitalization up to 5 years from the 1 year scan. Cox regression was used to identify 1 year CMR predictors of outcome after adjusting for baseline risk. A total of 262 patients (median age 68 years, 57% males) including 96 at risk for HF, 97 with HF and preserved ejection fraction, and 69 with HF and reduced ejection fraction were included. In the patients with HF, 55 events were identified during follow‐up. After adjustment for baseline clinical risk, Cox proportion hazard regressions only identified 1 year change in left ventricular (LV) mass index as a CMR predictor of outcome, adjusted hazard ratio 1.21 (1.02, 1.44) per 10% increase, P = 0.031. Cardiac remodelling defined as a 1 year change in LV mass index ≥15% was observed in 35% of patients with HF. Patients with adverse remodelling of LV mass index had more events on Kaplan–Meier analyses compared to those with no remodelling, log‐rank P = 0.004 for overall cohort, P = 0.035 for heart failure with preserved ejection fraction and P = 0.035 for heart failure and reduced ejection fraction. Conclusions Cardiac remodelling is common during serial CMR assessment of patients with chronic HF. Change in LV mass predicted long‐term outcomes whereas change in left ventricular ejection fraction did not.
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Affiliation(s)
- Lingyu Xu
- Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Pagano
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Kelvin Chow
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Gavin Y Oudit
- Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Mark J Haykowsky
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Yoko Mikami
- Libin Cardiovascular Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Andrew G Howarth
- Libin Cardiovascular Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - James A White
- Libin Cardiovascular Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan G Howlett
- Libin Cardiovascular Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason R B Dyck
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Todd J Anderson
- Libin Cardiovascular Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Justin A Ezekowitz
- Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Richard B Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - D Ian Paterson
- Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
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12
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Tsang W, Silversides CK, Rashid M, Roche SL, Alonso-Gonzalez R, Austin PC, Lee DS. Outcomes and healthcare resource utilization in adult congenital heart disease patients with heart failure. ESC Heart Fail 2021; 8:4139-4151. [PMID: 34402222 PMCID: PMC8497229 DOI: 10.1002/ehf2.13529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/11/2021] [Accepted: 07/05/2021] [Indexed: 12/14/2022] Open
Abstract
AIMS While heart failure (HF) is a leading cause of death in adults with congenital heart disease (ACHD), few studies report contemporary outcomes after the first HF hospitalization. We examined outcomes of ACHD patients newly admitted for HF compared with ACHD patients without HF and the general HF population without ACHD. METHODS AND RESULTS Using population databases from a single-payer health system from 1994 to 2018, ACHD patients newly admitted for HF were matched 1:1 to ACHD patients without HF (n = 4030 matched pairs). Similarly, ACHD patients newly admitted for HF were matched 1:1 to HF patients without ACHD (n = 4336 matched pairs). Patients with ACHD and HF (median age 68 years, 45% women) experienced higher mortality in short-term [30 day adjusted hazard ratio (HR) 4.68, 95% confidence interval (CI) 4.06, 5.43, P < 0.001], near-term (1 year HR 3.87, 95% CI 3.77, 4.92, P < 0.001), and long-term (24 year HR 1.59, 95% CI 1.13, 2.36, P = 0.008) follow-up. Patients with ACHD and HF had fewer baseline cardiovascular comorbidities than non-ACHD HF but demonstrated higher 30 day (HR 1.56, 95% CI 1.41, 1.73, P < 0.001), 1 year (HR 1.30, 95% CI 1.20, 1.40, P < 0.001), and 24 year (HR 2.40, 95% CI 1.73, 3.38, P < 0.001) mortality. Those with ACHD and HF also exhibited higher cardiovascular readmission rates at 30 days with HRs 9.15 (95% CI; 8.00, 10.48, P < 0.001) vs. ACHD without HF, and 1.71 (95% CI; 1.54, 1.85, P < 0.001) vs. HF without ACHD, and the higher readmission risk extended to 10 year follow-up. CONCLUSIONS Adults with congenital heart disease patients with new HF have high risks of death and cardiovascular hospitalization, and preventative strategies to improve outcomes are urgently needed.
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Affiliation(s)
- Wendy Tsang
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Toronto, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Toronto, Ontario, Canada.,Toronto Adult Congenital Heart Disease Program, Toronto, Ontario, Canada
| | - Mohammed Rashid
- ICES (formerly the Institute for Clinical Evaluative Sciences), 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - S Lucy Roche
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Toronto, Ontario, Canada.,Toronto Adult Congenital Heart Disease Program, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Toronto, Ontario, Canada.,Toronto Adult Congenital Heart Disease Program, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES (formerly the Institute for Clinical Evaluative Sciences), 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Douglas S Lee
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.,Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
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13
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Kosyakovsky LB, Austin PC, Ross HJ, Wang X, Abdel-Qadir H, Goodman SG, Farkouh ME, Croxford R, Lawler PR, Spertus JA, Lee DS. Early invasive coronary angiography and acute ischaemic heart failure outcomes. Eur Heart J 2021; 42:3756-3766. [PMID: 34331056 PMCID: PMC8491058 DOI: 10.1093/eurheartj/ehab423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/11/2021] [Accepted: 06/21/2021] [Indexed: 12/21/2022] Open
Abstract
Aims While myocardial ischaemia plays a major role in the pathogenesis of heart failure (HF), the indications for coronary angiography during acute HF are not established. We determined the association of early coronary angiography during acute HF hospitalization with 2-year mortality, cardiovascular death, HF readmissions, and coronary revascularization. Methods and results In a two-stage sampling process, we identified acute HF patients who presented to 70 emergency departments in Ontario (April 2010 to March 2013) and determined whether they underwent early coronary angiography within 14 days after presentation using administrative databases. After clinical record review, we defined a cohort with acute ischaemic HF as patients with at least one factor suggesting underlying ischaemic heart disease, including previous myocardial infarction, troponin elevation, or angina on presentation. We oversampled patients undergoing angiography. We used inverse-probability-of-treatment weighting (IPTW) to adjust for baseline differences. Of 7239 patients with acute HF, 2994 met inclusion criteria [median age 75 (interquartile range 65–83) years; 40.9% women]. Early angiography was performed in 1567 patients (52.3%) and was associated with lower all-cause mortality [hazard ratio (HR) 0.74, 95% confidence interval (CI) 0.61–0.90, P = 0.002], cardiovascular death (HR 0.72, 95% CI 0.56–0.93, P = 0.012), and HF readmissions (HR 0.84, 95% CI 0.71–0.99, P = 0.042) after IPTW. Those undergoing early angiography experienced higher rates of percutaneous coronary intervention (HR 2.58, 95% CI 1.73–3.86, P < 0.001) and coronary artery bypass grafting (HR 2.94, 95% CI 1.75–4.93, P < 0.001) within 2 years. Conclusions Early coronary angiography was associated with lower all-cause mortality, cardiovascular death, HF readmissions, and higher rates of coronary revascularization in acute HF patients with possible ischaemia.
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Affiliation(s)
| | - Peter C Austin
- ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada
| | - Heather J Ross
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Xuesong Wang
- ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada
| | - Husam Abdel-Qadir
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Women's College Hospital, University of Toronto, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Shaun G Goodman
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, 36 Queen St E, Toronto, ON, M5B 1W8, Canada
| | - Michael E Farkouh
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Ruth Croxford
- ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada
| | - Patrick R Lawler
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - John A Spertus
- Division of Cardiology, St. Luke's Mid-America Health Institute/UMKC and Department of Biomedical and Health Informatics at UMKC, 4401 Wornall Road, 9th Floor, Kansas City, MO 64111, USA
| | - Douglas S Lee
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
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14
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Lee KC, Liu S, Callahan P, Green T, Jarrett T, Cochran JD, Mei Y, Mobasseri S, Sayegh H, Rangarajan V, Flueckiger P, Vannan MA. Routine Use of Contrast on Admission Transthoracic Echocardiography for Heart Failure Reduces the Rate of Repeat Echocardiography during Index Admission. J Am Soc Echocardiogr 2021; 34:1253-1261.e4. [PMID: 34284098 DOI: 10.1016/j.echo.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 07/05/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The authors retrospectively evaluated the impact of ultrasound enhancing agent (UEA) use in the first transthoracic echocardiographic (TTE) examination, regardless of baseline image quality, on the number of repeat TTEs and length of stay (LOS) during a heart failure (HF) admission. METHODS There were 9,115 HF admissions associated with admission TTE examinations over a 4-year period (5,337 men; mean age, 67.6 ± 15.0 years). Patients were grouped into those who received UEAs (contrast group) in the first TTE study and those who did not (noncontrast group). Repeat TTE examinations were classified as justified if performed for concrete clinical indications during hospitalization. RESULTS In the 9,115 admissions for HF (5,600 in the contrast group, 3,515 in the noncontrast group), 927 patients underwent repeat TTE studies (505 in the contrast group, 422 in the noncontrast group), which were considered justified in 823 patients. Of the 104 patients who underwent unjustified repeat TTE studies, 80 (76.7%) belonged to the noncontrast group and 24 to the contrast group. Also, UEA use increased from 50.4% in 2014 to 74.3%, and the rate of unjustified repeat studies decreased from 1.3% to 0.9%. The rates of unjustified repeat TTE imaging were 2.3% and 0.4% (in the noncontrast and contrast groups, respectively), and patients in the contrast group were less likely to undergo unjustified repeat examinations (odds ratio, 0.18; 95% CI, 0.12-0.29; P < .0001). The mean LOS was significantly lower in the contrast group (9.5 ± 10.5 vs 11.1 ± 13.7 days). The use of UEA in the first TTE study was also associated with reduced LOS (linear regression, β1 = -0.47, P = .036), with 20% lower odds for odds of prolonged (>6 days) LOS. CONCLUSIONS The routine use of UEA in the first TTE examination for HF irrespective of image quality is associated with reduced unjustified repeat TTE testing and may reduce LOS during an index HF admission.
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Affiliation(s)
- K Charlotte Lee
- Georgia Institute of Technology, Atlanta, Georgia; Piedmont Heart Institute, Atlanta, Georgia
| | | | | | | | | | | | - Yajun Mei
- Georgia Institute of Technology, Atlanta, Georgia
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15
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MacKay EJ, Salmon MK, Fatuzzo MR, Neuman MD, Desai ND, Groeneveld PW, Augoustides JG. Validation of Claims Data for the Identification of Intraoperative Transesophageal Echocardiography During Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:3193-3198. [PMID: 34023202 DOI: 10.1053/j.jvca.2021.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/04/2021] [Accepted: 04/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The goal of this study was to assess the validity of Current Procedural Terminology (CPT) claims data for the identification of intraoperative transesophageal echocardiography (TEE) during cardiac surgery. DESIGN This study was a retrospective, cohort analysis. SETTING This study used data from electronic medical records (EMRs), in combination with CPT billing claims data, from two hospitals within the Penn Medicine Health System-Penn Presbyterian Medical Center and the Hospital of the University of Pennsylvania. PARTICIPANTS The cohort consisted of adult patients, aged ≥18 years, undergoing open cardiac valve surgery (repair or replacement), coronary artery bypass graft surgery, or aortic surgery between April 1 and October 31, 2019. INTERVENTIONS Agreement between TEE identified using CPT billing code(s) (93312-8 with or without 93320-1 or 93325) and TEE identified by manual EMR review. MEASUREMENTS AND MAIN RESULTS As identified by a reference standard (ie, EMR review) of the 873 cases that met inclusion criteria, 867 (99.31%) cases were performed with TEE and six cases were performed without TEE (<1%). Of the 867 cases performed with TEE, CPT code(s) correctly identified 866 cases, as indicated by having at least one of the CPT codes (93312-8 with or without 93320-1 or 93325). These CPT codes identified intraoperative TEE with a 99.88% sensitivity, 100.00% specificity, 100.00% positive predictive value, and 85.71% negative predictive value. When billing claims for TEE were restricted to the CPT code 93312 alone, the results were identical. CONCLUSIONS Billing claims using CPT code(s) identified true intraoperative TEE with a high sensitivity, specificity, excellent positive predictive value, and moderate negative predictive value. These results demonstrated that claims data are a valuable data source from which to study the effect of TEE in cardiac surgical patients.
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Affiliation(s)
- Emily J MacKay
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA; Penn's Cardiovascular Outcomes, Quality, and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA.
| | - Mandy K Salmon
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mia R Fatuzzo
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA
| | - Nimesh D Desai
- Penn's Cardiovascular Outcomes, Quality, and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA; Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Peter W Groeneveld
- Penn's Cardiovascular Outcomes, Quality, and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA; Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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16
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Stacey RB, Hundley WG. Integrating Measures of Myocardial Fibrosis in the Transition from Hypertensive Heart Disease to Heart Failure. Curr Hypertens Rep 2021; 23:22. [PMID: 33881630 DOI: 10.1007/s11906-021-01135-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize recent developments in identifying and quantifying both the presence and amount of myocardial fibrosis by imaging and biomarkers. Further, this review seeks to describe in general ways how this information may be used to identify hypertension and the transition to heart failure with preserved ejection fraction. RECENT FINDINGS Recent studies using cardiac magnetic resonance imaging highlight the progressive nature of fibrosis from normal individuals to those with hypertension to those with clinical heart failure. However, separating hypertensive patients from those with heart failure remains challenging. Recent studies involving echocardiography show the subclinical myocardial strain changes between hypertensive heart disease and heart failure. Lastly, recent studies highlight the potential use of biomarkers to identify those with hypertension at the greatest risk of developing heart failure. In light of the heterogeneous nature between hypertension and heart failure with preserved ejection fraction, an integrated approach with cardiac imaging and biomarker analysis may enable clinicians and investigators to more accurately characterize, prevent, and treat heart failure in those with hypertension.
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Affiliation(s)
- R Brandon Stacey
- Division of Cardiovascular Medicine, Wake Forest University School of Medicine, Watlington Hall, Medical Center Boulevard, Winston-Salem, NC, 27157-1045, USA.
| | - W Gregory Hundley
- Division of Cardiovascular Medicine, Wake Forest University School of Medicine, Watlington Hall, Medical Center Boulevard, Winston-Salem, NC, 27157-1045, USA.,Pauley Heart Center, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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17
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Raslan IR, Ross HJ, Fowler RA, Scales DC, Stelfox HT, Mak S, Tu JV, Farkouh ME, Stukel TA, Wang X, van Diepen S, Wunsch H, Austin PC, Lee DS. The associations between direct and delayed critical care unit admission with mortality and readmissions among patients with heart failure. Am Heart J 2021; 233:20-38. [PMID: 33166518 DOI: 10.1016/j.ahj.2020.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although greater than 20% of patients hospitalized with heart failure (HF) are admitted to a critical care unit, associated outcomes, and costs have not been delineated. We determined 30-day mortality, 30-day readmissions, and hospital costs associated with direct or delayed critical care unit admission. METHODS In a population-based analysis, we compared HF patients who were admitted to critical care directly from the emergency department (direct), after initial ward admission (delayed), or never admitted to critical care during their hospital stay (ward-only). RESULTS Among 178,997 HF patients (median age 80 [IQR 71-86] years, 49.6% men) 36,175 (20.2%) were admitted to critical care during their hospitalization (April 2003 to March 2018). Critical care patients were admitted directly from the emergency department (direct, 81.9%) or after initial ward admission (delayed, 18.1%). Multivariable-adjusted hazard ratios (HR) for all-cause 30-day mortality were: 1.69 for direct (95% confidence interval [CI]; 1.55, 1.84) and 4.92 for delayed (95% CI; 4.26, 5.68) critical care-admitted compared to ward-only patients. Multivariable-adjusted repeated events analysis demonstrated increased risk for all-cause 30-day readmission with both direct (HR 1.04, 95% CI; 1.01, 1.08, P = .013) and delayed critical care unit admissions (HR 1.20, 95% CI; 1.13, 1.28, P < .001). Median 30-day costs were $12,163 for direct admissions, $20,173 for delayed admissions, and $9,575 for ward-only patients (P < .001). CONCLUSIONS While critical care unit admission indicates increased risk of mortality and readmission at 30 days, those who experienced delayed critical care unit admission exhibited the highest risk of death and highest costs of care.
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Health Care Use Before First Heart Failure Hospitalization. JACC-HEART FAILURE 2020; 8:1024-1034. [DOI: 10.1016/j.jchf.2020.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 11/21/2022]
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Sanfilippo AJ, Kolos A, Chan K, Leong-Poi H, Sasson Z, Wald R, Woodward G, Yared K. Impact of a Mandated Accreditation Process on 1,045 Registered Echocardiographic Service Providers in a Previously Unregulated, Publicly Funded Environment. J Am Soc Echocardiogr 2020; 34:308-315. [PMID: 33191003 DOI: 10.1016/j.echo.2020.09.018] [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: 04/30/2020] [Revised: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND This review was undertaken to examine the impact of a standards-based, mandated accreditation process on several aspects of echocardiographic service delivery in a single-payer, previously unregulated environment. METHODS In the province of Ontario, virtually all echocardiographic services are funded by the Ministry of Health and Long Term Care. The Echocardiography Quality Improvement (EQI) process was introduced in 2012 and subsequently linked formally to reimbursement in 2016. Previously, payment for echocardiographic services in Ontario was unregulated. The impact of EQI on the number of facilities, echocardiographic volumes, costs, quality standards, and physician service provision were compared before and after implementation. RESULTS Of the initial 1,045 registrants, 604 (57.8%) have been accredited or accreditation is expected having successfully resolved identified deficiencies. The remaining registrants were either never functionally operating (323 [30.9%]) or have withdrawn services (118 [11.3%]) since mandatory registration became a requirement for reimbursement. A number of factors identified facilities that were able to most promptly meet EQI standards, including hospital-based, academic, and multiple-physician facilities. The average annual increase in the utilization of echocardiographic services before EQI was 6.7%, decreasing to 2.7% since. The proportion of repeat examinations decreased in community-based facilities. Since 2013, costs for echocardiographic services have totaled about $92.3 million less than predicted by pre-2012 trends. To address standards, some small, more isolated facilities sought out alliances with larger facilities, particularly those affiliated with academic hospitals. CONCLUSIONS EQI is demonstrably a means for improving quality while reducing the rate of growth and repeat examinations.
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Affiliation(s)
| | | | - Kwan Chan
- Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Zion Sasson
- University of Toronto, Toronto, Ontario, Canada
| | - Robert Wald
- University of Toronto, Toronto, Ontario, Canada
| | | | - Kibar Yared
- University of Toronto, Toronto, Ontario, Canada
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Angaran P, Dorian P, Ha AC, Thavendiranathan P, Tsang W, Leong-Poi H, Woo A, Dias B, Wang X, Austin PC, Lee DS. Association of Left Ventricular Ejection Fraction with Mortality and Hospitalizations. J Am Soc Echocardiogr 2020; 33:802-811.e6. [DOI: 10.1016/j.echo.2019.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 10/24/2022]
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21
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D'Amario D, Canonico F, Rodolico D, Borovac JA, Vergallo R, Montone RA, Galli M, Migliaro S, Restivo A, Massetti M, Crea F. Telemedicine, Artificial Intelligence and Humanisation of Clinical Pathways in Heart Failure Management: Back to the Future and Beyond. Card Fail Rev 2020; 6:e16. [PMID: 32612852 PMCID: PMC7312813 DOI: 10.15420/cfr.2019.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/12/2020] [Indexed: 12/28/2022] Open
Abstract
New technologies have been recently introduced to improve the monitoring of patients with chronic syndromes such as heart failure. Devices can now be employed to gather large amounts of data and data processing through artificial intelligence techniques may improve heart failure management and reduce costs. The analysis of large datasets using an artificial intelligence technique is leading to a paradigm shift in the era of precision medicine. However, the assessment of clinical safety and the evaluation of the potential benefits is still a matter of debate. In this article, the authors aim to focus on the development of these new tools and to draw the attention to their transition in daily clinical practice.
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Affiliation(s)
- Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS Rome, Italy
| | - Francesco Canonico
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS Rome, Italy
| | - Daniele Rodolico
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS Rome, Italy
| | - Josip A Borovac
- Department of Pathophysiology, University of Split School of Medicine Split, Croatia.,Working Group on Heart Failure of Croatian Cardiac Society Zagreb, Croatia
| | - Rocco Vergallo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS Rome, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS Rome, Italy
| | - Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS Rome, Italy
| | - Stefano Migliaro
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS Rome, Italy
| | - Attilio Restivo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS Rome, Italy
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22
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Hoang-Kim A, Parpia C, Freitas C, Austin PC, Ross HJ, Wijeysundera HC, Tu K, Mak S, Farkouh ME, Sun LY, Schull MJ, Mason R, Lee DS, Rochon PA. Readmission rates following heart failure: a scoping review of sex and gender based considerations. BMC Cardiovasc Disord 2020; 20:223. [PMID: 32408892 PMCID: PMC7222562 DOI: 10.1186/s12872-020-01422-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/09/2020] [Indexed: 12/23/2022] Open
Abstract
Background Although hospital readmission for heart failure (HF) is an issue for both men and women, little is known about differences in readmission rates by sex. Consequently, strategies to optimize readmission reduction programs and care strategies for women and men remain unclear. Our study aims were: (1) to identify studies examining readmission rates according to sex, and (2) to provide a qualitative overview of possible considerations for the impact of sex or gender. Methods We conducted a scoping review using the Arksey and O’Malley framework to include full text articles published between 2002 and 2017 drawn from multiple databases (MEDLINE, EMBASE), grey literature (i.e. National Technical information, Duck Duck Go), and expert consultation. Eligible articles included an index heart failure episode, readmission rates, and sex/gender-based analysis. Results The search generated 5887 articles, of which 746 underwent full abstract text consideration for eligibility. Of 164 eligible articles, 34 studies addressed the primary outcome, 103 studies considered sex differences as a secondary outcome and 25 studies stratified data for sex. Good inter-rater agreement was reached: 83% title/abstract; 88% full text; kappa: 0.69 (95%CI: 0.53–0.85). Twelve of 34 studies reported higher heart failure readmission rates for men and six studies reported higher heart failure readmission rates for women. Using non composite endpoints, five studies reported higher HF readmission rates for men compared to three studies reporting higher HF readmission rates for women. Overall, there was heterogeneity between studies when examined by sex, but one observation emerged that was related to the timing of readmissions. Readmission rates for men were higher when follow-up duration was longer than 1 year. Women were more likely to experience higher readmission rates than men when time to event was less than 1 year. Conclusions Future studies should consider different time horizons in their designs and avoid the use of composite measures, such as readmission rates combined with mortality, which are highly skewed by sex. Co-interventions and targeted post-discharge approaches with attention to sex would be of benefit to the HF patient population.
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Affiliation(s)
| | | | - Cassandra Freitas
- Peter Munk Cardiac Centre of University Health Network, Toronto, Canada
| | - Peter C Austin
- ICES, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Heather J Ross
- Peter Munk Cardiac Centre of University Health Network, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Ted Rogers Centre for Heart Research, Toronto, Canada
| | - Harindra C Wijeysundera
- ICES, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Karen Tu
- Faculty of Medicine, University of Toronto, Toronto, Canada.,North York General Hospital, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Susanna Mak
- Faculty of Medicine, University of Toronto, Toronto, Canada.,Sinai Health System, Toronto, Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre of University Health Network, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Louise Y Sun
- ICES, Toronto, Canada.,Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Michael J Schull
- ICES, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Robin Mason
- Women's College Research Institute, Toronto, Canada
| | - Douglas S Lee
- Peter Munk Cardiac Centre of University Health Network, Toronto, Canada. .,ICES, Toronto, Canada. .,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada. .,Faculty of Medicine, University of Toronto, Toronto, Canada. .,Ted Rogers Centre for Heart Research, Toronto, Canada.
| | - Paula A Rochon
- Women's College Research Institute, Toronto, Canada.,ICES, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
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Bosso G, Valvano A, Guarnaccia F, Fimiani B, Carbone V, Cittadini A, Zito GB, Oliviero U. Adherence to guidelines in the management of patients with chronic heart failure follow-up. J Cardiovasc Med (Hagerstown) 2020; 21:216-222. [DOI: 10.2459/jcm.0000000000000940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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24
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Freitas C, Wang X, Ge Y, Ross HJ, Austin PC, Pang PS, Ko DT, Farkouh ME, Stukel TA, McMurray JJV, Lee DS. Comparison of Troponin Elevation, Prior Myocardial Infarction, and Chest Pain in Acute Ischemic Heart Failure. CJC Open 2020; 2:135-144. [PMID: 32462127 PMCID: PMC7242506 DOI: 10.1016/j.cjco.2020.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/19/2020] [Indexed: 12/14/2022] Open
Abstract
Background Patients with heart failure (HF) with concomitant ischemic heart disease (IHD) have not been well characterized. We examined survival of patients with ischemic HF syndrome (IHFS), defined as presentation with acute HF and concomitant features suggestive of IHD. Methods Patients were included if they presented with acute HF to hospitals in Ontario, Canada. IHD was defined by any of the following criteria: angina/chest pain, prior myocardial infarction (MI), or troponin elevation that was above the upper limit of normal (mild) or suggestive of cardiac injury. Deaths were determined after hospital presentation. Results Of 5353 patients presenting with acute HF, 4088 (76.4%) exhibited features of IHFS. Patients with IHFS demonstrated a higher rate of 30-day (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.33-2.68) and 1-year death (HR, 1.16, 95% CI, 1.00-1.35) compared with those with nonischemic HF. Troponin elevation demonstrated the strongest association with mortality. Mildly elevated troponin was associated with increased hazard over 30-day (HR, 1.77; 95% CI, 1.12-2.81) and 1-year (HR, 1.63; 95% CI, 1.38-1.93) mortality. Troponins indicative of cardiac injury were associated with increased hazard of death over 30 days (HR, 2.33; 95% CI, 1.63-3.33) and 1 year (HR, 1.40; 95% CI, 1.21-1.61). The association between elevated troponin and higher mortality at 30 days was similar in left ventricular ejection fraction subcategories of HF with reduced ejection fraction, HF with mildly reduced ejection fraction, or HF with preserved ejection fraction (P interaction = 0.588). After multivariable adjustment, prior MI and angina were not associated with higher mortality risk. Conclusions In acute HF, elevated troponin, but not prior MI or angina, was associated with a higher risk of 30-day and 1-year mortality irrespective of left ventricular ejection fraction.
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Affiliation(s)
- Cassandra Freitas
- University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | | | - Yin Ge
- University of Toronto, Toronto, Ontario, Canada
| | - Heather J Ross
- University Health Network, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, Toronto, Ontario, Canada.,Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
| | - Peter C Austin
- University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dennis T Ko
- University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael E Farkouh
- University Health Network, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, Toronto, Ontario, Canada.,Heart & Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, Toronto, Ontario, Canada
| | - Therese A Stukel
- University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Douglas S Lee
- University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, Toronto, Ontario, Canada.,Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
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Braga JR, Austin PC, Ross HJ, Lee DS. Reply: Ischemic or Nonischemic Cardiomyopathy?: Relevance of Cardiac Magnetic Resonance in the Diagnosis of Dilated Cardiomyopathy. JACC. HEART FAILURE 2019; 7:995-996. [PMID: 31672311 DOI: 10.1016/j.jchf.2019.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 08/22/2019] [Indexed: 06/10/2023]
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26
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Affiliation(s)
- Vinay Kini
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
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