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Califf RM. Now is the time to fix the evidence generation system. Clin Trials 2023; 20:3-12. [PMID: 36647919 DOI: 10.1177/17407745221147689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Despite enormous advances in biomedical science, corresponding improvements in health outcomes lag significantly. This is particularly true in the United States, where life expectancy trails far behind that of other high-income countries. In addition, substantial disparities in life expectancy and other health outcomes exist as a function of race, ethnicity, wealth, education, and geographic location. A major reformation of our national system for generating medical evidence-the clinical research enterprise-is needed to facilitate the translation of biomedical research into useful products and interventions. Currently, premarket systems for generating and evaluating evidence work reasonably well, but the postmarket phase is disaggregated and often fails to answer essential questions that must be addressed to provide optimal clinical care and public health interventions for all Americans. Solving these problems will require a focus on three key domains: (1) improving the integration of and access to high-quality data from traditional clinical trials, electronic health records, and personal devices and wearable sensors; (2) restructuring clinical research operations to support and incentivize the involvement of patients and frontline clinicians; and (3) articulating ethical constructs that enable responsible data sharing to support improved implementation. Finally, we must also address the systemic tendency to optimize individual components of the clinical research enterprise without considering the effects on the system as a whole. Overcoming suboptimization by creating incentives for integration and sharing will be essential to achieve more timely and equitable improvement in health outcomes.
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Kwan ML, Cheng RK, Iribarren C, Shen H, Laurent CA, Roh JM, Hershman DL, Kushi LH, Greenlee H, Rana JS. Risk of heart failure with preserved versus reduced ejection fraction in women with breast cancer. Breast Cancer Res Treat 2022; 193:669-675. [PMID: 35429322 PMCID: PMC10461432 DOI: 10.1007/s10549-022-06586-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/27/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE While clinical heart failure (HF) is recognized as an adverse effect from breast cancer (BC) treatment, sparse data exist on specific HF phenotypes in affected BC survivors. We examined risk of HF by left ventricular ejection fraction (LVEF) status in women with a history of BC. METHODS 14,804 women diagnosed with all stages of invasive BC from 2005 to 2013 and with no history of HF were matched 1:5 to 74,034 women without BC on birth year, race, and ethnicity. LVEF values were extracted from echocardiography studies within 30 days before through 90 days after the HF clinical encounter. HF was stratified into HF with preserved ejection fraction (HFpEF, LVEF ≥ 45%) and HF with reduced ejection fraction (HFrEF, LVEF < 45%). Cumulative incidence rates (CIRs) were estimated with competing risk of overall death. Hazard ratios (HR) were calculated by multivariable Cox proportional hazards regression. RESULTS Mean time to HF diagnosis was 5.31 years (range 0.03-13.03) in cases and 5.25 years (range 0.01-12.94) in controls. 10-year CIRs were 1.2% and 0.9% for overall HF, 0.8% and 0.7% for HFpEF, and 0.4% and 0.2% for HFrEF in cases and controls, respectively. In fully adjusted models, an overall significant increased risk of HF in cases versus controls was observed (HR: 1.31, 95% CI 1.14, 1.51). The increased risk was seen for both HFrEF (HR: 1.59, 95% CI 1.22, 2.08) and HFpEF (HR: 1.22; 95% CI 1.03, 1.45). CONCLUSION BC survivors experienced higher risk of HF compared with women without BC, and the risk persisted across LVEF phenotypes. Systematic cardio-oncology surveillance should be considered to mitigate this risk in BC patients.
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Affiliation(s)
- Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Richard K Cheng
- University of Washington School of Medicine, Seattle, WA, USA
- Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Carlos Iribarren
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Hanjie Shen
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Cecile A Laurent
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Janise M Roh
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Heather Greenlee
- University of Washington School of Medicine, Seattle, WA, USA
- Seattle Cancer Care Alliance, Seattle, WA, USA
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jamal S Rana
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
- Department of Cardiology, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, CA, USA
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King-Dailey K, Frazier S, Bressler S, King-Wilson J. The Role of Nurse Practitioners in the Management of Heart Failure Patients and Programs. Curr Cardiol Rep 2022; 24:1945-1956. [PMID: 36434405 PMCID: PMC9702908 DOI: 10.1007/s11886-022-01796-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The goal of this paper is to highlight the multifaceted approach heart failure (HF) nurse practitioners (NPs) use to manage patients. We were seeking to answer if NPs have the scope of clinical skills to manage the complexity of HF patients. RECENT FINDINGS NP care in HF has been shown to reduce readmissions, improve timeliness of visits, decrease cost, and improve quality outcomes in small heterogeneous studies. The evidence supports that NPs provide multifaceted, patient-centered care for at all stages on the continuum of HF. Our goals as NPs are to reduce the healthcare financial strain and improve access to high quality care. Telehealth is an emerging technology that shows promise in HF management by improving access and decreasing readmissions. Telehealth use and recognition increased with the COVID-19 pandemic. Future research should focus on NP run clinics, cost effectiveness, and quality of care.
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Affiliation(s)
- Kathaleen King-Dailey
- Division of Cardiology, Penn State Health Heart and Vascular Institute, Mail Code H047, 500 University Dr., P.O. Box 850, Hershey, PA 17033 USA
| | - Suzanne Frazier
- Division of Cardiology, Penn State Health Heart and Vascular Institute, Mail Code H047, 500 University Dr., P.O. Box 850, Hershey, PA 17033 USA
| | - Sonya Bressler
- Division of Cardiology, Penn State Health Heart and Vascular Institute, Mail Code H047, 500 University Dr., P.O. Box 850, Hershey, PA 17033 USA
| | - Jennifer King-Wilson
- Division of Cardiology, Penn State Health Heart and Vascular Institute, Mail Code H047, 500 University Dr., P.O. Box 850, Hershey, PA 17033 USA
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