1
|
Kling SMR, Kalwani NM, Winget M, Gupta K, Saliba-Gustafsson EA, Baratta J, Garvert DW, Veruttipong D, Brown-Johnson CG, Vilendrer S, Gaspar C, Levin E, Tsai S. An initiative to promote value-based stress test selection in primary care and cardiology clinics: A mixed methods evaluation. J Eval Clin Pract 2024; 30:107-118. [PMID: 37459156 DOI: 10.1111/jep.13896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 03/01/2024]
Abstract
OBJECTIVES Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics. METHODS Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2. RESULTS Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001). CONCLUSIONS This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.
Collapse
Affiliation(s)
- Samantha M R Kling
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Neil M Kalwani
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Marcy Winget
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kush Gupta
- Stanford University School of Medicine, Stanford, California, USA
| | - Erika A Saliba-Gustafsson
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Juliana Baratta
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Donn W Garvert
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Darlene Veruttipong
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Cati G Brown-Johnson
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Stacie Vilendrer
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
| | | | - Eleanor Levin
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
| | - Sandra Tsai
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
| |
Collapse
|
2
|
de Vasconcelos Silva ACP, Araujo BM, Spiegel T, da Cunha Reis A. May value-based healthcare practices contribute to comprehensive care for cancer patients? A systematic literature review. J Cancer Policy 2022; 34:100350. [DOI: 10.1016/j.jcpo.2022.100350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/28/2022] [Accepted: 07/30/2022] [Indexed: 12/30/2022]
|
3
|
Shoieb SM, Alammari AH, Levasseur J, Silver H, Dyck JRB, El-Kadi AOS. Ameliorative Role of Fluconazole Against Abdominal Aortic Constriction-Induced Cardiac Hypertrophy in Rats. J Cardiovasc Pharmacol 2022; 79:833-845. [PMID: 35266922 DOI: 10.1097/fjc.0000000000001258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 02/26/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Cytochrome P450 1B1 (CYP1B1) is known to be involved in the pathogenesis of several cardiovascular diseases, including cardiac hypertrophy and heart failure, through the formation of cardiotoxic metabolites named as mid-chain hydroxyeicosatetraenoic acids (HETEs). Recently, we have demonstrated that fluconazole decreases the level of mid-chain HETEs in human liver microsomes, inhibits human recombinant CYP1B1 activity, and protects against angiotensin II-induced cellular hypertrophy in H9c2 cells. Therefore, the overall purpose of this study was to elucidate the potential cardioprotective effect of fluconazole against cardiac hypertrophy induced by abdominal aortic constriction (AAC) in rats. Male Sprague-Dawley rats were randomly assigned into 4 groups such as sham control rats, fluconazole-treated (20 mg/kg daily for 4 weeks, intraperitoneal) sham rats, AAC rats, and fluconazole-treated (20 mg/kg) AAC rats. Baseline and 5 weeks post-AAC echocardiography were performed. Gene and protein expressions were measured using real-time PCR and Western blot analysis, respectively. The level of mid-chain HETEs was determined using liquid chromatography-mass spectrometry. Echocardiography results showed that fluconazole significantly prevented AAC-induced left ventricular hypertrophy because it ameliorated the AAC-mediated increase in left ventricular mass and wall measurements. In addition, fluconazole significantly prevented the AAC-mediated increase of hypertrophic markers. The antihypertrophic effect of fluconazole was associated with a significant inhibition of CYP1B1, CYP2C23, and 12-LOX and a reduction in the formation rate of mid-chain HETEs. This study demonstrates that fluconazole protects against left ventricular hypertrophy, and it highlights the potential repurposing of fluconazole as a mid-chain HETEs forming enzymes' inhibitor for the protection against cardiac hypertrophy.
Collapse
Affiliation(s)
- Sherif M Shoieb
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada ; and
| | - Ahmad H Alammari
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada ; and
| | - Jody Levasseur
- Department of Pediatrics, Cardiovascular Research Centre, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Heidi Silver
- Department of Pediatrics, Cardiovascular Research Centre, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jason R B Dyck
- Department of Pediatrics, Cardiovascular Research Centre, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ayman O S El-Kadi
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada ; and
| |
Collapse
|
4
|
Hackett I, Ward RP. Appropriate Use Criteria for Echocardiography in the Era of Value-Based Care: Mission Accomplished or Future Mandates? Curr Cardiol Rep 2020; 22:69. [PMID: 32561996 PMCID: PMC7303569 DOI: 10.1007/s11886-020-01310-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Purpose of Review The purpose of this review is to highlight the past impact and current role of the Appropriate Use Criteria (AUC) for echocardiography in value-based healthcare, and to address future implications in light of the recent mandate from the Centers for Medicare and Medicaid Services to incorporate AUC for other imaging modalities. Recent Findings Several studies have proven that the AUC effectively stratify the clinical practice of echocardiography as they predict important echo abnormalities and impact optimal patient care. Recent investigations have tested new technologies and demonstrated the feasibility and scalability of the application of the AUC for echocardiography at the point of care. Summary The AUC for echocardiography has accomplished their core mission, as utilization has moderated over the last decade and mandatory implementation at the point of care for echocardiography remains rare. While a new mandate signals another wave of focus on appropriate utilization, echocardiography stands ready.
Collapse
Affiliation(s)
- Ian Hackett
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, DCAM Rm 5726, Chicago, IL, 60637, USA
| | - R Parker Ward
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, DCAM Rm 5726, Chicago, IL, 60637, USA.
| |
Collapse
|
5
|
Strom JB, Tanguturi VK, Nagueh SF, Klein AL, Manning WJ. Demonstrating the Value of Outcomes in Echocardiography: Imaging-Based Registries in Improving Patient Care. J Am Soc Echocardiogr 2019; 32:1608-1614. [PMID: 31563437 PMCID: PMC6899196 DOI: 10.1016/j.echo.2019.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Jordan B Strom
- Richard A. and Susan F. Smith Center for Cardiovascular Outcomes Research, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Varsha K Tanguturi
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sherif F Nagueh
- Department of Cardiology, Houston Methodist Hospital, Weill Cornell Medical College, Houston, Texas
| | - Allan L Klein
- The Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Warren J Manning
- Departments of Medicine (Cardiovascular Division) and Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
6
|
Role of Cytochrome p450 and Soluble Epoxide Hydrolase Enzymes and Their Associated Metabolites in the Pathogenesis of Diabetic Cardiomyopathy. J Cardiovasc Pharmacol 2019; 74:235-245. [DOI: 10.1097/fjc.0000000000000707] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
7
|
Stone JR, Lee L, Ward JP, Ward RP. High Prevalence of Clinically Important Echocardiographic Abnormalities in Patients with a Normal Electrocardiogram Referred for Transthoracic Echocardiography. J Am Soc Echocardiogr 2018; 31:926-932. [DOI: 10.1016/j.echo.2018.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Indexed: 10/14/2022]
|
8
|
Singh A, Ward RP. Appropriate Use Criteria for Echocardiography: Evolving Applications in the Era of Value-Based Healthcare. Curr Cardiol Rep 2017; 18:93. [PMID: 27553788 DOI: 10.1007/s11886-016-0758-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The current climate in healthcare is increasingly emphasizing a value-based approach to diagnostic testing. Cardiac imaging, including echocardiography, has been a primary target of ongoing reforms in healthcare delivery and reimbursement. The Appropriate Use Criteria (AUC) for echocardiography is a physician-derived tool intended to guide utilization in optimal patient care. To date, the AUC have primarily been employed solely as justification for reimbursement, though evolving broader applications to guide clinical decision-making suggest a far more valuable role in the delivery of high-quality and high-value healthcare.
Collapse
Affiliation(s)
- Amita Singh
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, MC6080, Chicago, IL, 60637, USA
| | - R Parker Ward
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, MC6080, Chicago, IL, 60637, USA.
| |
Collapse
|
9
|
Erbel R. Echokardiographie. Herz 2017; 42:229-231. [DOI: 10.1007/s00059-017-4557-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
10
|
|
11
|
Leischik R, Dworrak B, Sanchis-Gomar F, Lucia A, Buck T, Erbel R. Echocardiographic assessment of myocardial ischemia. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:259. [PMID: 27500160 DOI: 10.21037/atm.2016.07.06] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Over the last 60 years, echocardiography has emerged as a dominant and indispensable technique for the detection and assessment of coronary heart disease (CHD). In this review, we will describe and discuss this powerful tool of cardiology, especially in the hands of an experienced user, with a focus on myocardial ischemia. Technical development is still on-going, and various new ultrasound techniques have been established in the field of echocardiography in the last several years, including tissue Doppler imaging (TDI), contrast echocardiography, three-dimensional echocardiography (3DE), and speckle tracking echocardiography (i.e., strain/strain rate-echocardiography). High-end equipment with harmonic imaging, high frame rates and the opportunity to adjust mechanical indices has improved imaging quality. Like all new techniques, these techniques must first be subjected to comprehensive scientific assessment, and appropriate training that accounts for physical and physiological limits should be provided. These limits will constantly be redefined as echocardiographic techniques continue to change, which will present new challenges for the further development of ultrasound technology.
Collapse
Affiliation(s)
- Roman Leischik
- Faculty of Health, School of Medicine, University Witten/Herdecke, Hagen, Germany
| | - Birgit Dworrak
- Faculty of Health, School of Medicine, University Witten/Herdecke, Hagen, Germany
| | | | - Alejandro Lucia
- Research Institute Hospital 12 de Octubre ("i+12"), Madrid, Spain;; European University of Madrid, Madrid, Spain
| | - Thomas Buck
- Clinic of Cardiology, Klinikum Westfalen, Dortmund, Germany
| | - Raimund Erbel
- Institute of Medical Informatics, Biometry, Epidemiology, University Clinic Essen, Essen, Germany
| |
Collapse
|
12
|
Maayah ZH, Althurwi HN, Abdelhamid G, Lesyk G, Jurasz P, El-Kadi AO. CYP1B1 inhibition attenuates doxorubicin-induced cardiotoxicity through a mid-chain HETEs-dependent mechanism. Pharmacol Res 2016; 105:28-43. [DOI: 10.1016/j.phrs.2015.12.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 12/01/2015] [Accepted: 12/15/2015] [Indexed: 12/20/2022]
|
13
|
Abstract
The rdar morphotype, a multicellular behaviour of Salmonella enterica and Escherichia coli is characterized by the expression of the adhesive extracellular matrix components cellulose and curli fimbriae. The response regulator CsgD, which transcriptionally activates the biosynthesis of the exopolysaccharide cellulose and curli, also transforms cell physiology to the multicellular state. However, the only role of CsgD in cellulose biosynthesis is the activation of AdrA, a GGDEF domain protein that mediates production of the allosteric activator cyclic-di-(3'-5')guanylic acid (c-di-GMP). In S. enterica serovar Typhimurium a regulatory network consisting of 19 GGDEF/EAL domain-containing proteins tightly controls the concentration of c-di-GMP. c-di-GMP not only regulates the expression of cellulose, but also stimulates expression of adhesive curli and represses various modes of motility. Functions of characterized GGDEF and EAL domain proteins, as well as database searches, point to a global role for c-di-GMP as a novel secondary messenger that regulates a variety of cellular functions in response to diverse environmental stimuli already in the deepest roots of the prokaryotes.
Collapse
Affiliation(s)
- U Römling
- Microbiology and Tumor Biology Center, Karolinska Institutet, Box 280, 17177 Stockholm, Sweden.
| |
Collapse
|