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Reeves MJ, Fonarow GC, Smith EE, Sheth KN, Messe SR, Schwamm LH. Twenty Years of Get With The Guidelines-Stroke: Celebrating Past Successes, Lessons Learned, and Future Challenges. Stroke 2024; 55:1689-1698. [PMID: 38738376 PMCID: PMC11208062 DOI: 10.1161/strokeaha.124.046527] [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] [Indexed: 05/14/2024]
Abstract
The Get With The Guidelines-Stroke program which, began 20 years ago, is one of the largest and most important nationally representative disease registries in the United States. Its importance to the stroke community can be gauged by its sustained growth and widespread dissemination of findings that demonstrate sustained increases in both the quality of care and patient outcomes over time. The objectives of this narrative review are to provide a brief history of Get With The Guidelines-Stroke, summarize its major successes and impact, and highlight lessons learned. Looking to the next 20 years, we discuss potential challenges and opportunities for the program.
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Affiliation(s)
- Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Gregg C. Fonarow
- Division of Cardiology, Geffen School of Medicine, University of California Los Angeles (G.C.F.)
| | - Eric E. Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Kevin N. Sheth
- Center for Brain & Mind Health, Departments of Neurology & Neurosurgery (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Steven R. Messe
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (S.R.M.)
| | - Lee H. Schwamm
- Department of Neurology and Bioinformatics and Data Sciences (L.H.S.), Yale School of Medicine, New Haven, CT
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Wu X, Xu Y, Wei M, Li M, Lei X, Yuan H, Guo J, Zhang Q, Zhang X, Sun M, Fan T, Luo G. Oral anticoagulants status after acute ischemic stroke and prognosis in patients with atrial fibrillation. J Stroke Cerebrovasc Dis 2024; 33:107452. [PMID: 37931484 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107452] [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: 07/04/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVES To investigate the oral anticoagulants (OACs) use after acute ischemic stroke (AIS) and prognosis of patients with atrial fibrillation (AF). METHODS This was a real-world follow-up research of AIS patients with AF admitted to 5 hospitals in northwestern China. We visited these individuals every 6 months to check the type, dosage of OACs, and to record IS recurrence, bleeding, and death events and modified Rankin Scale (mRS) scores until December 2022. When one of the following occurring first was endpoint: IS recurrence, death or study end. Patients were divided into continuous anticoagulation group and non-continuous anticoagulation group based on whether they continued to take OACs from the moment they were discharged until the endpoint. We further analyzed the association between anticoagulation persistence and outcomes. RESULTS Among all 250 patients with OACs indication, 147 patients (58.8 %) received OACs at discharge. Only 37.9 % of patients (39/103) started OACs after discharge. Of the 147 patients treated with OACs, 21.8 % (32/147) discontinued anticoagulation after discharge. 239 of the 250 patients had completed the median 40-month follow-up with 91 patients in continuous anticoagulation group and 148 patients in non-continuous anticoagulation group. In the multivariate COX regression, non-continuous anticoagulation was an independent risk factor for poor prognosis (mRS>2) in AIS patients with AF (1.452[1.011, 2.086], p = 0.043). CONCLUSIONS This study revealed an upward trend in the use rate of OACs, but low OACs rates that meet guideline-based criteria and low anticoagulation persistence in AF patients after AIS in the northwestern China. Discontinuous anticoagulation was associated with an increased risk of poor prognosis in these patients.
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Affiliation(s)
- Xiaoyu Wu
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China; Atrial Fibrillation Centre and Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China
| | - Yue Xu
- Department of Neurology, Ninth hospital of Xi'an, No. 151 East Section of South Second Ring Road, Xi'an 710054, China
| | - Meng Wei
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China
| | - Mengmeng Li
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China
| | - Xiangyu Lei
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China
| | - Huijie Yuan
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China
| | - Jing Guo
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No.55 Xingshansi West Street, Xi'an 710061, China
| | - Qiang Zhang
- Department of Neurology, Shaanxi Provincial People's Hospital, No. 256 Youyi West Road, Xi'an 710068, China
| | - Xiao Zhang
- Department of Neurology, Xijing Hospital of Air Force Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Man Sun
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157 Xiwu Road, Xi'an 710004, China
| | - Tong Fan
- Department of Neurology, Xi'an Gaoxin Hospital, No. 16 Tuanjie South Road, Xi'an 710075, China
| | - Guogang Luo
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an 710061, China.
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Barros GWF, Eriksson M, Häggström J. Performance of modeling and balancing approach methods when using weights to estimate treatment effects in observational time-to-event settings. PLoS One 2023; 18:e0289316. [PMID: 38060567 PMCID: PMC10703278 DOI: 10.1371/journal.pone.0289316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/16/2023] [Indexed: 12/18/2023] Open
Abstract
In observational studies weighting techniques are often used to overcome bias due to confounding. Modeling approaches, such as inverse propensity score weighting, are popular, but often rely on the correct specification of a parametric model wherein neither balance nor stability are targeted. More recently, balancing approach methods that directly target covariate imbalances have been proposed, and these allow the researcher to explicitly set the desired balance constraints. In this study, we evaluate the finite sample properties of different modeling and balancing approach methods, when estimating the marginal hazard ratio, through Monte Carlo simulations. The use of the different methods is also illustrated by analyzing data from the Swedish stroke register to estimate the effect of prescribing oral anticoagulants on time to recurrent stroke or death in stroke patients with atrial fibrillation. In simulated scenarios with good overlap and low or no model misspecification the balancing approach methods performed similarly to the modeling approach methods. In scenarios with bad overlap and model misspecification, the modeling approach method incorporating variable selection performed better than the other methods. The results indicate that it is valuable to use methods that target covariate balance when estimating marginal hazard ratios, but this does not in itself guarantee good performance in situations with, e.g., poor overlap, high censoring, or misspecified models/balance constraints.
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Affiliation(s)
- Guilherme W. F. Barros
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Marie Eriksson
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Jenny Häggström
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
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Lin KJ, Singer DE, Ko D, Glynn R, Najafzadeh M, Lee SB, Bessette LG, Cervone A, DiCesare E, Kim DH. Frailty, Home Time, and Health Care Costs in Older Adults With Atrial Fibrillation Receiving Oral Anticoagulants. JAMA Netw Open 2023; 6:e2342264. [PMID: 37943558 PMCID: PMC10636636 DOI: 10.1001/jamanetworkopen.2023.42264] [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: 07/05/2023] [Accepted: 09/26/2023] [Indexed: 11/10/2023] Open
Abstract
Importance There are no data on patient-centered outcomes and health care costs by frailty in patients with atrial fibrillation (AF) taking oral anticoagulants (OACs). Objective To compare home time, clinical events, and health care costs associated with OACs by frailty levels in older adults with AF. Design, Setting, and Participants This community-based cohort study assessed Medicare fee-for-service beneficiaries 65 years or older with AF from January 1, 2013, to December 31, 2019. Data analysis was performed from January to December 2022. Exposures Apixaban, rivaroxaban, and warfarin use were measured from prescription claims. Frailty was measured using a validated claims-based frailty index. Main outcomes and measures Outcome measures were (1) home time (days alive out of the hospital and skilled nursing facility) loss greater than 14 days; (2) a composite end point of ischemic stroke, systemic embolism, major bleeding, or death; and (3) total cost per member per year after propensity score overlap weighting. Results The weighted population comprised 136 551 beneficiaries, including 45 950 taking apixaban (mean [SD] age, 77.6 [7.3] years; 51.3% female), 45 320 taking rivaroxaban (mean [SD] age, 77.6 [7.3] years; 51.9% female), and 45 281 taking warfarin (mean [SD] age, 77.6 [7.3] years; 52.0% female). Compared with apixaban, rivaroxaban was associated with increased risk of home time lost greater than 14 days (risk difference per 100 persons, 1.8 [95% CI, 1.5-2.1]), composite end point (rate difference per 1000 person-years, 21.3 [95% CI, 16.4-26.2]), and total cost (mean difference, $890 [95% CI, $652-$1127]), with greater differences among the beneficiaries with frailty. Use of warfarin relative to apixaban was associated with increased home time lost (risk difference per 100 persons, 3.2 [95% CI, 2.9-3.5]) and composite end point (rate difference per 1000 person-years, 29.4 [95% CI, 24.5-34.3]), with greater differences among the beneficiaries with frailty. Compared with apixaban, warfarin was associated with lower total cost (mean difference, -$1166 [95% CI, -$1396 to -$937]) but higher cost when excluding OAC cost (mean difference, $1409 [95% CI, $1177 to $1642]) regardless of frailty levels. Conclusions and Relevance In older adults with AF, apixaban was associated with increased home time and lower rates of clinical events than rivaroxaban and warfarin, especially for those with frailty. Apixaban was associated with lower total cost compared with rivaroxaban but higher cost compared with warfarin due to higher OAC cost. These findings suggest that apixaban may be preferred for older adults with AF, particularly those with frailty.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Daniel E. Singer
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Darae Ko
- Section of Cardiovascular Medicine, Boston Medical Center, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Robert Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lily Gui Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elyse DiCesare
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Hallet J, Rousseau M, Gupta V, Hirpara D, Zhao H, Coburn N, Darling G, Kidane B. Long-term Functional Outcomes Among Older Adults Undergoing Video-assisted Versus Open Surgery for Lung Cancer: A Population-based Cohort Study. Ann Surg 2023; 277:e1348-e1354. [PMID: 35129475 DOI: 10.1097/sla.0000000000005387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the long-term healthcare dependency outcomes of older adults undergoing VATS compared to open lung cancer resection. SUMMARY OF BACKGROUND DATA Although the benefits of VATS for lung cancer resection have been reported, there is a knowledge gap related to long-term functional outcomes central to decision-making for older adults. METHODS We conducted a population-based retrospective comparative cohort study of patients ≥70 years old undergoing lung cancer resection between 2010 and 2017 using linked administrative health databases. VATS was compared to open surgery for lung cancer resection. Outcomes were receipt of homecare and high time-at-home, defined as <14 institution-days within 1 year, in 5 years after surgery. We used time-to-event analyses. Homecare was analyzed as recurrent dichotomous outcome with Andersen-Gill multivariable models, and high time-at-home with Cox multivariable models. RESULTS Of 4974 patients, 2951 had VATS (59.3%). In the first three months postoperatively, homecare use ranged from 17.5% to 34.4% for VATS and 23.0% to 36.6% for open surgery. VATS was independently associated with lower need for postoperative homecare over 5 years (hazard ratio 0.82, 95% confidence interval 0.74-0.92). 1- and 5-year probability of high "time-at-home" were superior for VATS (74.4% vs 66.7% and 55.6% vs 45.4%, p < 0.001). VATS was independently associated with higher probability of high "time-at-home" (hazard ratio 0.81, 95% confidence interval 0.74-0.89) compared to open surgery. CONCLUSIONS Compared to open surgery, VATS was associated with lower homecare needs and higher probability of high "time-at-home," indicating reduced long-term functional dependence. Those important patient-centered endpoints reflect the overall long-term treatment burden on mortality and morbidity that can inform surgical decision-making.
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Affiliation(s)
- Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Center - Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Mathieu Rousseau
- Department of Thoracic Surgery, Université de Montréal, Montréal, Québec, Canada
| | - Vaibhav Gupta
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Dhruvin Hirpara
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Natalie Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Center - Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Gail Darling
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, University Health Network, Toronto, Ontario, Canada
| | - Biniam Kidane
- Section of Thoracic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Research Institute in Oncology and Hematology, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
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Harris J, Pouwels KB, Johnson T, Sterne J, Pithara C, Mahadevan K, Reeves B, Benedetto U, Loke Y, Lasserson D, Doble B, Hopewell-Kelly N, Redwood S, Wordsworth S, Mumford A, Rogers C, Pufulete M. Bleeding risk in patients prescribed dual antiplatelet therapy and triple therapy after coronary interventions: the ADAPTT retrospective population-based cohort studies. Health Technol Assess 2023; 27:1-257. [PMID: 37435838 PMCID: PMC10363958 DOI: 10.3310/mnjy9014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background Bleeding among populations undergoing percutaneous coronary intervention or coronary artery bypass grafting and among conservatively managed patients with acute coronary syndrome exposed to different dual antiplatelet therapy and triple therapy (i.e. dual antiplatelet therapy plus an anticoagulant) has not been previously quantified. Objectives The objectives were to estimate hazard ratios for bleeding for different antiplatelet and triple therapy regimens, estimate resources and the associated costs of treating bleeding events, and to extend existing economic models of the cost-effectiveness of dual antiplatelet therapy. Design The study was designed as three retrospective population-based cohort studies emulating target randomised controlled trials. Setting The study was set in primary and secondary care in England from 2010 to 2017. Participants Participants were patients aged ≥ 18 years undergoing coronary artery bypass grafting or emergency percutaneous coronary intervention (for acute coronary syndrome), or conservatively managed patients with acute coronary syndrome. Data sources Data were sourced from linked Clinical Practice Research Datalink and Hospital Episode Statistics. Interventions Coronary artery bypass grafting and conservatively managed acute coronary syndrome: aspirin (reference) compared with aspirin and clopidogrel. Percutaneous coronary intervention: aspirin and clopidogrel (reference) compared with aspirin and prasugrel (ST elevation myocardial infarction only) or aspirin and ticagrelor. Main outcome measures Primary outcome: any bleeding events up to 12 months after the index event. Secondary outcomes: major or minor bleeding, all-cause and cardiovascular mortality, mortality from bleeding, myocardial infarction, stroke, additional coronary intervention and major adverse cardiovascular events. Results The incidence of any bleeding was 5% among coronary artery bypass graft patients, 10% among conservatively managed acute coronary syndrome patients and 9% among emergency percutaneous coronary intervention patients, compared with 18% among patients prescribed triple therapy. Among coronary artery bypass grafting and conservatively managed acute coronary syndrome patients, dual antiplatelet therapy, compared with aspirin, increased the hazards of any bleeding (coronary artery bypass grafting: hazard ratio 1.43, 95% confidence interval 1.21 to 1.69; conservatively-managed acute coronary syndrome: hazard ratio 1.72, 95% confidence interval 1.15 to 2.57) and major adverse cardiovascular events (coronary artery bypass grafting: hazard ratio 2.06, 95% confidence interval 1.23 to 3.46; conservatively-managed acute coronary syndrome: hazard ratio 1.57, 95% confidence interval 1.38 to 1.78). Among emergency percutaneous coronary intervention patients, dual antiplatelet therapy with ticagrelor, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.06, 95% confidence interval 0.89 to 1.27). Among ST elevation myocardial infarction percutaneous coronary intervention patients, dual antiplatelet therapy with prasugrel, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.48, 95% confidence interval 1.02 to 2.12), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.10, 95% confidence interval 0.80 to 1.51). Health-care costs in the first year did not differ between dual antiplatelet therapy with clopidogrel and aspirin monotherapy among either coronary artery bypass grafting patients (mean difference £94, 95% confidence interval -£155 to £763) or conservatively managed acute coronary syndrome patients (mean difference £610, 95% confidence interval -£626 to £1516), but among emergency percutaneous coronary intervention patients were higher for those receiving dual antiplatelet therapy with ticagrelor than for those receiving dual antiplatelet therapy with clopidogrel, although for only patients on concurrent proton pump inhibitors (mean difference £1145, 95% confidence interval £269 to £2195). Conclusions This study suggests that more potent dual antiplatelet therapy may increase the risk of bleeding without reducing the incidence of major adverse cardiovascular events. These results should be carefully considered by clinicians and decision-makers alongside randomised controlled trial evidence when making recommendations about dual antiplatelet therapy. Limitations The estimates for bleeding and major adverse cardiovascular events may be biased from unmeasured confounding and the exclusion of an eligible subgroup of patients who could not be assigned an intervention. Because of these limitations, a formal cost-effectiveness analysis could not be conducted. Future work Future work should explore the feasibility of using other UK data sets of routinely collected data, less susceptible to bias, to estimate the benefit and harm of antiplatelet interventions. Trial registration This trial is registered as ISRCTN76607611. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jessica Harris
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Thomas Johnson
- Department of Cardiology, Bristol Heart Institute, Bristol, UK
| | - Jonathan Sterne
- National Institute for Health Research Biomedical Research Centre, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Christalla Pithara
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | | | - Barney Reeves
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Sabi Redwood
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Mumford
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Rogers
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre, University of Bristol, Bristol, UK
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Xue S, Qiu X, Wei M, Kong Q, Dong J, Wang Q, Li F, Song H. Changing trends and factors influencing anticoagulant use in patients with acute ischemic stroke and NVAF at discharge in the NOACs era. J Stroke Cerebrovasc Dis 2023; 32:106905. [PMID: 36473400 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/20/2022] [Indexed: 12/09/2022] Open
Abstract
OBJECTIVES We sought to explore the trends and influencing factors of the use of anticoagulants in patients with acute ischemic stroke and non-valvular atrial fibrillation (NVAF) at discharge in the era of novel oral anticoagulants (NOACs). METHODS We recruited consecutive inpatients with acute ischemic stroke and NVAF in a registered study (NCT04080830) from January 2016 to December 2021. The relevant data of patients were collected. We compared the proportions of anticoagulant treatment at discharge before and after NOACs entered China's medical insurance system. The proportion of each antithrombotic status as well as anticoagulant agents at discharge in every year were calculated, and the trends during the study period were analyzed. The relevant factors affecting anticoagulant use at discharge were further analyzed. RESULTS The proportion of anticoagulation at discharge increased significantly after NOACs entered China's medical insurance system in 2018 versus before (χ2 = 42.828, P < 0.001). There were statistically significant differences in antithrombotic status (χ2 = 69.954, P < 0.001) and in the proportion of different anticoagulant drugs (χ2 = 63.049, P<0.001) by year. Anticoagulant therapy (χ2 = 1.55, P = 0.671) and NOACs (χ2 = .178, P = 0.243) increased over 2016-2018 but was relatively stable during 2018-2021. Multivariate logistic regression analysis showed that age ≥75 years, coexisting cerebral artery stenosis, massive cerebral infarction and hemorrhagic transformation were independent risk factors affecting anticoagulants use (all P < 0.05). CONCLUSION NOACs have indeed improved anticoagulants use in patients with acute ischemic stroke and NVAF at discharge. However, some specific factors affect anticoagulation therapy use at discharge and hinder further improvement even in the NOACs era.
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Affiliation(s)
- Sufang Xue
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Xue Qiu
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Min Wei
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Qi Kong
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Jing Dong
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Qiujia Wang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Fangyu Li
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China.
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8
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Kattih B, Operhalski F, Boeckling F, Hecker F, Michael F, Vamos M, Hohnloser SH, Erath JW. Clinical outcomes of subcutaneous vs. transvenous implantable defibrillator therapy in a polymorbid patient cohort. Front Cardiovasc Med 2022; 9:1008311. [PMID: 36330004 PMCID: PMC9624387 DOI: 10.3389/fcvm.2022.1008311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background The subcutaneous implantable cardioverter-defibrillator (S-ICD) has been designed to overcome lead-related complications and device endocarditis. Lacking the ability for pacing or resynchronization therapy its usage is limited to selected patients at risk for sudden cardiac death (SCD). Objective The aim of this single-center study was to assess clinical outcomes of S-ICD and single-chamber transvenous (TV)-ICD in an all-comers population. Methods The study cohort comprised a total of 119 ICD patients who underwent either S-ICD (n = 35) or TV-ICD (n = 84) implantation at the University Hospital Frankfurt from 2009 to 2017. By applying an inverse probability-weighting (IPW) analysis based on the propensity score including the Charlson Comorbidity Index (CCI) to adjust for potential extracardiac comorbidities, we aimed for head-to-head comparison on the study composite endpoint: overall survival, hospitalization, and device-associated events (including appropriate and inappropriate shocks or system-related complications). Results The median age of the study population was 66.0 years, 22.7% of the patients were female. The underlying heart disease was ischemic cardiomyopathy (61.4%) with a median LVEF of 30%. Only 52.9% had received an ICD for primary prevention, most of the patients (67.3%) had advanced heart failure (NYHA class II–III) and 16.8% were in atrial fibrillation. CCI was 5 points in TV-ICD patients vs. 4 points for patients with S-ICD (p = 0.209) indicating increased morbidity. The composite endpoint occurred in 38 patients (31.9 %), revealing no significant difference between patients implanted with an S-ICD or TV-ICD (unweighted HR 1.50, 95 % confidence interval (CI) 0.78–2.90; p = 0.229, weighted HR 0.94, 95% CI, 0.61–1.50, p = 0.777). Furthermore, we observed no difference in any single clinical endpoint or device-associated outcome, neither in the unweighted cohort nor following inverse probability-weighting. Conclusion Clinical outcomes of the S-ICD and TV-ICD revealed no differences in the composite endpoint including survival, freedom of hospitalization and device-associated events, even after careful adjustment for potential confounders. Moreover, the CCI was evaluated in a S-ICD cohort demonstrating higher survival rates than predicted by the CCI in young, polymorbid (S-)ICD patients.
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Affiliation(s)
- Badder Kattih
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Felix Operhalski
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Felicitas Boeckling
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Florian Hecker
- Department of Cardiac Surgery, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Felix Michael
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Mate Vamos
- Cardiac Electrophysiology Division, Department of Internal Medicine, University of Szeged, Szeged, Hungary
| | - Stefan H. Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Julia W. Erath
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
- *Correspondence: Julia W. Erath
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9
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Mkoma GF, Johnsen SP, Iversen HK, Andersen G, Norredam M. Immigration status and utilization of secondary preventive treatment after ischemic stroke. Eur Stroke J 2022; 7:402-412. [PMID: 36478760 PMCID: PMC9720847 DOI: 10.1177/23969873221111870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: The objective of the study was to assess use and persistence of secondary preventive treatment after ischemic stroke comparing immigrants and Danish-born residents. Patients and methods: A cohort of patients discharged with ischemic stroke (IS) diagnosis ( n = 106,224) by immigration status was identified from the Danish Stroke Registry between 2005 and 2018. We investigated use (claiming at least one prescription in 180 days post-discharge according to information from the Register of Medicinal Products Statistics) and persistence of treatment within 180 days thereafter using multivariable logistic regression and Fine and Gray models. Results: Overall, 82,078 Danish-born residents (80.6%) and 3589 (80.7%) immigrants with IS used at least one of the recommended preventive medications post-discharge. Immigrants had lower odds of use of anticoagulants and angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB) (odds ratio (OR), 0.66; 95% confidence interval (CI), 0.53–0.82 and OR, 0.87; 95% CI, 0.75–0.98, respectively) but had higher odds of use of beta-blockers (OR, 1.25; 95% CI, 1.02–1.53) than Danish-born residents after adjustment for age at stroke, sex, sociodemographic factors, duration of residence, stroke severity, and comorbidities. The odds were most evident among immigrants originating from non-Western countries. Persistence of medication use did not differ between immigrants and Danish-born residents after adjustment for sociodemographic factors and comorbidities. Conclusion: Modest disparities in use of standard guideline recommended secondary preventive medications were observed when comparing immigrants and Danish-born residents with ischemic stroke. Furthermore, no differences in persistence of medication therapy were observed.
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Affiliation(s)
- George F Mkoma
- Danish Research Center for Migration, Ethnicity and Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Helle K Iversen
- Stroke Center Rigshospitalet, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Grethe Andersen
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Marie Norredam
- Danish Research Center for Migration, Ethnicity and Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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10
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Patorno E, Schneeweiss S, George MG, Tong X, Franklin JM, Pawar A, Mogun H, Moura LMVR, Schwamm LH. Linking the Paul Coverdell National Acute Stroke Program to commercial claims to establish a framework for real-world longitudinal stroke research. Stroke Vasc Neurol 2022; 7:114-123. [PMID: 34750282 PMCID: PMC9067267 DOI: 10.1136/svn-2021-001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/12/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Non-interventional large-scale research on real-world patients who had a stroke requires the use of multiple data sources ensuring access to longitudinal data from large populations with clinically-detailed information. We sought to establish a framework for longitudinal research on patients hospitalised with stroke by linking information-rich, deidentified inpatient data from the Paul Coverdell National Acute Stroke Program (PCNASP) to commercial and Medicare Advantage longitudinal claims data. METHODS All stroke admissions in PCNASP between 2008 and 2015 were evaluated for linkage to longitudinal claims from a commercial insurer using an algorithm based on six available common data fields (patient age, gender, admission date, discharge date, discharge diagnosis and state) and a hospital match. We evaluated the linkage quality (via the percentage of unique records in the linked dataset) and the representativeness of the linked population. We also described medical history, stroke severity and patterns of medication use among the PCNASP-claims linked cohort. RESULTS The linkage produced uniqueness equal to 99.1%. We identified 5644 linked and 98 896 unlinked patients who had an ischaemic stroke hospitalisation in claims data. Linked patients were younger than unlinked (69.7 vs 72.5 years), but otherwise similar by medical history, prestroke medication use or lab values. Stroke severity was mild and most patients were discharged home. Prestroke and discharge use of antihypertensive and statins in the PCNASP were greater than their use as measured by filled prescriptions in claims. CONCLUSIONS High-quality linkage between the PCNASP and commercial claims data is feasible. This linkage identified differences between reported or recommended versus actual out-of-hospital medication utilisation, highlighting the importance of longitudinal data availability for research aimed to improve the care of patients who had a stroke.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, NCCDPHP, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Xin Tong
- Division for Heart Disease and Stroke Prevention, NCCDPHP, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lidia M V R Moura
- Epilepsy and Neurophysiology Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lee H Schwamm
- Fireman Vascular Center and Stroke Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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11
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Spurling LJ, Moonesinghe SR, Oliver CM. Validation of the days alive and out of hospital outcome measure after emergency laparotomy: a retrospective cohort study. Br J Anaesth 2022; 128:449-456. [PMID: 35012739 DOI: 10.1016/j.bja.2021.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 07/29/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Days alive and out of hospital (DAOH) is a composite, patient-centred outcome measure describing a patient's postoperative recovery, encompassing hospitalisation and mortality. DAOH is the number of days not in hospital over a defined postoperative period; patients who die have DAOH of zero. The Standardising Endpoints in Perioperative Medicine (StEP) group recommended DAOH as a perioperative outcome. However, DAOH has never been validated in patients undergoing emergency laparotomy. Here, we validate DAOH after emergency laparotomy and establish the optimal duration of observation. METHODS Prospectively collected data of patients having emergency laparotomy in England (December 1, 2013-November 30, 2017) were linked to national hospital admission and mortality records for the year after surgery. We evaluated construct validity by assessing DAOH variation with known perioperative risk factors and predictive validity for 1 yr mortality using a multivariate Bayesian mixed-effects logistic regression. The optimal postoperative DAOH period (30 or 90 days) was judged on distributional and pragmatic properties. RESULTS We analysed 78 921 records. The median 30-day DAOH (DAOH30) was 16 (inter-quartile range [IQR], 0-22) days and the median DAOH90 was 75 (46-82) days. DAOH was shorter in the presence of known perioperative risk factors. For patients surviving the first 30 postoperative days, shorter DAOH30 was associated with higher 1-yr mortality (odds ratio=0.94; 95% credible interval, 0.94-0.94). CONCLUSION DAOH is a valid, patient-centred outcome after emergency laparotomy. We recommend its use in clinical trials, quality assurance, and quality improvement, measured at 30 days as mortality heavily skews DAOH measured at 90 days and beyond.
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Affiliation(s)
- Leigh-James Spurling
- Surgical Outcomes Research Centre (SOuRCe), Centre for Perioperative Medicine, Division of Surgical and Interventional Science, University College London, London, UK; Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK.
| | - S Ramani Moonesinghe
- Surgical Outcomes Research Centre (SOuRCe), Centre for Perioperative Medicine, Division of Surgical and Interventional Science, University College London, London, UK; Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK
| | - C Matthew Oliver
- Surgical Outcomes Research Centre (SOuRCe), Centre for Perioperative Medicine, Division of Surgical and Interventional Science, University College London, London, UK; Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK
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12
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Lockwood KJ, Porter J. Effectiveness of Hospital-Based Interventions by Occupational Therapy Practitioners on Reducing Readmissions: A Systematic Review With Meta-Analyses. Am J Occup Ther 2022; 76:7601180050. [PMID: 35044450 DOI: 10.5014/ajot.2022.048959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Readmission to the hospital can lead to poorer patient outcomes and increased health care costs. The effect of occupational therapy interventions for adult hospitalized patients on readmission rates has not been previously evaluated. OBJECTIVE To systematically examine the published literature to determine the effects of occupational therapy interventions for adult hospitalized patients on readmission rates. DATA SOURCES Systematic search of five electronic databases was performed from database inception until May 2020, supplemented by citation and reference list searches. Study Selection and Data Collection: This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered prospectively; methodological quality of the included studies was assessed using the Downs and Black checklist. Meta-analyses were conducted with clinically homogeneous data; the overall body of evidence was graded for quality. FINDINGS Meta-analysis of 7 studies with 16,718 participants provided low-quality evidence that 1-mo readmission rates were reduced when adult patients hospitalized for general medical and surgical care received additional occupational therapy interventions compared with standard care. Subgroup analysis of 4 studies provided moderate-quality evidence that interventions focusing on the transition from hospital to the community were effective in reducing 1-mo readmissions to hospitals compared with standard care. CONCLUSIONS AND RELEVANCE Occupational therapy interventions can be effective in reducing readmissions among some adult hospitalized patient populations, including those admitted for surgery or management of acute medical conditions, with stronger evidence to support transitional care interventions. What This Article Adds: Occupational therapy interventions can be effective in reducing readmissions among adult hospitalized patients. There is a continued need for occupational therapy practitioners to understand their value and contribution to reducing avoidable readmissions to hospitals.
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Affiliation(s)
- Kylee J Lockwood
- Kylee J. Lockwood, PhD, is Lecturer, Occupational Therapy, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia
| | - Judi Porter
- Judi Porter, PhD, is Professor in Dietetics, School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition, Deakin University, Geelong, Victoria, Australia;
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13
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Dalli LL, Kim J, Cadilhac DA, Greenland M, Sanfilippo FM, Andrew NE, Thrift AG, Grimley R, Lindley RI, Sundararajan V, Crompton DE, Lannin NA, Anderson CS, Whiley L, Kilkenny MF. Greater Adherence to Secondary Prevention Medications Improves Survival After Stroke or Transient Ischemic Attack: A Linked Registry Study. Stroke 2021; 52:3569-3577. [PMID: 34315251 DOI: 10.1161/strokeaha.120.033133] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although a target of 80% medication adherence is commonly cited, it is unclear whether greater adherence improves survival after stroke or transient ischemic attack (TIA). We investigated associations between medication adherence during the first year postdischarge, and mortality up to 3 years, to provide evidence-based targets for medication adherence. METHODS Retrospective cohort study of 1-year survivors of first-ever stroke or TIA, aged ≥18 years, from the Australian Stroke Clinical Registry (July 2010-June 2014) linked with nationwide prescription refill and mortality data (until August 2017). Adherence to antihypertensive agents, statins, and nonaspirin antithrombotic medications was based on the proportion of days covered from discharge until 1 year. Cox regression with restricted cubic splines was used to investigate nonlinear relationships between medication adherence and all-cause mortality (to 3 years postdischarge). Models were adjusted for age, sex, socioeconomic position, stroke factors, primary care factors, and concomitant medication use. RESULTS Among 8363 one-year survivors of first-ever stroke or TIA (44% aged ≥75 years, 44% female, 18% TIA), 75% were supplied antihypertensive agents. In patients without intracerebral hemorrhage (N=7446), 84% were supplied statins, and 65% were supplied nonaspirin antithrombotic medications. Median adherence was ≈90% for each medication group. Between 1% and 100% adherence, greater adherence to statins or antihypertensive agents, but not nonaspirin antithrombotic agents, was associated with improved survival. When restricted to linear regions above 60% adherence, each 10% increase in adherence was associated with a reduction in all-cause mortality of 13% for antihypertensive agents (hazard ratio, 0.87 [95% CI, 0.81-0.95]), 13% for statins (hazard ratio, 0.87 [95% CI, 0.80-0.95]), and 15% for nonaspirin antithrombotic agents (hazard ratio, 0.85 [95% CI, 0.79-0.93]). CONCLUSIONS Greater levels of medication adherence after stroke or TIA are associated with improved survival, even among patients with near-perfect adherence. Interventions to improve medication adherence are needed to maximize survival poststroke.
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Affiliation(s)
- Lachlan L Dalli
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.)
| | - Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, United Kingdom (M.G.).,Nuffield Department of Population Health, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, United Kingdom (M.G.)
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth (F.M.S.)
| | - Nadine E Andrew
- Peninsula Clinical School, Central Clinical School, Monash University, VIC, Australia. (N.E.A.)
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.)
| | - Rohan Grimley
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.).,Sunshine Coast Clinical School, School of Medicine, Griffith University, Birtinya, QLD, Australia (R.G.)
| | - Richard I Lindley
- Faculty of Medicine and Health, The University of Sydney, NSW, Australia (R.I.L.)
| | - Vijaya Sundararajan
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia (V.S.)
| | - Douglas E Crompton
- Department of Neurology, Northern Health, Epping, VIC, Australia (D.E.C.)
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, VIC, Australia. (N.A.L.).,Alfred Health, Melbourne, VIC, Australia (N.A.L.)
| | - Craig S Anderson
- The George Institute for Global Health, Sydney, NSW, Australia (C.S.A.).,The George Institute for Global Health, Peking University Health Science Center, China (C.S.A.)
| | | | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
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14
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Lin X, Wang H, Rong X, Huang R, Peng Y. Exploring stroke risk and prevention in China: insights from an outlier. Aging (Albany NY) 2021; 13:15659-15673. [PMID: 34086602 PMCID: PMC8221301 DOI: 10.18632/aging.203096] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 05/11/2021] [Indexed: 01/01/2023]
Abstract
In contrast to the declining trend in most regions worldwide, the incidence of stroke is increasing in China and is leading to an alarming burden for the national healthcare system. In this review, we have generated new insights from this outlier, and we aim to provide new information that will help decrease the global stroke burden, especially in China and other regions sharing similar problems with China. First of all, several unsolved aspects fundamentally accounting for this discrepancy were promising, including the serious situation of hypertension management, underdiagnosis of atrial fibrillation and underuse of anticoagulants, and unhealthy lifestyles (e.g., heavy smoking). In addition, efforts for further alleviating the incidence of stroke were recommended in certain fields, including targeted antiplatelet regimes and protections from cold wave-related stroke. Furthermore, advanced knowledge about cancer-related strokes, recurrent strokes and the status preceding stroke onset that we called stroke-prone status herein, is required to properly mitigate patient stroke risk, and to provide improved outcomes for patients after a stroke has occurred.
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Affiliation(s)
- Xinrou Lin
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hongxuan Wang
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiaoming Rong
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ruxun Huang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ying Peng
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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15
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Edwards SJ, Wakefield V, Jhita T, Kew K, Cain P, Marceniuk G. Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation. Health Technol Assess 2021; 24:1-184. [PMID: 31944175 DOI: 10.3310/hta24050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cryptogenic stroke is a stroke for which no cause is identified after standard diagnostic tests. Long-term implantable cardiac monitors may be better at diagnosing atrial fibrillation and provide an opportunity to reduce the risk of stroke recurrence with anticoagulants. OBJECTIVES The objectives were to assess the diagnostic test accuracy, clinical effectiveness and cost-effectiveness of three implantable monitors [BioMonitor 2-AF™ (Biotronik SE & Co. KG, Berlin, Germany), Confirm Rx™ (Abbott Laboratories, Lake Bluff, IL, USA) and Reveal LINQ™ (Medtronic plc, Minneapolis, MN, USA)] in patients who have had a cryptogenic stroke and for whom no atrial fibrillation is detected after 24 hours of external electrocardiographic monitoring. DATA SOURCES MEDLINE, EMBASE, The Cochrane Library, Database of Abstracts of Reviews of Effects and Health Technology Assessment databases were searched from inception until September 2018. REVIEW METHODS A systematic review was undertaken. Two reviewers agreed on studies for inclusion and performed quality assessment using the Cochrane Risk of Bias 2.0 tool. Results were discussed narratively because there were insufficient data for synthesis. A two-stage de novo economic model was developed: (1) a short-term patient flow model to identify cryptogenic stroke patients who have had atrial fibrillation detected and been prescribed anticoagulation treatment (rather than remaining on antiplatelet treatment) and (2) a long-term Markov model that captured the lifetime costs and benefits of patients on either anticoagulation or antiplatelet treatment. RESULTS One randomised controlled trial, Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL-AF) (Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-86), was identified, and no diagnostic test accuracy study was identified. The CRYSTAL-AF trial compared the Reveal™ XT (a Reveal LINQ predecessor) (Medtronic plc) monitor with standard of care monitoring. Twenty-six single-arm observational studies for the Reveal devices were also identified. The only data for BioMonitor 2-AF or Confirm Rx were from mixed population studies supplied by the companies. Atrial fibrillation detection in the CRYSTAL-AF trial was higher with the Reveal XT than with standard monitoring at all time points. By 36 months, atrial fibrillation was detected in 19% of patients with an implantable cardiac monitor and in 2.3% of patients receiving conventional follow-up. The 26 observational studies demonstrated that, even in a cryptogenic stroke population, atrial fibrillation detection rates are highly variable and most cases are asymptomatic; therefore, they probably would not have been picked up without an implantable cardiac monitor. Device-related adverse events, such as pain and infection, were low in all studies. The de novo economic model produced incremental cost effectiveness ratios comparing implantable cardiac monitors with standard of care monitoring to detect atrial fibrillation in cryptogenic stroke patients based on data for the Reveal XT device, which can be related to Reveal LINQ. The BioMonitor 2-AF and Confirm RX were included in the analysis by making a strong assumption of equivalence with Reveal LINQ. The results indicate that implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold. When each device is compared incrementally, BioMonitor 2-AF dominates Reveal LINQ and Confirm RX. LIMITATIONS The cost-effectiveness analysis for implantable cardiac monitors is based on a strong assumption of clinical equivalence and should be interpreted with caution. CONCLUSIONS All three implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold, compared with standard of care monitoring, for cryptogenic stroke patients with no atrial fibrillation detected after 24 hours of external electrocardiographic monitoring; however, further clinical studies are required to confirm their efficacy in cryptogenic stroke patients. STUDY REGISTRATION This study is registered as PROSPERO CRD42018109216. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steven J Edwards
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | | | - Tracey Jhita
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Kayleigh Kew
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Peter Cain
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Gemma Marceniuk
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
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16
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Cragg JJ, Azoulay L, Collins G, De Vera MA, Etminan M, Lalji F, Gershon AS, Guyatt G, Harrison M, Jutzeler C, Kassam R, Kendzerska T, Lynd L, Mansournia MA, Sadatsafavi M, Tong B, Warner FM, Tremlett H. The reporting of observational studies of drug effectiveness and safety: recommendations to extend existing guidelines. Expert Opin Drug Saf 2021; 20:1-8. [PMID: 33170749 DOI: 10.1080/14740338.2021.1849134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/06/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The use of observational data to assess drug effectiveness and safety can provide relevant information, much of which may not be feasible to obtain through randomized clinical trials. Because observational studies provide critical drug safety and effectiveness information that influences drug policy and prescribing practices, transparent, consistent, and accurate reporting of these studies is critical. AREAS COVERED We provide recommendations to extend existing reporting guidelines, covering the main components of primary research studies (methods, results, discussion). EXPERT OPINION Our recommendations include extending drug safety and effectiveness guidelines to include explicit checklist items on: study registration, causal diagrams, rationale for measures of effect, comprehensive assessment of bias, comprehensive data cleaning steps, drug equivalents, subject-level drug data visualization, sex and gender-based analyses and results, patient-oriented outcomes, and patient involvement in research.
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Affiliation(s)
- Jacquelyn J Cragg
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, BC, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University , Montreal, QC, Canada
| | - Gary Collins
- Centre for Statistics in Medicine, University of Oxford , Oxford, United Kingdom & EQUATOR
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
| | - Mahyar Etminan
- Departments of Ophthalmology and Medicine, Faculty of Medicine, University of British Columbia , Vancouver, BC, Canada
| | - Fawziah Lalji
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
| | - Andrea S Gershon
- Department of Medicine, University of Toronto , Toronto, Ontario
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence & Impact, McMaster University , Hamilton, Ontario, Canada
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
- Center for Health Evaluation and Outcome Sciences (CHEOS), St. Paul's Hospital , Vancouver, BC, Canada
| | - Catherine Jutzeler
- Department of Biosystems Science & Engineering, ETH Zurich , Zurich, Switzerland
| | - Rosemin Kassam
- School of Population and Public Health, University of British Columbia , Vancouver, BC, Canada
| | | | - Larry Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences , Tehran, Iran
| | - Mohsen Sadatsafavi
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
| | - Bobo Tong
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, BC, Canada
| | - Freda M Warner
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
| | - Helen Tremlett
- Division of Neurology, Department of Medicine, University of British Columbia , Vancouver, BC, Canada
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17
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Zhang L, Wu HL, Yu HF, Zhou JL. Time spent outside of the hospital, CKD progression, and mortality: a prospective cohort study. Int Urol Nephrol 2021; 53:1659-1663. [PMID: 33386581 DOI: 10.1007/s11255-020-02749-8] [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: 09/13/2020] [Accepted: 12/07/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Home time-being out of any healthcare facility-has been proposed as a patient-centered outcome. This novel measure has not been investigated in patients with chronic kidney disease (CKD). The aim of this study is to determine whether there was an association between home time and occurrence of end-stage renal disease (ESRD) or all-cause mortality during 1 year of follow-up. METHODS We assembled a prospective cohort of patients with CKD not requiring dialysis at the Nephrology Center of First Affiliated Hospital of Jiaxing University between May 2014 and April 2017 and followed up for 1 year. Home time was calculated as the number of days spent out of a hospital, rehabilitation facility, or skilled nursing facility. Outcomes included progression to ESRD and all-cause mortality. RESULTS Among 943 patients, 882 (93.5%) had complete follow-up through 1 year. Mean home time was 246.9 ± 126.7 days. In regression analysis, several patient characteristics were associated with significantly reduced home time, including diabetes mellitus, cardiovascular disease, and albuminuria. Home time was strongly correlated with time-to-event endpoints of ESRD (τ=0.324) and all-cause mortality (τ=0.785). CONCLUSIONS Home time is significantly reduced for patients with CKD not requiring dialysis and is highly correlated with traditional time-to-event endpoints. Home time serves as a novel, easily calculated, patient-centered outcome that may reflect effect of interventions on future CKD research.
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Affiliation(s)
- Lin Zhang
- Department of Nephrology, Affiliated Hospital of Jiaxing University, 1882 Zhonghuan South Road, Jiaxing, 314000, China
| | - Heng-Lan Wu
- Department of Nephrology, Affiliated Hospital of Jiaxing University, 1882 Zhonghuan South Road, Jiaxing, 314000, China
| | - Hai-Feng Yu
- Department of Nephrology, Affiliated Hospital of Jiaxing University, 1882 Zhonghuan South Road, Jiaxing, 314000, China
| | - Jun-Liang Zhou
- Department of Nephrology, Affiliated Hospital of Jiaxing University, 1882 Zhonghuan South Road, Jiaxing, 314000, China.
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Oehrlein EM, Luo X, Savone M, Lobban T, Kang A, Lee B, Gale R, Schoch S, Perfetto E. Engaging Patients in Real-World Evidence: An Atrial Fibrillation Patient Advisory Board Case Example. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 14:295-300. [PMID: 33355917 PMCID: PMC7884300 DOI: 10.1007/s40271-020-00479-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 10/31/2022]
Affiliation(s)
| | - Xuemei Luo
- Pfizer, Inc, Health Economics and Outcomes Research, Groton, CT, USA
| | | | - Trudie Lobban
- Heart Rhythm Alliance, Arrhythmia Alliance, PO Box 5507, Hilton Head Island, SC, 29938, USA
| | - Amiee Kang
- Bristol-Myers Squibb Company, 3401 Princeton Pike, Lawrence Township, NJ, 08648, USA
| | - Brian Lee
- Bristol-Myers Squibb Company, 3401 Princeton Pike, Lawrence Township, NJ, 08648, USA
| | - Rex Gale
- Board Member-Arrhythmia Alliance, P O Box 5507, Hilton Head Island, SC, 29938, USA
| | - Silke Schoch
- National Health Council, 1730 M St, Suite 500, Washington, DC, USA
| | - Eleanor Perfetto
- National Health Council, 1730 M St, Suite 500, Washington, DC, USA.,Department Pharmaceutical Health Services Research, University of Maryland Baltimore, 220 Arch Street 12th floor, Baltimore, MD, 21201, USA
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19
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Antiplatelet patterns and outcomes in patients with atrial fibrillation not prescribed an anticoagulant after stroke. Int J Cardiol 2020; 321:88-94. [PMID: 32805327 DOI: 10.1016/j.ijcard.2020.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/14/2020] [Accepted: 08/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND To determine association of discharge antiplatelet therapy prescription with 1-year outcomes among patients with AF admitted with acute ischemic stroke and discharged without oral anticoagulation. METHODS In a retrospective cohort study from the Get With The Guidelines-Stroke registry, we identified all Medicare fee-for-service beneficiaries 65 years or older with AF or atrial flutter admitted with acute ischemic stroke and discharged without oral anticoagulation from April 2003 through December 2014, and we determined association of discharge antiplatelet therapy prescription with 1-year outcomes using Medicare claims data. Primary outcomes were 1-year mortality and composite endpoint of major adverse cardiovascular/neurologic/bleeding events (MACNBE). RESULTS Of 64,228 subjects (median [interquartile range] age, 84 [78-89] years; 62.5% female), 54,621 (85.0%) were discharged with antiplatelet therapy, and 9607 (15.0%) were discharged with no antithrombotic therapy. The unadjusted rates of 1-year mortality were lower among patients receiving antiplatelet therapy (37.3%) than among those receiving no antithrombotic therapy (48.1%); unadjusted rates of MACNBE were lower for those receiving antiplatelet therapy (45.5%) compared with those receiving no antithrombotic therapy (55.2%). After adjusting for potential confounders, antiplatelet therapy prescription was associated with reduced 1-year mortality (adjusted hazard ratio [HR] 0.64, 95% confidence interval [CI] 0.62-0.66, P < .001) and MACNBE (adjusted HR 0.69, 95% CI 0.67-0.71, P < .001). CONCLUSIONS Among Medicare beneficiaries with AF admitted for acute ischemic stroke but not discharged on oral anticoagulant therapy, antiplatelet therapy, compared with no antithrombotic therapy, was associated with reduced 1-year mortality and MACNBE.
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20
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Lee KC, Sturgeon D, Lipsitz S, Weissman JS, Mitchell S, Cooper Z. Mortality and Health Care Utilization Among Medicare Patients Undergoing Emergency General Surgery vs Those With Acute Medical Conditions. JAMA Surg 2020; 155:216-223. [PMID: 31877209 DOI: 10.1001/jamasurg.2019.5087] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Emergency general surgery (EGS) represents 11% of hospitalizations, and almost half of these hospitalized patients are older adults. Older adults have high rates of mortality and readmissions after EGS, yet little is known as to how these outcomes compare with acute medical conditions that have been targets for quality improvement. Objective To examine whether Medicare beneficiaries who undergo EGS experience similar 1-year outcomes compared with patients admitted with acute medical conditions. Design, Setting, and Participants This population-based, retrospective cohort study using Medicare claims data from January 1, 2008, to December 31, 2014, included adults 65 years or older with at least 1 year of Medicare claims who had urgent or emergency admissions for 1 of the 5 highest-burden EGS procedures (partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy) or a primary diagnosis of an acute medical condition (pneumonia, heart failure, or acute myocardial infarction). Patients undergoing EGS and those with acute medical conditions were matched 1:1 in a 2-step algorithm: (1) exact match by hospital or (2) propensity score match with age, sex, race/ethnicity, Charlson Comorbidity Index, individual comorbid conditions, claims-based frailty index, year of admission, and any intensive care unit stay. Data analysis was performed from July 16, 2018, to November 13, 2019. Exposures Partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy or a primary diagnosis pneumonia, heart failure, or acute myocardial infarction. Main Outcomes and Measures One-year mortality, postdischarge health care utilization (emergency department visit, additional hospitalization, intensive care unit stay, or total hospital encounters), and days at home during 1 year. Results A total of 481 417 matched pairs (mean [SD] age, 78.9 [7.8] years; 272 482 [56.6%] female) with adequate covariate balance were included in the study. Patients undergoing EGS experienced higher 30-day mortality (60 683 [12.6%] vs 56 713 [11.8%], P < .001) yet lower 1-year mortality (142 846 [29.7%] vs 158 385 [32.9%], P < .001) compared with medical patients. Among 409 363 pairs who survived discharge, medical patients experienced higher rates of total hospital encounters in the year after discharge (4 vs 3 per person-year; incidence rate ratio, 1.31; 95% CI, 1.30-1.32) but had similar mean days at home compared with patients undergoing EGS (293 vs 309 days; incident rate ratio, 1.004; 95% CI, 1.004-1.004). Conclusions and Relevance In this study, older patients undergoing EGS had similarly high 1-year rates of mortality, hospital use, and days away from home as acutely ill medical patients. These findings suggest that EGS should also be targeted for national quality improvement programs.
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Affiliation(s)
- Katherine C Lee
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, University of California at San Diego, La Jolla
| | - Daniel Sturgeon
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan Mitchell
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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21
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Chesney TR, Haas B, Coburn NG, Mahar AL, Zuk V, Zhao H, Wright FC, Hsu AT, Hallet J. Patient-Centered Time-at-Home Outcomes in Older Adults After Surgical Cancer Treatment. JAMA Surg 2020; 155:e203754. [PMID: 33026417 DOI: 10.1001/jamasurg.2020.3754] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Functional outcomes are central to cancer care decision-making by older adults. Objective To assess the long-term functional outcomes of older adults after a resection for cancer using time at home as the measure. Design, Setting, and Participants This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). The analysis included adults 70 years or older with a new diagnosis of cancer between January 1, 2007, and December 31, 2017, who underwent a resection 90 days to 180 days after the diagnosis. Patients were followed up until and censored at the date of death, date of last contact, or December 31, 2018. Main Outcomes and Measures The main outcome was time at home, dichotomized as high time at home (defined as ≤14 institution days annually) and low time at home (defined as >14 institution days) during the 5 years after surgical cancer treatment. Time-to-event analyses with Kaplan-Meier methods and multivariable Cox proportional hazards regression models were used. Results A total of 82 037 patients were included, with a median (interquartile range) follow-up of 46 (23-80) months. Of these patients, 52 119 were women (63.5%) and the mean (SD) age was 77.5 (5.7) years. The median (interquartile range) number of days at home per days alive per patient was high, at 0.98 (0.94-0.99) in postoperative year 1, 0.99 (0.97-1.00) in year 2, 0.99 (0.96-1.00) in year 3, 0.99 (0.96-1.00) in year 4, and 0.99 (0.96-1.00) in year 5. The probability of high time at home was 70.3% (95% CI, 70.0%-70.6%) at postoperative year 1 and 53.2% (95% CI, 52.8%-53.5%) at postoperative year 5. Advancing age (≥85 years: hazard ratio [HR], 2.11; 95% CI, 2.04-2.18); preoperative frailty (HR, 1.74; 95% CI, 1.68-1.80); high material deprivation (5th quintile: HR, 1.25; 95% CI, 1.20-1.29); rural residency (HR, 1.14; 95% CI, 1.10-1.18); high-intensity surgical procedure (HR, 2.04; 95% CI, 1.84-2.25); and gastrointestinal (HR, 1.23; 95% CI, 1.18-1.27), gynecologic (HR, 1.31; 95% CI, 1.18-1.45), and oropharyngeal (HR, 1.05; 95% CI, 0.95-1.16) cancers were associated with low time at home. Inpatient acute care was responsible for 76.0% and long-term care was responsible for 2.0% of institution days in postoperative year 1. Inpatient days decreased to 31.0% by year 3, but days in long-term care increased over time. Conclusions and Relevance This study found that older adults predominantly experienced high time at home after resection for cancer, reflecting the overall favorable functional outcomes in this population. The oldest adults and those with preoperative frailty and material deprivation appeared to be the most vulnerable to low time at home, and efforts to optimize and manage expectations about surgical outcomes can be targeted for this population; this information is important for patient counseling regarding surgical cancer treatment and for preparation for postoperative recovery.
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Affiliation(s)
- Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Frances C Wright
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
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22
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Lee KC, Streid J, Sturgeon D, Lipsitz S, Weissman JS, Rosenthal RA, Kim DH, Mitchell SL, Cooper Z. The Impact of Frailty on Long-Term Patient-Oriented Outcomes after Emergency General Surgery: A Retrospective Cohort Study. J Am Geriatr Soc 2020; 68:1037-1043. [PMID: 32043562 PMCID: PMC7234900 DOI: 10.1111/jgs.16334] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/11/2019] [Accepted: 12/14/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Few studies examine the impact of frailty on long-term patient-oriented outcomes after emergency general surgery (EGS). We measured the prevalence of frailty among older EGS patients and examined the impact of frailty on 1-year outcomes. DESIGN Retrospective cohort study using 2008 to 2014 Medicare claims. SETTING Acute care hospitals. PARTICIPANTS Patients 65 years or older who received one of the five EGS procedures with the highest mortality burden (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy). MEASUREMENTS A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < .15), pre-frail (.15 ≤ CFI < .25), mildly frail (.25 ≤ CFI < .35), and moderately to severely frail (CFI ≥ .35). Multivariable Cox regression compared 1-year mortality. Multivariable Poisson regression compared rates of post-discharge hospital encounters (hospitalizations, intensive care unit stay, emergency department visit) and home time over 1 year after discharge. All regression models adjusted for age, sex, race, admission from facility, procedure, sepsis, inpatient palliative care delivery, trauma center designation, hospital bed size, and teaching status, and they were clustered by patient and hospital referral region. RESULTS Among 468 459 older EGS adults, 37.4% were pre-frail, 12.4% were mildly frail, and 3.6% were moderately to severely frail. Patients with mild frailty experienced a higher risk of 1-year mortality compared with non-frail patients (hazard ratio = 1.97; confidence interval [CI] = 1.94-2.01). In the year after discharge, patients with mild and moderate to severe frailty had more hospital encounters compared with non-frail patients (7.8 and 11.5 vs 2.0 per person-year; incidence rate ratio [IRR] = 4.01; CI = 3.93-4.08 vs IRR = 5.89; CI = 5.70-6.09, respectively). Patients with mild and moderate to severe frailty also had fewer days at home in the year after discharge compared with non-frail patients (256 and 203 vs 302 mean days; IRR = .97; CI = .96-.97 vs IRR = .95; CI = .94-.95, respectively). CONCLUSION Older EGS patients with frailty are at increased risk for poor 1-year outcomes and decreased home time. Targeted interventions for older EGS patients with frailty during the index EGS hospitalization are urgently needed to improve long-term outcomes. J Am Geriatr Soc 68:1037-1043, 2020.
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Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Surgery, University of California, San Diego, California
| | | | - Dan Sturgeon
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stuart Lipsitz
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joel S Weissman
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Dae H Kim
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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23
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Faure M, Castilloux AM, Lillo-Le-Louet A, Bégaud B, Moride Y. Secondary Stroke Prevention: A Population-Based Cohort Study on Anticoagulation and Antiplatelet Treatments, and the Risk of Death or Recurrence. Clin Pharmacol Ther 2020; 107:443-451. [PMID: 31502245 DOI: 10.1002/cpt.1625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/26/2019] [Indexed: 01/05/2023]
Abstract
Using claims databases of a public healthcare program (Quebec) for the years 2010-2013, we conducted a cohort study of patients with acute ischemic stroke (AIS) to describe secondary prevention treatments and determine how they stood against practice guidelines. We compared the risk of death or AIS recurrence over 1 year in patients treated with anticoagulants, antiplatelets, and/or other cardiovascular drugs. In the month after discharge, 44.3% of the patients did not receive the recommended treatment and > 20% did not have any treatment. Untreated patients were younger, had less comorbidities, and a more severe AIS. Anticoagulants and antiplatelets were associated with a reduced risk of death or recurrence (hazard ratio (HR) 0.27; 95% confidence interval (CI) 0.20-0.36 and HR 0.25; 95% CI 0.16-0.38, respectively) compared with the untreated group. Effect size was similar for the other treatments. Findings confirm treatment benefits shown in clinical trials and emphasize the importance of AIS secondary prevention.
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Affiliation(s)
- Mareva Faure
- Faculty of Pharmacy, Université de Montréal, Montréal, Québec, Canada
| | | | - Agnès Lillo-Le-Louet
- Centre Régional de Pharmacovigilance de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Bernard Bégaud
- Département de Pharmacologie médicale, Université de Bordeaux, Bordeaux, France
| | - Yola Moride
- Faculty of Pharmacy, Université de Montréal, Montréal, Québec, Canada.,Center for Pharmacoepidemiology and Treatment Science, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
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24
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Xian Y, Xu H, O'Brien EC, Shah S, Thomas L, Pencina MJ, Fonarow GC, Olson DM, Schwamm LH, Bhatt DL, Smith EE, Hannah D, Maisch L, Lytle BL, Peterson ED, Hernandez AF. Clinical Effectiveness of Direct Oral Anticoagulants vs Warfarin in Older Patients With Atrial Fibrillation and Ischemic Stroke: Findings From the Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study. JAMA Neurol 2019; 76:1192-1202. [PMID: 31329212 DOI: 10.1001/jamaneurol.2019.2099] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Current guidelines recommend direct oral anticoagulants (DOACs) over warfarin for stroke prevention in patients with atrial fibrillation (AF) who are at high risk. Despite demonstrated efficacy in clinical trials, real-world data of DOACs vs warfarin for secondary prevention in patients with ischemic stroke are largely based on administrative claims or have not focused on patient-centered outcomes. Objective To examine the clinical effectiveness of DOACs (dabigatran, rivaroxaban, or apixaban) vs warfarin after ischemic stroke in patients with AF. Design, Setting, and Participants This cohort study included patients who were 65 years or older, had AF, were anticoagulation naive, and were discharged from 1041 Get With The Guidelines-Stroke-associated hospitals for acute ischemic stroke between October 2011 and December 2014. Data were linked to Medicare claims for long-term outcomes (up to December 2015). Analyses were completed in July 2018. Exposures DOACs vs warfarin prescription at discharge. Main Outcomes and Measures The primary outcomes were home time, a patient-centered measure defined as the total number of days free from death and institutional care after discharge, and major adverse cardiovascular events. A propensity score-overlap weighting method was used to account for differences in observed characteristics between groups. Results Of 11 662 survivors of acute ischemic stroke (median [interquartile range] age, 80 [74-86] years), 4041 (34.7%) were discharged with DOACs and 7621 with warfarin. Except for National Institutes of Health Stroke Scale scores (median [interquartile range], 4 [1-9] vs 5 [2-11]), baseline characteristics were similar between groups. Patients discharged with DOACs (vs warfarin) had more days at home (mean [SD], 287.2 [114.7] vs 263.0 [127.3] days; adjusted difference, 15.6 [99% CI, 9.0-22.1] days) during the first year postdischarge and were less likely to experience major adverse cardiovascular events (adjusted hazard ratio [aHR], 0.89 [99% CI, 0.83-0.96]). Also, in patients receiving DOACs, there were fewer deaths (aHR, 0.88 [95% CI, 0.82-0.95]; P < .001), all-cause readmissions (aHR, 0.93 [95% CI, 0.88-0.97]; P = .003), cardiovascular readmissions (aHR, 0.92 [95% CI, 0.86-0.99]; P = .02), hemorrhagic strokes (aHR, 0.69 [95% CI, 0.50-0.95]; P = .02), and hospitalizations with bleeding (aHR, 0.89 [95% CI, 0.81-0.97]; P = .009) but a higher risk of gastrointestinal bleeding (aHR, 1.14 [95% CI, 1.01-1.30]; P = .03). Conclusions and Relevance In patients with acute ischemic stroke and AF, DOAC use at discharge was associated with better long-term outcomes relative to warfarin.
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Affiliation(s)
- Ying Xian
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Emily C O'Brien
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Shreyansh Shah
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Michael J Pencina
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles
| | | | - Lee H Schwamm
- Harvard Medical School, Massachusetts General Hospital, Boston
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Deidre Hannah
- Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research Study, Durham, North Carolina
| | - Lesley Maisch
- Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research Study, Durham, North Carolina
| | - Barbara L Lytle
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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25
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Wang A, Li Z, Rymer JA, Kosinski AS, Yerokun B, Cox ML, Gulack BC, Sherwood MW, Lopes RD, Inohara T, Thourani V, Kirtane AJ, Holmes D, Hughes GC, Harrison JK, Smith PK, Vemulapalli S. Relation of Postdischarge Care Fragmentation and Outcomes in Transcatheter Aortic Valve Implantation from the STS/ACC TVT Registry. Am J Cardiol 2019; 124:912-919. [PMID: 31375245 DOI: 10.1016/j.amjcard.2019.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/03/2019] [Accepted: 06/10/2019] [Indexed: 11/15/2022]
Abstract
Fragmented care following elective surgery has been associated with poor outcomes. The association between fragmented care and outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) is unknown. We examined patients who underwent TAVI from 2011 to 2015 at 374 sites in the STS/ACC TVT Registry, linked to Center for Medicare and Medicaid Services claims data. Fragmented care was defined as at least one readmission to a site other than the implanting TAVI center within 90 days after discharge, whereas continuous care was defined as readmission to the same implanting center. We compared adjusted 1-year outcomes, including stroke, bleeding, heart failure, mortality, and all-cause readmission in patients who received fragmented versus continuous care. Among 8,927 patients who received a TAVI between 2011 and 2015, 27.4% were readmitted within 90 days of discharge. Most patients received fragmented care (57.0%). Compared with the continuous care group, the fragmented care group was more likely to have severe chronic lung disease, cerebrovascular disease, and heart failure. States that had lower TAVI volume per Center for Medicare and Medicaid Services population had greater fragmentation. Patients living > 30 minutes from their TAVI center had an increased risk of fragmented care 1.07 (confidence interval [CI] 1.06 to 1.09, p < 0.001). After adjustment for comorbidities and procedural complications, fragmented care was associated with increased 1-year mortality (hazards ratio 1.18, CI 1.04 to 1.35, p = 0.010) and all-cause readmission (hazards ratio 1.08, CI 1.00 to 1.16, p = 0.051. In conclusion, fragmented readmission following TAVI is common, and is associated with increased 1-year mortality and readmission. Efforts to improve coordination of care may improve these outcomes and optimize long-term benefits yielded from TAVI.
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Affiliation(s)
- Alice Wang
- Department of General Surgery, Duke University Medical Center, Durham, North Carolina
| | - Zhuokai Li
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Andrzej S Kosinski
- Duke Clinical Research Institute, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Babatunde Yerokun
- Department of General Surgery, Duke University Medical Center, Durham, North Carolina
| | - Morgan L Cox
- Department of General Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brian C Gulack
- Department of General Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew W Sherwood
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Renato D Lopes
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Taku Inohara
- Duke Clinical Research Institute, Durham, North Carolina
| | - Vinod Thourani
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University Hospital, Atlanta, Georgia
| | - Ajay J Kirtane
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - David Holmes
- Department of Medicine, Division of Cardiology, Mayo Clinic, Rochester, Minnesota
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - J Kevin Harrison
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Peter K Smith
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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Samuel M, Brophy JM. Challenges in Assessing the Incidence of Atrial Fibrillation Hospitalizations. Can J Cardiol 2019; 35:1291-1293. [PMID: 31500888 DOI: 10.1016/j.cjca.2019.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 05/30/2019] [Accepted: 06/01/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Michelle Samuel
- Division of Clinical Epidemiology, McGill University Health Centre Research Institute, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - James M Brophy
- Division of Clinical Epidemiology, McGill University Health Centre Research Institute, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Division of Cardiology, McGill University Health Centre Research Institute, Montreal, Quebec, Canada.
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Wu B, Hu H, Cai A, Ren C, Liu S. The safety and efficacy of dexmedetomidine versus propofol for patients undergoing endovascular therapy for acute stroke: A prospective randomized control trial. Medicine (Baltimore) 2019; 98:e15709. [PMID: 31124948 PMCID: PMC6571375 DOI: 10.1097/md.0000000000015709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND It is uncertain if dexmedetomidine has more favorable pharmacokinetic profile than the traditional sedative drug propofol in patients who undergo endovascular therapy for acute stroke. We conducted a prospective randomized control trial to compare the safety and efficacy of dexmedetomidine with propofol for patients undergoing endovascular therapy for acute stroke. METHODS A total of 80 patients who met study inclusion criteria were received either propofol (n = 45) or dexmedetomidine (n = 35) between January 2016 and August 2018. We recorded the favorable neurologic outcome (modified Rankin score <3) both at discharge and 3 months after stroke, National Institute of Health Stroke scale (NIHSS) at 48 hours post intervention, modified thrombolysis in myocardial infarction score on digital subtraction angiography, intraprocedural hemodynamics, recovery time, relevant time intervals, satisfaction score of the surgeon, mortality, and complications. RESULTS There were no significant differences between the 2 groups (P > .05) with respect to heart rate, respiratory rate, and SPO2 during the procedure. The mean arterial pressure (MAP) was significantly low in the propofol group until 15 minutes after anesthesia was induced. No difference was recorded between the groups at the incidence of fall in MAP >20%, MAP >40% and time spent with MAP fall >20% from baseline MAP. In the propofol group, the time spent with MAP fall >40% from baseline MAP was significantly long (P < .05). Midazolam and fentanyl were similar between the 2 groups (P > .05) that used vasoactive drugs. The time interval from stroke onset to CT room, from stroke onset to groin puncture, and from stroke onset to recanalization/end of the procedure, was not significantly different between the 2 groups (P > .05). The recovery time was longer in the dexmedetomidine group (P < .05). There was no difference between the groups with respect to complications, favorable neurological outcome, and mortality both at hospital discharge and 3 months later, successful recanalization and NIHSS score after 48 hours (P > .05). However, the satisfaction score of the surgeon was higher in the dexmedetomidine group (P < .05). CONCLUSIONS Dexmedetomidine was undesirable than propofol as a sedative agent during endovascular therapy in patients with acute stroke for a long-term functional outcome, though the satisfaction score of the surgeon was higher in the dexmedetomidine group.
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Affiliation(s)
- Bin Wu
- Department of Anaesthesiology, Liaocheng People's Hospital
| | - Hongping Hu
- Department of Anaesthesiology, Liaocheng Third People's Hospital, Liaocheng, Shandong, China
| | - Ailan Cai
- Department of Anaesthesiology, Liaocheng People's Hospital
| | - Chunguang Ren
- Department of Anaesthesiology, Liaocheng People's Hospital
| | - Shengjie Liu
- Department of Anaesthesiology, Liaocheng People's Hospital
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Bell M, Eriksson LI, Svensson T, Hallqvist L, Granath F, Reilly J, Myles PS. Days at Home after Surgery: An Integrated and Efficient Outcome Measure for Clinical Trials and Quality Assurance. EClinicalMedicine 2019; 11:18-26. [PMID: 31317130 PMCID: PMC6610780 DOI: 10.1016/j.eclinm.2019.04.011] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Surgical audit, sometimes including public reporting, is an important foundation of high quality health care. We aimed to assess the validity of a novel outcome metric, days at home up to 30 days after surgery, as a surgical outcome measure in clinical trials and quality assurance. METHODS This was a multicentre, registry-based cohort study. We used prospectively collected hospital and national healthcare registry data obtained from patients aged 18 years or older undergoing a broad range of surgeries in Sweden over a 10-year period. The association between days at home up to 30 days after surgery and patient (older age, poorer physical status, comorbidity) and surgical (elective or non-elective, complexity, duration) risk factors, process of care outcomes (re-admissions, discharge destination), clinical outcomes (major complications, 30-day mortality) and death up to 1 year after surgery were measured. FINDINGS From January, 2005, to December, 2014, we obtained demographic and perioperative data on 636,885 patients from 21 Swedish hospitals. Mortality at 30 days and one year was 1.8% and 7.3%, respectively. The median (IQR) days at home up to 30 days after surgery was 27 (23-29), being significantly lower among high-risk patients, those recovering from more complex surgical procedures, and suffering serious postoperative complications (all p < 0.0001). Patients with 8 days or less at home up to 30 days after surgery had a nearly 7-fold higher risk of death up to 1 year postoperatively when compared with those with 29 or 30 days at home (adjusted HR 6.78 [95% CI: 6.44-7.13]). INTERPRETATION Days at home up to 30 days after surgery is a valid, easy to measure patient-centred outcome metric. It is highly sensitive to changes in surgical risk and impact of complications, and has prognostic importance; it is therefore a valuable endpoint for perioperative clinical trials and quality assurance. FUNDING Swedish National Research Council Medicine and Stockholm County Council ALF-project grant (LE), and the Australian National Health and Medical Research Council (PM).
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Affiliation(s)
- Max Bell
- Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Lars I. Eriksson
- Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Tobias Svensson
- Department of Medicine, Clinical Epidemiology Unit, Karolinska Institute, Stockholm, Sweden
| | - Linn Hallqvist
- Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Granath
- Department of Medicine, Clinical Epidemiology Unit, Karolinska Institute, Stockholm, Sweden
| | - Jennifer Reilly
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Australia
- The Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia
| | - Paul S. Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Australia
- The Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia
- Corresponding author at: Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Commercial Road, Melbourne, Victoria 3004, Australia.
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Bangalore S, Schwamm LH, Smith EE, Hellkamp AS, Xian Y, Schulte PJ, Saver JL, Fonarow GC, Bhatt DL. Relation of Admission Blood Pressure to In-hospital and 90-Day Outcomes in Patients Presenting With Transient Ischemic Attack. Am J Cardiol 2019; 123:1083-1095. [PMID: 30685057 DOI: 10.1016/j.amjcard.2018.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/20/2018] [Accepted: 12/26/2018] [Indexed: 10/27/2022]
Abstract
The association between admission blood pressure (BP) and outcomes in patients with transient ischemic attack (TIA) is not well defined. Patients in the United States national Get With The Guidelines-Stroke registry with a TIA were included. Admission systolic and diastolic BP was used to compute mean arterial pressure and pulse pressure (PP). A subset of this cohort was linked to Centers for Medicare and Medicaid claims data for postdischarge outcomes. The in-hospital outcomes of interest were: mortality, not discharged home, and inability to ambulate independently at discharge. Postdischarge, 30-day and 90-day outcomes of interest were mortality, readmission for stroke, and readmission for major cardiovascular event-composite of death, cerebrovascular, or cardiovascular readmission. Among the 218,803 patients with TIA, lower admission systolic blood pressure (SBP) was associated with worse in-hospital outcomes. Compared with patients with SBP of 150 mm Hg, a lower SBP of 120 mm Hg was associated with higher risk of in-hospital death (adjusted OR = 1.79; 95% CI = 1.50 to 2.12), not being discharged home (adjusted OR = 1.31; 95% CI = 1.27 to 1.36), or inability to ambulate independently at discharge (adjusted OR = 1.27; 95% CI = 1.23 to 1.31). Similarly, among the 64,352 patients in the Centers for Medicare and Medicaid-linked cohort, an inverse association between systolic BP and postdischarge mortality (p <0.0001), and major cardiovascular event (p = 0.0001) was observed at 30-days and at 90-days postdischarge. However, there was no relation between SBP and readmission for stroke either at 30-days (p = 0.35) or at 90-days (p = 0.11). Results were largely similar for diastolic BP, mean arterial pressure, PP, and outcomes. In conclusion, in patients with a transient ischemic attack, a BP paradox was observed, with higher admission BP associated with improved in-hospital, 30-day, and 90-day postdischarge outcomes.
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30
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Concannon TW, Grant S, Welch V, Petkovic J, Selby J, Crowe S, Synnot A, Greer-Smith R, Mayo-Wilson E, Tambor E, Tugwell P. Practical Guidance for Involving Stakeholders in Health Research. J Gen Intern Med 2019; 34:458-463. [PMID: 30565151 PMCID: PMC6420667 DOI: 10.1007/s11606-018-4738-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 08/30/2018] [Accepted: 10/25/2018] [Indexed: 11/29/2022]
Abstract
Stakeholder engagement is increasingly common in health research, with protocols for engaging multiple stakeholder groups becoming normative in patient-centered outcomes research. Previous work has focused on identifying relevant stakeholder groups with whom to work and on working with stakeholders in evidence implementation. This paper draws on the expertise of a team from four countries-Canada, Australia, the UK, and the USA-to provide researchers with practical guidance for carrying out multi-stakeholder-engaged projects: we present a list of questions to assist in selecting appropriate roles and modes of engagement; we introduce a matrix to help summarize engagement activities; and we provide a list of online resources. This guidance, matrix, and list of resources can assist researchers to consider more systematically which stakeholder groups to involve, in what study roles, and by what modes of engagement. By documenting how stakeholders are paired up with specific roles, the matrix also provides a potential structure for evaluating the impact of stakeholder engagement.
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Affiliation(s)
- Thomas W Concannon
- The RAND Corporation, Boston, MA, USA.
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.
| | - Sean Grant
- The RAND Corporation, Santa Monica, CA, USA
| | - Vivian Welch
- University of Ottawa Centre for Global Health, Ottawa, ON, Canada
| | | | - Joseph Selby
- Patient Centered Outcomes Research Institute, Washington, DC, USA
| | | | - Anneliese Synnot
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Evan Mayo-Wilson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ellen Tambor
- Center for Medical Technology Policy, Baltimore, MD, USA
| | - Peter Tugwell
- Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa Hospital Research Institute, Bruyere Research Institute, Ottawa, ON, Canada
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Lee H, Shi SM, Kim DH. Home Time as a Patient-Centered Outcome in Administrative Claims Data. J Am Geriatr Soc 2018; 67:347-351. [PMID: 30578532 DOI: 10.1111/jgs.15705] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 10/15/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Home time, the number of days alive and spent out of hospital and skilled nursing facility, has been proposed as a patient-centered outcome that can be readily calculated in administrative claims data. OBJECTIVES To compare home time against existing patient-centered outcome measures. DESIGN Retrospective cohort study. SETTING Community. PARTICIPANTS A total of 4594 Medicare beneficiaries 65 years or older with complete survey and claims data in the Medicare Current Beneficiary Survey 2010 to 2011. MEASUREMENTS Home time was calculated from the 2011 claims data (range, 0-365 days). The 1-year incidence of patient-centered outcomes (poor self-rated health, mobility impairment, depression, limited social activity, and difficulty in self-care) was measured. The minimum clinically important difference (MCID) was derived by contrasting the mean home time between those who experienced functional decline or death and those who did not. RESULTS The mean home time was 355.8 days (SD, 42.1 days); 84.1% had a home time of 365 days, and 5.7% had a home time of 336 days or fewer. The incidence of poor self-rated health ranged from 2% (home time, 365 days) to 21% (home time, less than 337 days). Similarly, the corresponding incidence risks were 11% to 59% for mobility impairment, 5% to 19% for depression, 17% to 67% for limited social activity, and 13% to 68% for difficulty in self-care. The risk of mobility impairment, depression, and difficulty in self-care increased steeply after home time loss of 15 days or greater. The MCID of home time was 18.6 days. CONCLUSION A loss in home time is associated with decline in several patient-centered outcome measures in community-dwelling Medicare beneficiaries. These results provide empirical evidence to promote adoption of home time and its clinical interpretation for database studies of medical interventions. J Am Geriatr Soc 67:347-351, 2019.
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Affiliation(s)
- Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sandra M Shi
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
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Saji N, Sakurai T, Ito K, Tomimoto H, Kitagawa K, Miwa K, Tanaka Y, Kozaki K, Kario K, Eto M, Suzuki K, Shimizu A, Niida S, Hirakawa A, Toba K. Protective effects of oral anticoagulants on cerebrovascular diseases and cognitive impairment in patients with atrial fibrillation: protocol for a multicentre, prospective, observational, longitudinal cohort study (Strawberry study). BMJ Open 2018; 8:e021759. [PMID: 30478106 PMCID: PMC6254414 DOI: 10.1136/bmjopen-2018-021759] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Non-valvular atrial fibrillation (NVAF) is known as a robust risk factor for stroke. Recent reports have suggested a risk of dementia with NVAF, but much remains unknown regarding the relationship between this mechanism and the potential protective effects of novel anticoagulants (direct oral anticoagulants (DOACs), or non-vitamin K oral anticoagulants). METHODS AND ANALYSIS This study, the strategy to obtain warfarin or DOAC's benefit by evaluating registry, is an investigator-initiated, multicentre, prospective, observational, longitudinal cohort study comparing the effects of warfarin therapy and DOACs on cerebrovascular diseases and cognitive impairment over an estimated duration of 36 months. Once a year for 3 years, the activities of daily living and cognitive functioning of non-demented patients with NVAF will be assessed. Demographics, risk factors, laboratory investigations, lifestyle, social background and brain MRI will be assessed. ETHICS AND DISSEMINATION This protocol has been approved by the ethics committee of the National Center for Geriatrics and Gerontology (No. 1017) and complies with the Declaration of Helsinki. Informed consent will be obtained before study enrolment and only coded data will be stored in a secured database. The results will be published in peer-reviewed journals and presented at scientific meetings to ensure the applicability of the findings in clinical practice. TRIAL REGISTRATION NUMBER UMIN000025721.
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Affiliation(s)
- Naoki Saji
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Takashi Sakurai
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and Gerontology, Obu, Japan
- Department of Cognition and Behavioural Science, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kengo Ito
- Innovation Center for Clinical Research, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Hidekazu Tomimoto
- Department of Neurology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women’s Medical University School of Medicine, Tokyo, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuji Tanaka
- Department of Neurology, Gifu Municipal Hospital, Gifu, Japan
- Health Service Center, Aichi University of Education, Kariya, Japan
| | - Koichi Kozaki
- Department of Geriatric Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Masato Eto
- International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keisuke Suzuki
- Innovation Center for Clinical Research, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Atsuya Shimizu
- Department of Cardiology, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Shumpei Niida
- Medical Genome Center, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Akihiro Hirakawa
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenji Toba
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and Gerontology, Obu, Japan
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Jones DA, Whittaker P, Rathod KS, Richards AJ, Andiapen M, Antoniou S, Mathur A, Ahluwalia A. Sodium Nitrite-Mediated Cardioprotection in Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction: A Cost-Effectiveness Analysis. J Cardiovasc Pharmacol Ther 2018; 24:113-119. [PMID: 30081658 DOI: 10.1177/1074248418784940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES In the follow-up of patients in a trial of intracoronary sodium nitrite given during primary percutaneous coronary intervention (PCI) after acute myocardial infarction (AMI), we found a reduction in the incidence of major adverse cardiac events (MACEs). Specifically, MACE rates were 5.2% versus 25.0% with placebo at 3 years ( P = .013). Such MACE reductions should also be associated with economic benefit. Thus, we assessed the cost utility of sodium nitrite therapy versus standard primary PCI only. METHODS AND RESULTS We developed a model to simulate costs and quality-adjusted life years (QALYs) over the first 36 months after ST-Segment Elevation Myocardial Infarction (STEMI). Decision tree analysis was used to assess different potential cardiovascular outcomes after STEMI for patients in both treatment groups. Model inputs were derived from the NITRITE-AMI study. Cost of comparative treatments and follow-up in relation to cardiovascular events was calculated from the United Kingdom National Health Service perspective. Higher procedural costs for nitrite treatment were offset by lower costs for repeat revascularization, myocardial infarction, and hospitalization for heart failure compared to primary PCI plus placebo. Nitrite treatment was associated with higher utility values (0.91 ± 0.19 vs 0.82 ± 0.30, P = .041). The calculated incremental cost-effectiveness ratio of £2177 per QALY indicates a cost-effective strategy. Furthermore, positive results were maintained when input parameters varied, indicating the robustness of our model. In fact, based on the difference in utility values, the cost of nitrite could increase by 4-fold (£2006 per vial) and remain cost-effective. CONCLUSION This first analysis of sodium nitrite as a cardioprotective treatment demonstrates cost-effectiveness. Although more comparative analysis and assessment of longer follow-up times are required, our data indicate the considerable potential of nitrite-mediated cardioprotection.
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Affiliation(s)
- Daniel A Jones
- 1 Barts NIHR Biomedical Research Centre, Barts and The London Medical School, Queen Mary University, London, United Kingdom.,2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom.,3 Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Peter Whittaker
- 3 Department of Health Policy, London School of Economics and Political Science, London, United Kingdom.,4 Department of Emergency Medicine, Cardiovascular Research Institute, Wayne State University, Detroit, MI, USA
| | - Krishnaraj S Rathod
- 1 Barts NIHR Biomedical Research Centre, Barts and The London Medical School, Queen Mary University, London, United Kingdom.,2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Amy J Richards
- 2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Mervyn Andiapen
- 2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Sotiris Antoniou
- 2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Anthony Mathur
- 1 Barts NIHR Biomedical Research Centre, Barts and The London Medical School, Queen Mary University, London, United Kingdom.,2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Amrita Ahluwalia
- 1 Barts NIHR Biomedical Research Centre, Barts and The London Medical School, Queen Mary University, London, United Kingdom.,2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
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Gundlund A, Xian Y, Peterson ED, Butt JH, Gadsbøll K, Bjerring Olesen J, Køber L, Torp-Pedersen C, Gislason GH, Loldrup Fosbøl E. Prestroke and Poststroke Antithrombotic Therapy in Patients With Atrial Fibrillation: Results From a Nationwide Cohort. JAMA Netw Open 2018; 1:e180171. [PMID: 30646049 PMCID: PMC6324317 DOI: 10.1001/jamanetworkopen.2018.0171] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
IMPORTANCE Antithrombotic therapies are effective in both primary and secondary stroke prophylaxis in high-risk patients with atrial fibrillation (AF), but they are often underused in community practice. OBJECTIVE To examine prestroke and poststroke antithrombotic treatment patterns and long-term outcomes in patients with AF presenting with ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of Danish patients with AF, with a prestroke CHA2DS2-VASc score of 1 or higher for men and 2 or higher for women, and presenting with ischemic stroke was conducted from January 1, 2004, to January 31, 2017. Data on hospital admission, prescription fillings, and vital status were assessed using several Danish nationwide registries. EXPOSURES Patients who survived 100 days after discharge were divided into 3 groups according to poststroke antithrombotic therapy: oral anticoagulation (OAC) therapy, antiplatelet therapy alone, or no antithrombotic therapy. MAIN OUTCOMES AND MEASURES Long-term outcomes (thromboembolic events and bleeding complications) were examined using multivariable Cox regression analyses across the 3 groups. RESULTS Among 30 626 patients with AF admitted with ischemic stroke, 11 139 patients (36.3%) received OAC therapy (44.3% female; median age, 79 years [interquartile range, 73-85 years]), 11 874 (38.8%) received antiplatelet therapy alone (55.0% female; median age, 82 years [interquartile range, 75-88 years]), and 7613 (24.9%) received no antithrombotic therapy before stroke (53.8% female; median age, 80 years [interquartile range, 71-86 years]). Following stroke, 31.3% of those receiving antiplatelet therapy alone and 43.7% of those receiving no antithrombotic therapy before stroke shifted to OAC therapy. Yet, 37.5% of patients with stroke did not receive OAC therapy following stroke. However, OAC treatment rates increased over time. During a maximum of 10 years of follow-up, 17.5%, 21.2%, and 21.5% experienced a new thromboembolic event and 72.7%, 86.4%, and 86.2% died among those treated with OAC therapy, antiplatelet therapy, or no antithrombotic therapy, respectively. Poststroke OAC therapy was associated with lower risk of recurrent thromboembolic events (adjusted hazard ratio, 0.81; 95% CI, 0.73-0.89) and no significant difference in bleeding complications (adjusted hazard ratio, 0.97; 95% CI, 0.86-1.10), compared with no poststroke antithrombotic therapy. In contrast, there were no significant differences for those treated with poststroke antiplatelet therapy and no antithrombotic therapy. CONCLUSIONS AND RELEVANCE Patients with AF receiving poststroke OAC therapy had lower risk of recurrent thromboembolic events. Our findings suggest a substantial opportunity for improving primary and secondary stroke prophylaxis in high-risk patients with AF.
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Affiliation(s)
- Anna Gundlund
- Department of Cardiology, Gentofte Hospital, Hellerup, Denmark
| | - Ying Xian
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Jawad H. Butt
- Department of Cardiology, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Kasper Gadsbøll
- Department of Cardiology, Gentofte Hospital, Hellerup, Denmark
| | | | - Lars Køber
- Department of Cardiology, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Epidemiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Gunnar H. Gislason
- Department of Cardiology, Gentofte Hospital, Hellerup, Denmark
- Danish Heart Foundation, Copenhagen, Denmark
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, University Hospital of Copenhagen, Copenhagen, Denmark
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Kim IS, Kim HJ, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Appropriate doses of non-vitamin K antagonist oral anticoagulants in high-risk subgroups with atrial fibrillation: Systematic review and meta-analysis. J Cardiol 2018; 72:284-291. [PMID: 29706404 DOI: 10.1016/j.jjcc.2018.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/13/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND We evaluated the dose-dependent efficacy, safety, and all-cause mortality of non-vitamin K antagonist oral anticoagulants (NOACs) in "atrial fibrillation (AF) patients who were OAC-naïve," or "AF patients with prior-stroke history" with those who were known to be high-risk subgroups under OAC. METHODS After a systematic database search (Medline, EMBASE, CENTRAL, SCOPUS, and Web of Science), five phase-III randomized trials comparing NOACs and warfarin in "OAC-naïve/OAC-experienced," or "with/without prior-stroke history" subgroups were included. The outcomes were pooled using a random-effects model to determine the relative risk (RR) for stroke/systemic thromboembolism (SSTE), major bleeding, intracranial hemorrhage, and all-cause mortality. RESULTS 1. In OAC-naïve patients, standard-dose NOACs showed superior efficacy and safety with lower mortality [RR 0.90 (0.84-0.97), p=0.008, I2=0%] compared to warfarin. 2. For OAC-experienced patients, low-dose NOACs showed equivalent efficacy but reduced risk of major bleeding [RR 0.61 (0.40-0.91), p=0.02, I2=89%], and had lower all-cause mortality [RR 0.86 (0.75-0.99), p=0.04, I2=38%] compared to warfarin. 3. For patients with prior-stroke history, low-dose NOACs showed equivalent efficacy, but reduced risk of major bleeding [RR 0.58 (0.48-0.70), p<0.001, I2=0%] and all-cause mortality [RR 0.76 (0.66-0.88), p<0.001, I2=0%] compared to warfarin. 4. Among patients without prior-stroke history, standard-dose NOAC was superior to warfarin for both SSTE prevention [RR 0.78 (0.66-0.91), p=0.002, I2=43%] and all-cause mortality [RR 0.91 (0.85-0.97), p=0.004, I2=0%]. CONCLUSIONS In conclusion, standard-dose NOAC showed lower all-cause mortality than warfarin in OAC-naïve patients with AF, and low-dose NOAC was better than warfarin among the patients with prior-stroke history in terms of all-cause mortality.
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Affiliation(s)
- In-Soo Kim
- Yonsei University Health System, Seoul, Republic of Korea
| | - Hyun-Jung Kim
- Department of Preventive Medicine, Institute for Evidence-based Medicine, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Tae-Hoon Kim
- Yonsei University Health System, Seoul, Republic of Korea
| | - Jae-Sun Uhm
- Yonsei University Health System, Seoul, Republic of Korea
| | - Boyoung Joung
- Yonsei University Health System, Seoul, Republic of Korea
| | | | - Hui-Nam Pak
- Yonsei University Health System, Seoul, Republic of Korea.
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Price A, Schroter S, Snow R, Hicks M, Harmston R, Staniszewska S, Parker S, Richards T. Frequency of reporting on patient and public involvement (PPI) in research studies published in a general medical journal: a descriptive study. BMJ Open 2018; 8:e020452. [PMID: 29572398 PMCID: PMC5875637 DOI: 10.1136/bmjopen-2017-020452] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES While documented plans for patient and public involvement (PPI) in research are required in many grant applications, little is known about how frequently PPI occurs in practice. Low levels of reported PPI may mask actual activity due to limited PPI reporting requirements. This research analysed the frequency and types of reported PPI in the presence and absence of a journal requirement to include this information. DESIGN AND SETTING A before and after comparison of PPI reported in research papers published in The BMJ before and 1 year after the introduction of a journal policy requiring authors to report if and how they involved patients and the public within their papers. RESULTS Between 1 June 2013 and 31 May 2014, The BMJ published 189 research papers and 1 (0.5%) reported PPI activity. From 1 June 2015 to 31 May 2016, following the introduction of the policy, The BMJ published 152 research papers of which 16 (11%) reported PPI activity. Patients contributed to grant applications in addition to designing studies through to coauthorship and participation in study dissemination. Patient contributors were often not fully acknowledged; 6 of 17 (35%) papers acknowledged their contributions and 2 (12%) included them as coauthors. CONCLUSIONS Infrequent reporting of PPI activity does not appear to be purely due to a failure of documentation. Reporting of PPI activity increased after the introduction of The BMJ's policy, but activity both before and after was low and reporting was inconsistent in quality. Journals, funders and research institutions should collaborate to move us from the current situation where PPI is an optional extra to one where PPI is fully embedded in practice throughout the research process.
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Affiliation(s)
- Amy Price
- The BMJ, London, UK
- Department for Continuing Education, The University of Oxford, Oxford, UK
| | | | - Rosamund Snow
- Health Experiences Institute, Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
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Lee DJ, Avulova S, Conwill R, Barocas DA. Patient engagement in the design and execution of urologic oncology research. Urol Oncol 2017; 35:552-558. [DOI: 10.1016/j.urolonc.2017.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 06/27/2017] [Accepted: 07/01/2017] [Indexed: 12/27/2022]
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Myles PS, Shulman MA, Heritier S, Wallace S, McIlroy DR, McCluskey S, Sillar I, Forbes A. Validation of days at home as an outcome measure after surgery: a prospective cohort study in Australia. BMJ Open 2017; 7:e015828. [PMID: 28821518 PMCID: PMC5629653 DOI: 10.1136/bmjopen-2017-015828] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To evaluate 'days at home up to 30 days after surgery' (DAH30) as a patient-centred outcome measure. DESIGN Prospective cohort study. DATA SOURCE Using clinical trial data (seven trials, 2109 patients) we calculated DAH30 from length of stay, readmission, discharge destination and death up to 30 days after surgery. MAIN OUTCOME The association between DAH30 and serious complications after surgery. RESULTS One or more complications occurred in 263 of 1846 (14.2%) patients, including 19 (1.0%) deaths within 30 days of surgery; 245 (11.6%) patients were discharged to a rehabilitation facility and 150 (7.1%) were readmitted to hospital within 30 days of surgery. The median DAH30 was significantly less in older patients (p<0.001), those with poorer physical functioning (p<0.001) and in those undergoing longer operations (p<0.001). Patients with serious complications had less days at home than patients without serious complications (20.5 (95% CI 19.1 to 21.9) vs 23.9 (95% CI 23.8 to 23.9) p<0.001), and had higher rates of readmission (16.0% vs 5.9%; p<0.001). After adjusting for patient age, sex, physical status and duration of surgery, the occurrence of postoperative complications was associated with fewer days at home after surgery (difference 3.0(95% CI 2.1 to 4.0) days; p<0.001). CONCLUSIONS DAH30 has construct validity and is a readily obtainable generic patient-centred outcome measure. It is a pragmatic outcome measure for perioperative clinical trials.
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Affiliation(s)
- Paul S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark A Shulman
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephane Heritier
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sophie Wallace
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - David R McIlroy
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stuart McCluskey
- Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Isabella Sillar
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Forbes
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Fox KAA, Accetta G, Pieper KS, Bassand JP, Camm AJ, Fitzmaurice DA, Kayani G, Kakkar AK. Why are outcomes different for registry patients enrolled prospectively and retrospectively? Insights from the global anticoagulant registry in the FIELD-Atrial Fibrillation (GARFIELD-AF). EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2017; 4:27-35. [DOI: 10.1093/ehjqcco/qcx030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/15/2017] [Indexed: 01/26/2023]
Affiliation(s)
- Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Queen’s Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Gabriele Accetta
- Thrombosis Research Institute, Emmanuel Kaye Building, Manresa Road, London SW3 6LR, UK
| | - Karen S Pieper
- Duke Clinical Research Institute, 2400 Pratt St, Durham, NC 27705, USA
| | - Jean-Pierre Bassand
- Thrombosis Research Institute, Emmanuel Kaye Building, Manresa Road, London SW3 6LR, UK
- University of Besançon, 1 Rue Claude Goudimel, Besançon 25000, France
| | - A John Camm
- Molecular and Clinical Sciences Research Institute, Cardiology Clinical Academic Group, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK
- Imperial College London, Kensington, London SW7 2AZ, UK
| | | | - Gloria Kayani
- Thrombosis Research Institute, Emmanuel Kaye Building, Manresa Road, London SW3 6LR, UK
| | - Ajay K Kakkar
- Thrombosis Research Institute, Emmanuel Kaye Building, Manresa Road, London SW3 6LR, UK
- University of London, Gower St, Kings Cross, London WC1E 6BT, UK
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Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol 2017; 2:94-105. [PMID: 28959497 PMCID: PMC5600018 DOI: 10.1136/svn-2017-000092] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 04/26/2017] [Indexed: 01/06/2023] Open
Abstract
The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.
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Affiliation(s)
- Cora H Ormseth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Medical Center, Los Angeles, California, USA
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, California, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Vaida B. Patient-Centered Outcomes Research: Early Evidence From A Burgeoning Field. Health Aff (Millwood) 2017; 35:595-602. [PMID: 27044957 DOI: 10.1377/hlthaff.2016.0239] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Bara Vaida
- Bara Vaida is an independent journalist in Washington, D.C
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Orkaby AR, Ozonoff A, Reisman JI, Miller DR, Zhao S, Rose AJ. Continued Use of Warfarin in Veterans with Atrial Fibrillation After Dementia Diagnosis. J Am Geriatr Soc 2016; 65:249-256. [PMID: 28039854 DOI: 10.1111/jgs.14573] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the effectiveness of warfarin in older adults with dementia. DESIGN Retrospective cohort study. SETTING Department of Veterans Affairs national healthcare system. PARTICIPANTS Veterans aged 65 and older (73% aged ≥75, 99% male, 91% white) who had been receiving warfarin for nonvalvular atrial fibrillation for at least 6 months, were newly diagnosed with dementia in fiscal year 2007 or 2008, and were not enrolled in Medicare Advantage (n = 2,572). MEASUREMENTS The onset of dementia was defined according to International Classification of Diseases, Ninth Revision, code. Participants were followed for up to 4 years for persistence of warfarin therapy, anticoagulation control, major hemorrhage, ischemic stroke, and all-cause mortality. RESULTS The average CHADS2 score was 3.3 ± 1.3. After a diagnosis of dementia, 405 individuals (16%) persisted on warfarin therapy. Unadjusted Cox proportional hazards analysis demonstrated a protective effect of warfarin in prevention of ischemic stroke (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.46-0.89, P = .008), major bleeding (HR = 0.72, 95% CI = 0.55-0.94, P = .02), and all-cause mortality (HR = 0.66, 95% CI = 0.55-0.79, P < .001). Using propensity score matching, the protective effect of continuing warfarin persisted in prevention of stroke (HR = 0.74, 95% CI = 0.54-0.996, P = .047) and mortality (HR = 0.72, 95% CI = 0.60-0.87, P < .001), with no statistically significant decrease in risk of major bleeding (HR = 0.78, 95% CI = 0.61-1.01, P = .06). CONCLUSION Discontinuing warfarin after a diagnosis of dementia is associated with a significant increase in stroke and mortality.
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Affiliation(s)
- Ariela R Orkaby
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Al Ozonoff
- Center for Patient Safety and Quality Research, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Joel I Reisman
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts.,School of Public Health, Boston University, Boston, Massachusetts
| | - Shibei Zhao
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Adam J Rose
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts.,Department of Medicine, Section of Internal Medicine, Boston University Medical Center, Boston, Massachusetts
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Callander EJ, McDermott R. Measuring the effects of CVD interventions and studies across socioeconomic groups: A brief review. Int J Cardiol 2016; 227:635-643. [PMID: 27829524 DOI: 10.1016/j.ijcard.2016.10.085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 10/28/2016] [Indexed: 12/11/2022]
Abstract
There is a known socioeconomic skew in prevalence and outcomes of cardiovascular disease (CVD). To document the proportion of clinical trials and observational studies related to CVD recently published in peer-reviewed journals that report the socio-economic distributional differences in their outcomes. We undertook a review of peer-reviewed clinical trials and observational studies relating to CVD published between 01/06/2015-31/12/2015 in PubMed; and identified the proportion that included measures of socioeconomic status and the proportion that stratified results by, or controlled for, socioeconomic status when reporting outcomes. 414 peer reviewed publications reporting the outcomes of clinical trials or observational studies that related to CVD were identified. 32 of these reported on the socioeconomic status of participants. Of these, 20 stratified the results by socioeconomic status or adjusted the results for socioeconomic status. 18 studies measured education attainment, 5 measured income, 1 measured rurality and 1 measured occupation. Of the 414 articles reporting the outcomes of clinical trials or observational studies related to cardiovascular disease in 2015, the effectiveness of the intervention, or the differences in outcomes, between socioeconomic groups was assessed in 5% of studies. This lack of consideration of the effectiveness of trial outcomes or the differences in outcomes across socioeconomic groups impairs the ability of readers, healthcare professionals and policy makers to assess the impact of new treatments or interventions in closing the inequality gap associated with CVD.
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Affiliation(s)
- Emily J Callander
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia.
| | - Robyn McDermott
- Centre for Research Excellence in Chronic Disease Prevention, James Cook University, Townsville, Australia
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O’Brien EC, Xian Y, Xu H, Wu J, Saver JL, Smith EE, Schwamm LH, Peterson ED, Reeves MJ, Bhatt DL, Maisch L, Hannah D, Lindholm B, Olson D, Prvu Bettger J, Pencina M, Hernandez AF, Fonarow GC. Hospital Variation in Home-Time After Acute Ischemic Stroke. Stroke 2016; 47:2627-33. [DOI: 10.1161/strokeaha.116.013563] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 08/09/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Stroke survivors identify home-time as a high-priority outcome; there are limited data on factors influencing home-time and home-time variability among discharging hospitals.
Methods—
We ascertained home-time (ie, time alive out of a hospital, inpatient rehabilitation facility, or skilled nursing facility) at 90 days and 1-year post discharge by linking data from Get With The Guidelines-Stroke Registry patients (≥65 years) to Medicare claims. Using generalized linear mixed models, we estimated adjusted mean home-time for each hospital. Using linear regression, we examined associations between hospital characteristics and risk-adjusted home-time.
Results—
We linked 156 887 patients with ischemic stroke at 989 hospitals to Medicare claims (2007–2011). Hospital mean home-time varied with an overall unadjusted median of 59.5 days over the first 90 days and 270.2 days over the first year. Hospital factors associated with more home-time over 90 days included higher annual stroke admission volume (number of ischemic stroke admissions per year); South, West, or Midwest geographic regions (versus Northeast); and rural location; 1-year patterns were similar. Lowest home-time quartile patients (versus highest) were more likely to be older, black, women, and have more comorbidities and severe strokes. Home-time variation decreased after risk adjustment (interquartile range, 57.4–61.4 days over 90 days; 266.3–274.2 days over 1 year). In adjusted analyses, increasing annual stroke volume and rural location were associated with significantly more home-time.
Conclusions—
In older ischemic stroke survivors, home-time post discharge varies by hospital annual stroke volume, severity of case-mix, and region. In adjusted analyses, annual ischemic stroke admission volume and rural location were associated with more home-time post stroke.
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Affiliation(s)
- Emily C. O’Brien
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Ying Xian
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Haolin Xu
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Jingjing Wu
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Jeffrey L. Saver
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Eric E. Smith
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Lee H. Schwamm
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Eric D. Peterson
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Mathew J. Reeves
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Deepak L. Bhatt
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Lesley Maisch
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Deidre Hannah
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Brianna Lindholm
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - DaiWai Olson
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Janet Prvu Bettger
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Michael Pencina
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Adrian F. Hernandez
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Gregg C. Fonarow
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
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Topazian R, Bollinger J, Weinfurt KP, Dvoskin R, Mathews D, Brelsford K, DeCamp M, Sugarman J. Physicians' perspectives regarding pragmatic clinical trials. J Comp Eff Res 2016; 5:499-506. [PMID: 27417953 DOI: 10.2217/cer-2016-0024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Practicing physicians inevitably become involved in pragmatic clinical trials (PCTs), including comparative effectiveness research. We sought to identify physicians' perspectives related to PCTs. METHODS In-depth semistructured interviews with 20 physicians in the USA. RESULTS Although physicians are generally willing to participate in PCTs, their support is predicated on several factors including expected benefits, minimization of time and workflow burdens and physician engagement. Physicians communicated a desire to respect patients' rights and interests while maintaining a high level of care. CONCLUSION Future work is needed to systematically assess the impact of PCTs on clinicians in meeting their ethical obligations to patients and the burdens clinicians are willing to accept in exchange for potential benefits.
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Affiliation(s)
- Rachel Topazian
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Juli Bollinger
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Kevin P Weinfurt
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.,Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Rachel Dvoskin
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Debra Mathews
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Kathleen Brelsford
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Matthew DeCamp
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA.,Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA.,Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Validation of algorithms to identify stroke risk factors in patients with acute ischemic stroke, transient ischemic attack, or intracerebral hemorrhage in an administrative claims database. Int J Cardiol 2016; 215:277-82. [DOI: 10.1016/j.ijcard.2016.04.069] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/11/2016] [Indexed: 11/19/2022]
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48
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Safety and efficacy of non-vitamin K oral anticoagulant treatment compared with warfarin in patients with non-valvular atrial fibrillation who develop acute ischemic stroke or transient ischemic attack: a multicenter prospective cohort study (daVinci study). J Thromb Thrombolysis 2016; 42:453-62. [DOI: 10.1007/s11239-016-1376-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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