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Huang ES, Sinclair A, Conlin PR, Cukierman-Yaffe T, Hirsch IB, Huisingh-Scheetz M, Kahkoska AR, Laffel L, Lee AK, Lee S, Lipska K, Meneilly G, Pandya N, Peek ME, Peters A, Pratley RE, Sherifali D, Toschi E, Umpierrez G, Weinstock RS, Munshi M. The Growing Role of Technology in the Care of Older Adults With Diabetes. Diabetes Care 2023; 46:1455-1463. [PMID: 37471606 PMCID: PMC10369127 DOI: 10.2337/dci23-0021] [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: 03/03/2023] [Accepted: 05/24/2023] [Indexed: 07/22/2023]
Abstract
The integration of technologies such as continuous glucose monitors, insulin pumps, and smart pens into diabetes management has the potential to support the transformation of health care services that provide a higher quality of diabetes care, lower costs and administrative burdens, and greater empowerment for people with diabetes and their caregivers. Among people with diabetes, older adults are a distinct subpopulation in terms of their clinical heterogeneity, care priorities, and technology integration. The scientific evidence and clinical experience with these technologies among older adults are growing but are still modest. In this review, we describe the current knowledge regarding the impact of technology in older adults with diabetes, identify major barriers to the use of existing and emerging technologies, describe areas of care that could be optimized by technology, and identify areas for future research to fulfill the potential promise of evidence-based technology integrated into care for this important population.
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Affiliation(s)
| | | | - Paul R. Conlin
- Harvard Medical School, Boston, MA
- Veteran Affairs Boston Healthcare System, Boston, MA
| | - Tali Cukierman-Yaffe
- Division of Endocrinology, Diabetes, and Metabolism, Ramat Gan, Israel
- Sheba Medical Centre, Ramat Gan, Israel
- Epidemiology Department, Sackler Faculty of Medicine, Herczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | | | | | - Sei Lee
- University of California San Francisco, San Francisco, CA
| | | | - Graydon Meneilly
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Naushira Pandya
- Department of Geriatrics, Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL
| | | | - Anne Peters
- University of Southern California, Los Angeles, CA
| | - Richard E. Pratley
- AdventHealth Diabetes Institute, AdventHealth Translational Research Institute, AdventHealth, Orlando, FL
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2
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Pauwelyn M, Ingelaere S, Hoffmann R, Vijgen J, Mairesse GH, Blankoff I, Vandekerckhove Y, de Waroux JBLP, Vandenberk B, Willems R. Implantable cardiac defibrillators in octogenarians. J Geriatr Cardiol 2023; 20:23-31. [PMID: 36875166 PMCID: PMC9975482 DOI: 10.26599/1671-5411.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
OBJECTIVE Implantable cardiac defibrillators (ICD) implantation in the very elderly remains controversial. We aimed to describe the experience and outcome of patients over 80 years old implanted with an ICD in Belgium. METHODS Data were extracted from the national QERMID-ICD registry. All implantations performed in octogenarians between February 2010 and March 2019 were analysed. Data on baseline patient characteristics, type of prevention, device configuration and all-cause mortality were available. To determine predictors of mortality, multivariable Cox proportional hazard regression modelling was performed. RESULTS Nationwide, 704 primo ICD implantations were performed in octogenarians (median age 82, IQR 81-83 years; 83% male and 45% secondary prevention). During a mean follow-up of 3.1 ± 2.3 years, 249 (35%) patients died, of which 76 (11%) within the first year after implantation. In multivariable Cox regression analysis age (HR = 1.15, P = 0.004), oncological history (HR = 2.43, P = 0.027) and secondary prevention (HR = 2.23, P = 0.001) were independently associated with 1-year mortality. A better preserved left ventricular ejection fraction (LVEF) was associated with a better outcome (HR = 0.97, P = 0.002). Regarding overall mortality multivariable analysis withheld age, history of atrial fibrillation, centre volume and oncological history as significant predictors. Higher LVEF was again protective (HR = 0.99, P = 0.008). CONCLUSIONS Primary ICD implantation in octogenarians is not often performed in Belgium. Among this population, 11% died within the first year after ICD implantation. Advanced age, oncological history, secondary prevention and a lower LVEF were associated with an increased one-year mortality. Age, low LVEF, atrial fibrillation, centre volume and oncological history were indicative of higher overall mortality.
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Affiliation(s)
| | - Sebastian Ingelaere
- University Hospitals Leuven, Cardiology, Leuven, Belgium.,KU Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
| | | | - Johan Vijgen
- Jessa Ziekenhuis, Department of Cardiology, Hasselt, Belgium
| | | | - Ivan Blankoff
- CHU Charleroi, Department of Cardiology, Charleroi, Belgium
| | | | | | - Bert Vandenberk
- KU Leuven, Department of Cardiovascular Sciences, Leuven, Belgium.,University of Calgary, Libin Cardiovascular Institute, Calgary, Canada
| | - Rik Willems
- University Hospitals Leuven, Cardiology, Leuven, Belgium.,KU Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
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3
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Kim J, Choi J, Shin MS, Park JK, An M, Kim SH, Choi N, Lee MO, Heo S. Effect of physical and psychocognitive function and perceived health status on 12-month adverse cardiac events among implantable cardioverter-defibrillator recipients. Heart Lung 2020; 49:530-536. [PMID: 32434703 DOI: 10.1016/j.hrtlng.2020.04.010] [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: 01/28/2020] [Revised: 03/31/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Post-implant recovery in patients with implantable cardioverter-defibrillators (ICDs) is often compromised because of reduced physical and psycho-cognitive function and poor health perception, leading to short event-free survival. OBJECTIVES To examine the effects of psychocognitive function, health perception, and ICD-related factors on 12-month cardiac events among ICD patients. METHODS Using a prospective study design, ICD patients underwent baseline assessment and were followed for 12 months to assess cardiac events. RESULTS Cardiac events occurred in 14 patients (18.9%) (N = 74: age, 58 years; primary ICDs, 45.9%). Time after ICD implant (odds ratio [OR] = 1.002; p = .028) and executive function (OR = 1.021; p = .027) were significant predictors of 12-month cardiac events, while other physical and psychological indices were not. CONCLUSIONS Reduced executive function and longer time after implant predicted the events. Healthcare professionals need to assess executive function and provide treatment and support to improve executive function.
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Affiliation(s)
- JinShil Kim
- Gachon University, College of Nursing, Incheon, South Korea
| | - Jiin Choi
- Office of Hospital Information, Seoul National University Hospital, Seoul, South Korea
| | - Mi-Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University, College of Medicine, Incheon, South Korea
| | - Jin-Kyu Park
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Hanyang University Medical Center, Seoul, South Korea
| | - Minjeong An
- Chonnam National University, College of Nursing, Gwangju, South Korea
| | - Sun Hwa Kim
- Department of Nursing, Hanyang University Medical Center, Seoul, South Korea.
| | - Nayeon Choi
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Korea
| | - Mee Ok Lee
- Gachon University Gil Medical Center, Incheon, South Korea
| | - Seongkum Heo
- Mercer University, Georgia Baptist College of Nursing, Atlanta, USA
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4
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Abstract
BACKGROUND Advance care planning and palliative care are gaining recognition as critical care components for adults with CHD, yet these often do not occur. Study objectives were to evaluate ACHD providers' 1) comfort managing patients' physical symptoms and psychosocial needs and 2) perspectives on the decision/timing of advance care planning initiation and palliative care referral. METHODS Cross-sectional study of ACHD providers. Six hypothetical patients were described in case format, followed by questions regarding provider comfort managing symptoms, initiating advance care planning, and palliative care referral. RESULTS Fifty providers (72% physicians) completed surveys. Participants reported low levels of personal palliative care knowledge, without variation by gender, years in practice, or prior palliative care training. Providers appeared more comfortable managing physical symptoms and discussing prognosis than addressing psychosocial needs. Providers recognised advance directives as important, although the percentage who would initiate advance care planning ranged from 18 to 67% and referral to palliative care from 14 to 32%. Barriers and facilitators to discussing advance care planning with patients were identified. Over 20% indicated that advance care planning and end-of-life discussions are best initiated with the development of at least one life-threatening complication/hospitalisation. CONCLUSIONS Providers noted high value in advance directives yet were themselves less likely to initiate advance care planning or refer to palliative care. This raises the critical questions of when, how, and by whom discussion of these important matters should be initiated and how best to support ACHD providers in these endeavours.
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5
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Thompson JH, Thylén I, Moser DK. Shared Decision-Making About End-of-Life Care Scenarios Compared Among Implantable Cardioverter Defibrillator Patients: A National Cohort Study. Circ Heart Fail 2019; 12:e005619. [PMID: 31601115 DOI: 10.1161/circheartfailure.118.005619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Authors of expert guidelines and consensus statements recommend that decisions at the end-of-life (EOL) be discussed before and after implantation of an implantable cardioverter defibrillator (ICD) and include promotion of shared decision-making. The purpose of this study was to describe experiences, attitudes, and knowledge about the ICD at EOL in ICD recipients and to compare experiences, attitudes, and knowledge in ICD recipients with and without heart failure (HF). We further sought to determine factors associated with having discussions about EOL. METHODS AND RESULTS Using a national registry in Sweden of all ICD recipients (n=5355) in 2012, an EOL questionnaire, along with other ICD-related measures, was completed by 2403 ICD recipients. Of the participants, 1275 (n=53%) had HF. Their responses in the knowledge, experience, and attitude domains were almost identical to those without HF. Forty percent of patients with and without HF did not want to discuss their illness trajectory or deactivation of their ICD ever. In logistic regression analyses, we found that having had an ICD shock (OR, 2.05; CI, 1.64-2.56), having high levels of anxiety (OR, 1.41; CI, 1.04-1.92), and having high levels of ICD concerns (OR, 1.53; CI, 1.22-1.92) were the only significant predictors of having discussions with providers about EOL scenarios (P<0.001 for full model). CONCLUSIONS HF was not a predictor of having an EOL conversation. Further research is needed to determine if attitudes related to not wanting to discuss EOL interfere with good quality of life and of death, or if shared decision-making should be encouraged in these individuals.
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Affiliation(s)
| | - Ingela Thylén
- Departments of Cardiology and Medical and Health Sciences, Linköping University, Sweden (I.T.)
| | - Debra K Moser
- College of Nursing, University of Kentucky, Lexington (J.H.T., D.K.M.)
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6
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Training, Triggers, and a Team for the Right Discussions. J Am Coll Cardiol 2019; 74:1693-1696. [DOI: 10.1016/j.jacc.2019.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 07/28/2019] [Indexed: 11/21/2022]
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7
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Reeder HT, Shen C, Buxton AE, Haneuse SJ, Kramer DB. Joint Shock/Death Risk Prediction Model for Patients Considering Implantable Cardioverter-Defibrillators. Circ Cardiovasc Qual Outcomes 2019; 12:e005675. [PMID: 31412732 PMCID: PMC6697057 DOI: 10.1161/circoutcomes.119.005675] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The risk of death or appropriate therapy varies widely among recipients of implantable cardioverter-defibrillators (ICDs). The goals of this study were to develop a risk prediction tool that jointly considers future outcome probabilities of ICD shock and death. METHODS AND RESULTS We performed a secondary analysis of patients receiving ICDs as part of the SCD-HeFT trial (Sudden Cardiac Death in Heart Failure Trial). We applied an illness-death regression model to jointly model both ICD shocks and death under the semi-competing risks framework, which predicts for each patient their probability of having received ICD shocks, dying, or both at any given point in time. Among 803 ICD recipients (mean age, 60 years; 23% women) followed for a median of 41.1 months, 430 (53.5%) patients completed the study without dying or receiving an ICD shock, 206 (25.7%) received at least 1 shock but survived, 113 (14.1%) died before experiencing a shock, and 54 (6.7%) received at least 1 shock and subsequently died. Predicted outcome probabilities based on baseline demographic and clinical variables reveal substantial heterogeneity in joint shock and death risks, both between patients at each time point and for each single patient across time. Overall, predictive performance for ICD shock and death individually was adequate, based on area under the curve at 5 years of 0.65 for shocks and of 0.79 for death. CONCLUSIONS Our analysis of outcomes after ICD implantation provides an alternative predictive model for individual risk of death or ICD shocks. If validated, this may provide a useful tool for individualized counseling regarding likely outcomes after device implantation, while also informing the design of further studies to focus the clinical effectiveness and cost-effectiveness of ICD therapy. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00000609.
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Affiliation(s)
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Alfred E. Buxton
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | | | - Daniel B. Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
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8
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Halliday BP, Gulati A, Ali A, Newsome S, Lota A, Tayal U, Vassiliou VS, Arzanauskaite M, Izgi C, Krishnathasan K, Singhal A, Chiew K, Gregson J, Frenneaux MP, Cook SA, Pennell DJ, Collins P, Cleland JGF, Prasad SK. Sex- and age-based differences in the natural history and outcome of dilated cardiomyopathy. Eur J Heart Fail 2018; 20:1392-1400. [PMID: 29862606 PMCID: PMC6392171 DOI: 10.1002/ejhf.1216] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/16/2018] [Accepted: 04/18/2018] [Indexed: 12/28/2022] Open
Abstract
Aim To evaluate the relationship between sex, age and outcome in dilated cardiomyopathy (DCM). Methods and results We used proportional hazard modelling to examine the association between sex, age and all‐cause mortality in consecutive patients with DCM. Overall, 881 patients (290 women, median age 52 years) were followed for a median of 4.9 years. Women were more likely to present with heart failure (64.0% vs. 54.5%; P = 0.007) and had more severe symptoms (P < 0.0001) compared to men. Women had smaller left ventricular end‐diastolic volume (125 mL/m2 vs. 135 mL/m2; P < 0.001), higher left ventricular ejection fraction (40.2% vs. 37.9%; P = 0.019) and were less likely to have mid‐wall late gadolinium enhancement (23.0% vs. 38.9%; P < 0.0001). During follow‐up, 149 (16.9%) patients died, including 41 (4.7%) who died suddenly. After adjustment, all‐cause mortality [hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.41–0.92; P = 0.018] was lower in women, with similar trends for cardiovascular (HR 0.60, 95% CI 0.35–1.05; P = 0.07), non‐sudden (HR 0.63, 95% CI 0.39–1.02; P = 0.06) and sudden death (HR 0.70, 95% CI 0.30–1.63; P = 0.41). All‐cause mortality (per 10 years: HR 1.36, 95% CI 1.20–1.55; P < 0.0001) and non‐sudden death (per 10 years: HR 1.51, 95% CI 1.26–1.82; P < 0.00001) increased with age. Cumulative incidence curves confirmed favourable outcomes, particularly in women and those <60 years. Increased all‐cause mortality in patients >60 years of age was driven by non‐sudden death. Conclusion Women with DCM have better survival compared to men, which may partly be due to less severe left ventricular dysfunction and a smaller scar burden. There is increased mortality driven by non‐sudden death in patients >60 years of age that is less marked in women. Outcomes with contemporary treatment were favourable, with a low incidence of sudden death.
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Affiliation(s)
- Brian P Halliday
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK
| | - Ankur Gulati
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | - Aamir Ali
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK
| | - Simon Newsome
- London School of Hygiene and Tropical Medicine, London, UK
| | - Amrit Lota
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK
| | - Upasana Tayal
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK
| | - Vassilios S Vassiliou
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - Monika Arzanauskaite
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | - Cemil Izgi
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | - Kaushiga Krishnathasan
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | - Arvind Singhal
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | - Kayla Chiew
- National Heart & Lung Institute, Imperial College, London, UK
| | - John Gregson
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Stuart A Cook
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK.,National Heart Centre Singapore, Singapore
| | - Dudley J Pennell
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK
| | - Peter Collins
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK
| | - John G F Cleland
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK.,Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Sanjay K Prasad
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK
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9
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Steiner JM, Patton KK, Prutkin JM, Kirkpatrick JN. Moral Distress at the End of a Life: When Family and Clinicians Do Not Agree on Implantable Cardioverter-Defibrillator Deactivation. J Pain Symptom Manage 2018; 55:530-534. [PMID: 29191724 DOI: 10.1016/j.jpainsymman.2017.11.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/18/2017] [Accepted: 11/21/2017] [Indexed: 10/18/2022]
Abstract
A 63-year-old man with end-stage ischemic cardiomyopathy presented with incessant ventricular tachycardia. He had been hospitalized multiple times in the past year for severe heart failure. As he approached end of life and was regularly receiving defibrillator shocks, his care team recommended deactivation of his implantable cardioverter-defibrillator. However, his family did not wish to allow deactivation, reporting a religious obligation to prolong his life, regardless of the risk of suffering. The patient was unable to adequately participate in the decision-making process. An implantable cardioverter-defibrillator can serve to avoid sudden death but may lead to a prolonged death from heart failure. This possibility forces the examination of values regarding prolongation of life, sometimes producing disagreement among stakeholders. Although ethical consensus holds that defibrillator deactivation is legal and ethical, disagreements about life prolongation may complicate decision making. The ethical, technical, and medical complexity involved in this case speaks to the need for clear, prospective communication involving the patient, the patient's family, and members of the care team.
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Affiliation(s)
- Jill M Steiner
- Division of Cardiology, University of Washington, Seattle, Washington, USA.
| | - Kristen K Patton
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Jordan M Prutkin
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - James N Kirkpatrick
- Division of Cardiology, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
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10
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Knoepke CE, Matlock DD. Preliminary Development of an Informational Media Use Measure for Patients with Implanted Defibrillators: Toward a Model of Social-Ecological Assessment of Patient Education and Support. HEALTH & SOCIAL WORK 2017; 42:199-206. [PMID: 28575348 PMCID: PMC6251581 DOI: 10.1093/hsw/hlx023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 08/09/2016] [Accepted: 08/25/2016] [Indexed: 06/07/2023]
Abstract
Social work interventions in health care, particularly those that involve working with people being treated for chronic and life-threatening conditions, frequently involve efforts to educate patients about their disease, treatment options, safety planning, medical adherence, and other associated issues. Despite an intuitive notion that patients access information about all of these issues through a variety of media-both inside and outside the clinical encounter, created by professionals and by others-there currently exists no validated means of assessing patients' use of these forms of information. To address this gap, authors first created candidate item measures with input from both physicians and a small group of diverse patients who currently have an implantable cardioverter defibrillator (ICD), a sophisticated cardiac device for which a trajectory model of social work intervention was recently outlined. Authors then surveyed a group of 205 individuals who have these devices, assessing their use of various media to learn about ICDs. They then conducted factor and item analysis to refine and remove poorly performing items while delineating forms of media use by type. The resultant preliminary measure of informational media use can be further refined and adapted for use with any clinical population.
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Affiliation(s)
- Christopher E Knoepke
- Christopher E. Knoepke, PhD, MSW, LCSW, is postdoctoral fellow and Daniel D. Matlock, MD, MPH, is associate professor, School of Medicine, University of Colorado–Denver. Address correspondence to Christopher E. Knoepke, School of Medicine, University of Colorado, 13199 E. Montview Boulevard, Rm 210-17, Aurora, CO 80045; e-mail: . The project described was supported by a contract with the Patient-Centered Outcomes Research Institute
| | - Daniel D Matlock
- Christopher E. Knoepke, PhD, MSW, LCSW, is postdoctoral fellow and Daniel D. Matlock, MD, MPH, is associate professor, School of Medicine, University of Colorado–Denver. Address correspondence to Christopher E. Knoepke, School of Medicine, University of Colorado, 13199 E. Montview Boulevard, Rm 210-17, Aurora, CO 80045; e-mail: . The project described was supported by a contract with the Patient-Centered Outcomes Research Institute
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11
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Kramer DB, Habtemariam D, Adjei-Poku Y, Samuel M, Engorn D, Reynolds MR, Mitchell SL. The Decisions, Interventions, and Goals in Impla Ntable Cardioverter-Def Ibrillator Therap Y (DIGNITY) Pilot Study. J Am Heart Assoc 2017; 6:JAHA.117.006881. [PMID: 28939708 PMCID: PMC5634310 DOI: 10.1161/jaha.117.006881] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Implantable cardioverter‐defibrillators (ICDs) are commonly implanted in older patients, including those with multiple comorbidities. There are few prospective studies assessing the clinical course and end‐of‐life circumstances for these patients. Methods and Results We prospectively followed 51 patients with ICDs for up to 18 months to longitudinally assess in terms of (1) advance care planning, (2) health status, (3) healthcare utilization, and (4) end‐of‐life circumstances through quarterly phone interviews and electronic medical record review. The mean age was 71.1±8.3, 74.5% were men, and 19.6% were non‐white. Congestive heart failure was predominant (82.4%), as was chronic kidney disease (92%). At baseline, a total of 12% of subjects met criteria for major depression, and 78.4% met criteria for mild cognitive impairment. From this initial study cohort, 76% survived to 18 months and completed all follow‐up interviews, 18% died, and 19% withdrew or were lost to follow‐up. Though living will completion and healthcare proxy assignment were common (cumulative outcome at 18 months 88% and 98%, respectively), discussions of prognosis were uncommon (baseline, 9.8%; by 18 months, 22.7%), as were conversations regarding ICD deactivation (baseline, 15.7%; by 18 months, 25.5%). Five decedents with available data received shocks in the days immediately prior to death, including 3 of whom ultimately had their ICDs deactivated prior to death. Conclusions We demonstrated the feasibility of prospective enrollment and follow‐up of older, vulnerable ICD patients. Early findings suggest a high burden of cognitive and psychological impairment, poor communication with providers, and frequent shocks at the end of life. These findings will inform the design of a larger cohort study designed to further explore the experiences of living and dying with an ICD in this important patient population.
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Affiliation(s)
- Daniel B Kramer
- Hebrew SeniorLife Institute for Aging Research, Boston, MA .,Harvard Medical School, Boston, MA.,Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Daniel Habtemariam
- Hebrew SeniorLife Institute for Aging Research, Boston, MA.,Harvard Medical School, Boston, MA
| | - Yaw Adjei-Poku
- Harvard Medical School, Boston, MA.,Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michelle Samuel
- Harvard Medical School, Boston, MA.,Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Diane Engorn
- Hebrew SeniorLife Institute for Aging Research, Boston, MA.,Harvard Medical School, Boston, MA
| | - Matthew R Reynolds
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA.,Lahey Hospital and Medical Center, Burlington, MA
| | - Susan L Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, MA.,Harvard Medical School, Boston, MA
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12
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Barriers to Goals of Care Discussions With Patients Who Have Advanced Heart Failure: Results of a Multicenter Survey of Hospital-Based Cardiology Clinicians. J Card Fail 2017. [PMID: 28648852 DOI: 10.1016/j.cardfail.2017.06.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Conversations about goals of care in hospital are important to patients who have advanced heart failure (HF). METHODS We conducted a multicenter survey of cardiology nurses, fellows, and cardiologists at 8 Canadian teaching hospitals. The primary outcome was the importance of barriers to goals-of-care discussions in hospital (1 = extremely unimportant; 7 = extremely important). We also elicited perspectives on roles of different practitioners in having these conversations. RESULTS Questionnaires were returned by 770/1024 (75.2%) eligible clinicians. The most important perceived barriers were: family members' and patients' difficulty in accepting a poor prognosis (mean [SD] score 5.9 [1.1] and 5.7 [1.2], respectively), family members' and patients' lack of understanding about the limitations and harms of life-sustaining treatments (5.8 [1.1] and 5.7 [1.2], respectively), and lack of agreement among family members about goals of care (5.8 [1.2]). Interprofessional team members were viewed as having different but important roles in goals-of-care discussions. CONCLUSIONS Cardiology clinicians perceive family and patient-related factors as the most important barriers to goals-of-care discussions in hospital. Many members of the interprofessional team were viewed as having important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication about goals of care in advanced HF.
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Gelfman LP, Bakitas M, Warner Stevenson L, Kirkpatrick JN, Goldstein NE. The State of the Science on Integrating Palliative Care in Heart Failure. J Palliat Med 2017; 20:592-603. [PMID: 29493362 DOI: 10.1089/jpm.2017.0178] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Heart failure (HF) is a chronic progressive illness associated with physical and psychological burdens, high morbidity, mortality, and healthcare utilization. Palliative care is interdisciplinary care that aims to relieve suffering and improve quality of life for persons with serious illness and their families. It is offered simultaneously with disease-oriented care, unlike hospice or end-of-life care. Despite the demonstrated benefits of palliative care in other populations, evidence for palliative care in the HF population is limited. OBJECTIVE The objective of this article is to describe the current evidence and the gaps in the evidence that will need to be improved to demonstrate the benefits of integrating palliative care into the care of patients with advanced HF and their family caregivers. METHODS We reviewed the literature to examine the state of the science and to identify gaps in palliative care integration for persons with HF and their families. We then convened an interdisciplinary working group at an NIH/NPCRC sponsored workshop to review the evidence base and develop a research agenda to address these gaps. RESULTS We identified four key research priorities to improve palliative care for patients with HF and their families: (1) to better understand patients' uncontrolled symptoms, (2) to better characterize and address the needs of the caregivers of advanced HF patients, (3) to improve patient and family understanding of HF disease trajectory and the importance of advance care planning, and (4) to determine the best models of palliative care, including models for those who want to continue life-prolonging therapies. CONCLUSIONS The goal of this research agenda is to motivate patient, provider, policy, and payor stakeholders, including funders, to identify the key research topics that have the potential to improve the quality of care for patients with HF and their families.
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Affiliation(s)
- Laura P Gelfman
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center , Bronx, New York
| | - Marie Bakitas
- 3 School of Nursing, University of Alabama at Birmingham , Birmingham, Alabama
| | - Lynne Warner Stevenson
- 4 Division of Cardiovascular Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | - James N Kirkpatrick
- 5 Division of Cardiology, Department of Bioethics and Humanities, University of Washington Medical Center , Seattle, Washington
| | - Nathan E Goldstein
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center , Bronx, New York
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Wordingham SE, McIlvennan CK, Dionne-Odom JN, Swetz KM. Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life. Curr Heart Fail Rep 2016; 13:20-9. [PMID: 26829929 DOI: 10.1007/s11897-016-0282-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few.
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Affiliation(s)
- Sara E Wordingham
- Department of Medicine, Division of Hematology/Oncology, Palliative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Colleen K McIlvennan
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora and Colorado Cardiovascular Outcomes Research Consortium, Denver, CO, USA.
| | | | - Keith M Swetz
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center; Birmingham VA Medical Center; and Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA.
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McIlvennan CK, Swetz KM. Lack of Agreement With What We Think Is Right Does Not Necessarily Equal an Ethical Problem: Respecting Patients' Goals of Care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:13-15. [PMID: 27366837 DOI: 10.1080/15265161.2016.1187220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Keith M Swetz
- b University of Alabama School of Medicine and Birmingham Veterans Affairs Medical Center
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Hatfield LA, Kramer DB, Volya R, Reynolds MR, Normand SLT. Geographic and Temporal Variation in Cardiac Implanted Electric Devices to Treat Heart Failure. J Am Heart Assoc 2016; 5:e003532. [PMID: 27468928 PMCID: PMC5015279 DOI: 10.1161/jaha.116.003532] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/05/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cardiac implantable electric devices are commonly used to treat heart failure. Little is known about temporal and geographic variation in use of cardiac resynchronization therapy (CRT) devices in usual care settings. METHODS AND RESULTS We identified new CRT with pacemaker (CRT-P) or defibrillator generators (CRT-D) implanted between 2008 and 2013 in the United States from a commercial claims database. For each implant, we characterized prior medication use, comorbidities, and geography. Among 17 780 patients with CRT devices (median age 69, 31% women), CRT-Ps were a small and increasing share of CRT devices, growing from 12% to 20% in this study period. Compared to CRT-D recipients, CRT-P recipients were older (median age 76 versus 67), and more likely to be female (40% versus 30%). Pre-implant use of β-blockers and angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers was low in both CRT-D (46%) and CRT-P (31%) patients. The fraction of CRT-P devices among all new implants varied widely across states. Compared to the increasing national trend, the share of CRT-P implants was relatively increasing in Kansas and relatively decreasing in Minnesota and Oregon. CONCLUSIONS In this large, contemporary heart failure population, CRT-D use dwarfed CRT-P, though the latter nearly doubled over 6 years. Practice patterns vary substantially across states and over time. Medical therapy appears suboptimal in real-world practice.
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Affiliation(s)
| | - Daniel B Kramer
- Harvard Medical School, Boston, MA Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | - Sharon-Lise T Normand
- Harvard Medical School, Boston, MA Harvard T. H. Chan School of Public Health, Boston, MA
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17
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Kramer DB, Reynolds MR, Normand SL, Parzynski CS, Spertus JA, Mor V, Mitchell SL. Hospice Use Following Implantable Cardioverter-Defibrillator Implantation in Older Patients: Results From the National Cardiovascular Data Registry. Circulation 2016; 133:2030-7. [PMID: 27016104 PMCID: PMC4872640 DOI: 10.1161/circulationaha.115.020677] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/23/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Older recipients of implantable cardioverter-defibrillators (ICDs) are at increased risk for short-term mortality in comparison with younger patients. Although hospice use is common among decedents aged >65, its use among older ICD recipients is unknown. METHODS AND RESULTS Medicare patients aged >65 matched to data in the National Cardiovascular Data Registry - ICD Registry from January 1, 2006 to March 31, 2010 were eligible for analysis (N=194 969). The proportion of ICD recipients enrolled in hospice, cumulative incidence of hospice admission, and factors associated with time to hospice enrollment were evaluated. Five years after device implantation, 50.9% of patients were either deceased or in hospice. Among decedents, 36.8% received hospice services. The cumulative incidence of hospice enrollment, accounting for the competing risk of death, was 4.7% (95% confidence interval [CI], 4.6%-4.8%) within 1 year and 21.3% (95% CI, 20.7%-21.8%) at 5 years. Factors most strongly associated with shorter time to hospice enrollment were older age (adjusted hazard ratio, 1.77; 95% CI, 1.73-1.81), class IV heart failure (versus class I; adjusted hazard ratio, 1.79; 95% CI, 1.66-1.94); ejection fraction <20 (adjusted hazard ratio, 1.57; 95% CI, 1.48-1.67), and greater hospice use among decedents in the patients' health referral region. CONCLUSIONS More than one-third of older patients dying with ICDs receive hospice care. Five years after implantation, half of older ICD recipients are either dead or in hospice. Hospice providers should be prepared for ICD patients, whose clinical trajectories and broader palliative care needs require greater focus.
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Affiliation(s)
- Daniel B Kramer
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.).
| | - Matthew R Reynolds
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Sharon-Lise Normand
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Craig S Parzynski
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - John A Spertus
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Vincent Mor
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Susan L Mitchell
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
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18
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Kramer DB, Hatfield LA, Normand SLT. Comparative effectiveness of cardiac implantable electrical devices. Heart 2015; 101:1773-5. [PMID: 26303153 PMCID: PMC4699558 DOI: 10.1136/heartjnl-2015-308295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Daniel B Kramer
- Cardiovascular Division, Department of Medicine, Beth Israel
Deaconess Medical Center, Boston, Massachusetts, USA
- HSL-IFAR, Hebrew SeniorLife Institute for Aging Research, Boston,
Massachusetts, USA
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston,
Massachusetts, USA
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston,
Massachusetts, USA
- Department of Biostatistics, Harvard TH Chan School of Public
Health, Boston, Massachusetts, USA
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