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Zhang Z, Subramaniam DS, Howard SW, Johnston KJ, Frick WH, Enard K, Hinyard L. Use of Palliative Care Among Adults With Newly Diagnosed Heart Failure: Insights From a US National Insured Patient Sample. J Am Heart Assoc 2024; 13:e035459. [PMID: 39206718 DOI: 10.1161/jaha.124.035459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/26/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Despite the known benefits for individuals with heart failure (HF), incomplete data suggest a low use of palliative care (PC) for HF in the United States. We aimed to investigate the national PC use for adults with HF by determining when they received their first PC consultation (PCC) and the associations with clinical factors following diagnosis of HF. METHODS AND RESULTS We conducted a retrospective cohort study in a national all-payer electronic health record database to identify adults (aged ≥18 years) with newly diagnosed HF between 2011 and 2018. The proportion of those who received PCC within 5 years following a diagnosis of HF, and associations of time to first PCC with patient characteristics and HF-specific clinical markers were determined. We followed 127 712 patients for a median of 792 days, of whom 18.3% received PCC in 5 years. Shorter time to receive PCC was associated with diagnoses of HF in 2016 to 2018 (compared with 2010-2015: adjusted hazard ratio [aHR], 1.421 [95% CI, 1.370-1.475]), advanced HF (aHR, 2.065 [95% CI, 1.940-2.198]), cardiogenic shock (aHR, 2.587 [95% CI, 2.414-2.773]), implantable cardioverter-defibrillator (aHR, 5.718 [95% CI, 5.327-6.138]), and visits at academic medical centers (aHR, 1.439 [95% CI, 1.381-1.500]). CONCLUSIONS Despite an expanded definition of PC and recommendations by professional societies, PC for HF remains low in the United States. Racial and geographic variations in access and use of PC exist for patients with HF. Future studies should interrogate the mechanisms of PC underusage, especially before advanced stages, and address barriers to PC services across the health care system.
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Affiliation(s)
- Zidong Zhang
- Advanced HEAlth Data (AHEAD) Institute, Saint Louis University School of Medicine St. Louis MO USA
| | - Divya S Subramaniam
- Advanced HEAlth Data (AHEAD) Institute, Saint Louis University School of Medicine St. Louis MO USA
- Department of Health & Clinical Outcomes Research Saint Louis University School of Medicine St. Louis MO USA
| | | | | | - William H Frick
- Division of Cardiology, Department of Internal Medicine Saint Louis University School of Medicine St. Louis MO USA
| | - Kimberly Enard
- Department of Health Management and Policy, College for Public Health and Social Justice Saint Louis University St. Louis MO USA
| | - Leslie Hinyard
- Advanced HEAlth Data (AHEAD) Institute, Saint Louis University School of Medicine St. Louis MO USA
- Department of Health & Clinical Outcomes Research Saint Louis University School of Medicine St. Louis MO USA
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Feder S, Iannone L, Lendvai D, Zhan Y, Akgün K, Ersek M, Luhrs C, Allen LA, Bekelman DB, Goldstein N, Kavalieratos D. Clinician Insights into Effective Components, Delivery Characteristics and Implementation Strategies of Ambulatory Palliative Care for People with Heart Failure: A Qualitative Analysis. J Card Fail 2024:S1071-9164(24)00265-3. [PMID: 39098653 DOI: 10.1016/j.cardfail.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/28/2024] [Accepted: 07/02/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVES To elicit perspectives from specialist palliative care (SPC) and cardiology clinicians concerning the necessary components, delivery characteristics and implementation strategies of successful ambulatory SPC for people with heart failure (HF). BACKGROUND Palliative care is a recommended component of guideline-directed care for people with HF. However, optimal strategies to implement SPC within ambulatory settings are unknown. METHODS We conducted a qualitative descriptive study composed of semistructured interviews with SPC and cardiology clinicians at Veterans Affairs Medical Centers (VAMCs) with the highest number of ambulatory SPC consultations within the VA system among people with HF between 2021 and 2022. Clinicians were asked how they provided ambulatory SPC and what they felt were the necessary components, delivery characteristics and implementation strategies of care delivery. Interviews were analyzed using directed content analysis. RESULTS We interviewed 14 SPC clinicians and 9 cardiology clinicians at 7 national VAMCs; 43% were physicians, and 48% were advanced-practice registered nurses/physician associates. Essential components of ambulatory SPC encompassed discussion of goals of care (eg, prognosis, advance directives) and connecting patients/caregivers to resources (eg, home care). Preferred delivery characteristics included integrated (ie, embedded) approaches to SPC delivery, standardized patient selection and referral procedures, and formalized procedures for handoffs to and from SPC. Strategies that addressed SPC implementation included deploying palliative champions, educating non-SPC clinicians on the value of ambulatory SPC for people with HF and developing ambulatory models through leadership support. CONCLUSIONS/IMPLICATIONS Facilitating the broader adoption of ambulatory SPC among people with HF may be achieved by prioritizing these mutually valued and necessary features of SPC delivery.
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Affiliation(s)
- Shelli Feder
- Yale School of Nursing, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT.
| | - Lynne Iannone
- VA Connecticut Healthcare System, West Haven, CT; Yale School of Medicine, New Haven, CT
| | - Dora Lendvai
- Yale School of Nursing, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT
| | - Yan Zhan
- Yale School of Nursing, New Haven, CT
| | - Kathleen Akgün
- VA Connecticut Healthcare System, West Haven, CT; Yale School of Medicine, New Haven, CT
| | - Mary Ersek
- Michael C. Cresenz VA Medical Center, Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - Carol Luhrs
- VA New York Harbor Healthcare System, New York, NY
| | - Larry A Allen
- Division of Cardiology, University of Colorado School of Medicine, Boulder, CO
| | - David B Bekelman
- Department of Medicine, VA Eastern Colorado Health Care System and Division of General Internal Medicine and the University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nathan Goldstein
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
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McCleskey SG, Vargas Bustamante A, Ahluwalia SC, Nuckols TK, Kominski GF, Chuang E. Racial Differences in Treatment Intensity at the End of Life Among Older Adults with Heart Failure: Evidence from the Health and Retirement Study. J Palliat Med 2024; 27:854-860. [PMID: 38546482 DOI: 10.1089/jpm.2023.0369] [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: 07/26/2024] Open
Abstract
Background: Black Americans experience the highest prevalence of heart failure (HF) and the worst clinical outcomes of any racial or ethnic group, but little is known about end-of-life care for this population. Objective: Compare treatment intensity between Black and White older adults with HF near the end of life. Design: Negative binomial and logistic regression analyses of pooled, cross-sectional data from the Health and Retirement Study (HRS). Setting/Subjects: A total of 1607 U.S. adults aged 65 years and older with HF who identify as Black or White, and whose proxy informant participated in an HRS exit interview between 2002 and 2016. Measurements: We compared four common measures of treatment intensity at the end of life (number of hospital admissions, receipt of care in an intensive care unit (ICU), utilization of life support, and whether the decedent died in a hospital) between Black and White HF patients, controlling for demographic, social, and health characteristics. Results: Racial identity was not significantly associated with the number of hospital admissions or admission to an ICU in the last 24 months of life. However, Black HF patients were more likely to spend time on life support (odds ratio [OR] = 2.16, confidence interval [CI] = 1.35-3.44, p = 0.00) and more likely to die in a hospital (OR = 1.53, CI = 1.03-2.28, p = 0.04) than White HF patients. Conclusion: Black HF patients were more likely to die in a hospital and to spend time on life support than White HF patients. Thoughtful and consistent engagement with HF patients regarding treatment preferences is an important step in addressing inequities.
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Affiliation(s)
- Sara G McCleskey
- Behavioral and Policy Sciences, RAND, Santa Monica, California, USA
| | - Arturo Vargas Bustamante
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | | | - Teryl K Nuckols
- Behavioral and Policy Sciences, RAND, Santa Monica, California, USA
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gerald F Kominski
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Emmeline Chuang
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
- School of Social Welfare, University of California, Berkeley, Berkeley, California, USA
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Feder SL, Han L, Zhan Y, Abel EA, Akgün KM, Fried T, Ersek M, Redeker NS. Variation in Specialist Palliative Care Reach and Associated Factors Among People With Advanced Heart Failure in the Department of Veterans Affairs. J Pain Symptom Manage 2024; 68:22-31.e1. [PMID: 38561132 PMCID: PMC11168897 DOI: 10.1016/j.jpainsymman.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024]
Abstract
CONTEXT Clinical practice guidelines recommend palliative care for people with advanced heart failure (aHF), yet it remains underutilized. OBJECTIVES We examined medical center variation in specialist palliative care (SPC) and identified factors associated with variation among people with aHF. METHODS We conducted a retrospective cohort study of 21,654 people with aHF who received healthcare in 83 Veterans Affairs Medical Centers (VAMCs) from 2018-2020. We defined aHF with ICD-9/10 codes and hospitalizations. We used random intercept multilevel logistic regression to derive SPC reach (i.e., predicted probability) for each VAMC adjusting for demographic and clinical characteristics. We then examined VAMC-level SPC delivery characteristics associated with predicted SPC reach including the availability of outpatient SPC (proportion of outpatient consultations), cardiology involvement (number of outpatient cardiology-initiated referrals), and earlier SPC (days from aHF identification to consultation). RESULTS Of the sample the mean age = 72.9+/-10.9 years, 97.9% were male, 61.6% were White, and 32.2% were Black. The predicted SPC reach varied substantially across VAMCs from 9% to 57% (mean: 28% [95% Confidence Interval: 25%-30%]). Only the availability of outpatient SPC was independently associated with higher SPC reach. VAMCs, in which outpatient delivery made up the greatest share of SPC consultations (9% or higher) had 11% higher rates of SPC reach relative to VAMCs with a lower proportion of outpatient SPC. CONCLUSION SPC reach varies widely across VAMCs for people with aHF. Outpatient palliative is common among high-reach VAMCs but its role in reach warrants further investigation. Strategies used by high-reach VAMCs may be potential targets to test for implementation and dissemination.
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Affiliation(s)
- Shelli L Feder
- Yale School of Nursing(S.L.F., Y.Z.), Orange, Connecticut, USA; VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA.
| | - Ling Han
- VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA; Yale Program on Aging(L.H., K.M.A., T.F.), New Haven, Connecticut, USA
| | - Yan Zhan
- Yale School of Nursing(S.L.F., Y.Z.), Orange, Connecticut, USA
| | - Erica A Abel
- VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA
| | - Kathleen M Akgün
- VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA; Yale Program on Aging(L.H., K.M.A., T.F.), New Haven, Connecticut, USA
| | - Terri Fried
- VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA; Yale Program on Aging(L.H., K.M.A., T.F.), New Haven, Connecticut, USA; Yale School of Medicine(T.F.), Department of Internal Medicine, New Haven, CT, USA
| | - Mary Ersek
- Veteran Experience Center(M.E.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennysylvania, USA; Leonard Davis Institute(M.E.), University of Pennsylvania, Philadelphia, Pennysylvania, USA
| | - Nancy S Redeker
- University of Connecticut School of Nursing(N.S.R.), Storrs, Connecticut, USA
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Algu K, Wales J, Anderson M, Omilabu M, Briggs T, Kurahashi AM. Naming racism as a root cause of inequities in palliative care research: a scoping review. BMC Palliat Care 2024; 23:143. [PMID: 38858646 PMCID: PMC11163751 DOI: 10.1186/s12904-024-01465-9] [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: 12/29/2023] [Accepted: 05/22/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist. OBJECTIVE To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings. METHODS Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results. RESULTS We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common. CONCLUSION While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.
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Affiliation(s)
- Kavita Algu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada.
| | - Joshua Wales
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Michael Anderson
- Waakebiness-Bryce Institute for Indigenous Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Mariam Omilabu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Thandi Briggs
- Home and Community Care Support Services Toronto Central, 250 Dundas St. W, Toronto, ON, M5T 2Z5, Canada
| | - Allison M Kurahashi
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
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Patarroyo - Aponte G, Shoar S, Ashley DM, Noorbaksh A, Patel D, Young AY, Akkanti BH, Warner MT, Patarroyo - Aponte MM, Kar B, Gregoric ID, Ha C, Patel B. The Role of Palliative Care Consultation in Withdrawal of Life-Sustaining Treatment among ICU Patients Receiving Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO): A Retrospective Case-Control Study. Am J Hosp Palliat Care 2024; 41:150-157. [PMID: 37117039 PMCID: PMC10751975 DOI: 10.1177/10499091231173092] [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: 04/30/2023] Open
Abstract
Background: Extracorporeal membrane oxygenation (ECMO) has extended the survivability of critically ill patients beyond their unsupported prognosis and has widened the timeframe for making an informed decision about the goal of care. However, an extended time window for survival does not necessarily translate into a better outcome and the sustaining treatment is ultimately withdrawn in many patients. Emerging evidence has implicated the determining role of palliative care consult (PCC) in direction of the care that critically ill patients receive. Objective: To evaluate the impact of PCC in withdrawal of life-sustaining treatment (WOLST) among critically ill patients, who were placed on venovenous ECMO (VV-ECMO) at the intensive care unit (ICU) of a tertiary care hospital. Methods: In a retrospective observational study, electronic medical records of 750 patients admitted to the ICU of our hospital between January 1, 2015, and October 31, 2021, were reviewed. Data was collected for patients on VV-ECMO, for whom WOLST was withdrawn during the ICU stay. Clinical characteristics and the underlying reasons for WOLST were compared between those who received PCC (PCC group) and those who did not (non-PCC group). Results: A total of 95 patients were included in our analysis, 63 in the PCC group and 32 in the non-PCC group. The average age of the study population was 48.8 ± 12.6 years, and 64.2% were male. There was no statistically significant difference between the two groups in terms of demographics or clinical characteristics at the time of ICU admission. The average duration of ICU stay and VV-ECMO were 14.1 ± 19.9 days and 9.4 ± 16.6 days, respectively. The number of PCC visits was correlated with the length of ICU stay. The average duration of ICU stay (40.3 ± 33.2 days vs 27.8 ± 19.3 days, P = .05) and ECMO treatment (31.9 ± 27 days vs 18.6 ± 16.1 days, P = .01) were significantly longer in patients receiving PCC than those not receiving PCC. However, the frequency of life sustaining measures or the underlying reasons for WOLST did not significantly differ between the two groups (P > .05). Conclusion: Among ICU patients requiring ECMO support, longer duration of ICU stay and treatment with a higher number of life-sustaining measures seemed to be correlated with the number of PCC visits. The underlying reasons for WOLST seem not to be affected by PCC.
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Affiliation(s)
- Gabriel Patarroyo - Aponte
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
| | - Saeed Shoar
- Department of Clinical Research, Scientific Collaborative Initiative, Houston/Largo, TX/MD, USA
| | - Deptmer M. Ashley
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
| | - Ali Noorbaksh
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Dev Patel
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Alisha Y. Young
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
| | - Bindu H. Akkanti
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
| | - Mark T. Warner
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
| | - Maria M. Patarroyo - Aponte
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Biswajit Kar
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Igor D. Gregoric
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Caroline Ha
- Department of Palliative Care and Rehabilitation Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Bela Patel
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
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Garg I, Gangu K, Zabel KM, Shuja H, Sohail AH, Nasrullah A, Sohail S, Combs SA, Sheikh AB. Trends in utilisation of palliative care services in COVID-19 patients and their impact on hospital resources in the USA: insights from the national inpatient sample. BMJ Support Palliat Care 2024:spcare-2023-004621. [PMID: 38135484 DOI: 10.1136/spcare-2023-004621] [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: 09/30/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVES Poor prognosis and lack of effective therapeutic options have made palliative care an integral part of the management of severe COVID-19. However, clinical studies on the role of palliative care in severe COVID-19 patients are lacking. The objective of our study was to evaluate the utility of palliative care in intubated COVID-19 patients and its impact on in-hospital outcomes. METHODS Rate of palliative care consult, patient-level variables (age, sex, race, income, insurance type), hospital-level variables (region, type, size) and in-hospital outcome variables (mortality, cost, disposition, complications) were recorded. RESULTS We retrospectively analysed 263 855 intubated COVID-19 patients using National Inpatient Sample database from 1 January 2020 to 31 December 2020. 65 325 (24.8%) patients received palliative care consult. Factors associated with an increased rate of palliative care consults included: female gender (p<0.001), older age (p<0.001), Caucasian race (p<0.001), high household income (p<0.001), Medicare insurance (p<0.001), admission to large-teaching hospitals (p<0.001), patients with underlying comorbidities, development of in-hospital complications and the need for intensive care procedures. Patients receiving palliative consults had shorter hospital length of stay (LOS) (p<0.001) and no difference in hospitalisation cost (p=0.15). CONCLUSIONS Palliative care utilisation rate in intubated COVID-19 patients was reflective of disease severity and disparities in healthcare access. Palliative care may help reduce hospital LOS. Our findings also highlight importance of improving access to palliative care services and its integration into the multidisciplinary management of severe COVID-19 patients.
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Affiliation(s)
- Ishan Garg
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Karthik Gangu
- The University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Hina Shuja
- Karachi Medical and Dental College, Karachi, Pakistan
| | - Amir Humza Sohail
- NYU Langone Health, New York, New York, USA
- NYU Langone, NYU Grossman Long Island School of Medicine, New York, New York, USA
| | | | | | - Sara A Combs
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Abu Baker Sheikh
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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8
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Thandra A, Balakrishna AM, Walters RW, Alugubelli N, Koripalli VS, Alla VM. Trends in and predictors of multiple readmissions following heart failure hospitalization: A National wide analysis from the United States. Am J Med Sci 2023; 365:145-151. [PMID: 36152813 DOI: 10.1016/j.amjms.2022.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 05/23/2022] [Accepted: 09/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Readmission following Heart failure (HF) hospitalization is common: 25% are readmitted within a month of discharge and ≈50% within 6 months. A small proportion of these patients can have multiple readmissions within this period, adding disproportionately to the health care costs. In this study, we assessed the trends, predictors and costs associated with multiple readmissions using National readmissions database (NRD). METHODS We queried NRD for HF hospitalizations from 2010 to 2018 using ICD-9/10-CM codes. Multinomial logistic regression was used to compare readmission cohorts, with the multivariable model adjusting for other factors. All analyses accounted for the NRD sampling design were conducted using SAS v. 9.4 with p < 0.05 used to indicate statistical significance. RESULTS Within the study period, an estimated 6,763,201 HF hospitalizations were identified. Of these, 58% had no readmission; 26% had 1 readmission; and 16% had ≥2 readmissions within 90 days of index hospitalization. There was no statistically significant change in readmission rates during the observation period. Multiple readmissions which accounted for 37% of all readmissions contributed to 57% of readmission costs. Younger age was identified as a predictor of multiple readmissions while sex, comorbidities and the type of insurance were not significantly different from those with single readmission. CONCLUSIONS Multiple readmissions in HF are common (16%), have remained unchanged between 2010 and 2018 and impose a significant health care cost burden. Future research should focus on identifying these patients for targeted intervention that may minimize excessive readmissions particularly in those patients who are in the palliation phase of HF.
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Affiliation(s)
- Abhishek Thandra
- Department of Medicine, Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, United States.
| | | | - Ryan W Walters
- Department of Medicine, Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE, United States
| | - Navya Alugubelli
- Department of Medicine, Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, United States
| | | | - Venkata M Alla
- Department of Medicine, Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, United States
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9
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Gruen J, Gandhi P, Gillespie-Heyman S, Shamas T, Adelman S, Ruskin A, Bauer M, Merchant N. Hospitalisations for heart failure: increased palliative care referrals - a veterans affairs hospital initiative. BMJ Support Palliat Care 2023:spcare-2022-004118. [PMID: 36609533 DOI: 10.1136/spcare-2022-004118] [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: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Heart failure (HF) portends significant morbidity and mortality. Integrating palliative care (PC) with HF management improves quality of life and preparedness planning. At a Veterans Affairs hospital, PC was used in 6.5% of patients admitted for HF from October 2019 to September 2020. We sought to increase the percentage of referrals to PC to 20%. METHODS PC referral guidelines were developed and used to screen all HF admissions between October 2020 and May 2021. Point-of-care education on the benefits of PC was delivered to teams caring for patients who met PC referral criteria. Changes were tested using Plan-Do-Study-Act (PDSA) cycles. Results were analysed using run charts. RESULTS During the study period, there were 109 HF admissions in patients who were not already followed by PC. Thirty-one (28%) received a new PC consult. The mean age was 81±9.5 years, median B-type natriuretic peptide was 1202 pg/mL, and mean length of stay was 8±5 days. After our intervention, there was an upward shift in the percentage of new referrals to PC with 6 values above the baseline median, which represents a significant change. CONCLUSIONS Through multiple PDSA cycles, referrals to PC for patients admitted with HF increased from 6.5% to 28%. Point-of-care education was an effective tool to teach medical teams about the benefits of PC. Inpatient teams more consistently and independently considered PC for patients with HF, representing a cultural shift. This quality improvement model may serve as a paradigm to improve the care of HF patients.
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Affiliation(s)
- Jadry Gruen
- Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Parul Gandhi
- Cardiovascular Disease, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Cardiovascular Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sarah Gillespie-Heyman
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Tracy Shamas
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Samuel Adelman
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Andrea Ruskin
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Margaret Bauer
- Mental Health, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Naseema Merchant
- Hospital Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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10
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Morris AA, Khazanie P, Drazner MH, Albert NM, Breathett K, Cooper LB, Eisen HJ, O'Gara P, Russell SD. Guidance for Timely and Appropriate Referral of Patients With Advanced Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e238-e250. [PMID: 34503343 DOI: 10.1161/cir.0000000000001016] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Among the estimated 6.2 million Americans living with heart failure (HF), ≈5%/y may progress to advanced, or stage D, disease. Advanced HF has a high morbidity and mortality, such that early recognition of this condition is important to optimize care. Delayed referral or lack of referral in patients who are likely to derive benefit from an advanced HF evaluation can have important adverse consequences for patients and their families. A 2-step process can be used by practitioners when considering referral of a patient with advanced HF for consideration of advanced therapies, focused on recognizing the clinical clues associated with stage D HF and assessing potential benefits of referral to an advanced HF center. Although patients are often referred to an advanced HF center to undergo evaluation for advanced therapies such as heart transplantation or implantation of a left ventricular assist device, there are other reasons to refer, including access to the infrastructure and multidisciplinary team of the advanced HF center that offers a broad range of expertise. The intent of this statement is to provide a framework for practitioners and health systems to help identify and refer patients with HF who are most likely to derive benefit from referral to an advanced HF center.
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11
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Sokol LL, Bega D, Yeh C, Kluger BM, Lum HD. Disparities in Palliative Care Utilization Among Hospitalized People With Huntington Disease: A National Cross-Sectional Study. Am J Hosp Palliat Care 2021; 39:516-522. [PMID: 34291654 DOI: 10.1177/10499091211034419] [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: 11/17/2022] Open
Abstract
BACKGROUND People with Huntington's disease (HD) often become institutionalized and more frequently die away from the home setting. The reasons behind differences in end-of-life care are poorly understood. Less than 5% of people with HD report utilization of palliative care (PC) or hospice services, regardless of the lack of curative therapies for this neurodegenerative disease. It is unknown what factors are associated with in-patient specialty PC consultation in this population and how PC might be related to discharge disposition. OBJECTIVES To determine what HD-specific (e.g., psychosis) and serious illness-specific factors (e.g., resuscitation preferences) are associated with PC encounters in people with HD and explore how PC encounters are associated with discharge disposition. DESIGN We analyzed factors associated with PC consultation for people with HD using discharge data from the National Inpatient Sample and the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. An anonymized, cross-sectional, and stratified sample of 20% of United States hospitalizations from 2007 through 2014 were included using ICD-9 codes. RESULTS 8521 patients with HD were admitted to the hospital. Of those, 321 (3.8%) received specialty PC. Payer type, (specifically private insurer or other insurer as compared to Medicare), income, (specifically the top quartile as compared to the bottom quartile), mortality risk, D.N.R., aspiration pneumonia, and depression were significantly associated with PC in a multivariate model. Among those who received PC, the odds ratio (OR) of discharge to a facility was 0.43 (95% CI, 0.32-0.58), whereas the OR of discharge to home with services was 2.25 (95% CI 1.57-3.23), even after adjusting for possible confounders. CONCLUSIONS Among patients with HD, economic factors, depression, and serious illness-specific factors were associated with PC, and PC was associated with discharge disposition. These findings have implications for the adaptation of inpatient PC models to meet the needs of persons with HD.
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Affiliation(s)
- Leonard L Sokol
- The Ken and Ruth Davee Department of Neurology, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,McGaw Bioethics Scholars Program, Center for Bioethics and Humanities, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Danny Bega
- The Ken and Ruth Davee Department of Neurology, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Movement Disorders, The Ken and Ruth Davee Department of Neurology, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chen Yeh
- Department of Preventive Medicine, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Benzi M Kluger
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA.,Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Hillary D Lum
- Eastern Colorado VA Geriatric Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.,Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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12
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Quelal K, Olagoke O, Shahi A, Torres A, Ezegwu O, Golzar Y. Trends and Predictors of Palliative Care Consultation Among Patients Admitted for LVAD: A Retrospective Analysis From the Nationwide Inpatient Sample Database From 2006-2014. Am J Hosp Palliat Care 2021; 39:353-360. [PMID: 34080439 DOI: 10.1177/10499091211021837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Left ventricular assist devices (LVADs) are an essential part of advanced heart failure (HF) management, either as a bridge to transplantation or destination therapy. Patients with advanced HF have a poor prognosis and may benefit from palliative care consultation (PCC). However, there is scarce data regarding the trends and predictors of PCC among patients undergoing LVAD implantation. AIM This study aims to assess the incidence, trends, and predictors of PCC in LVAD recipients using the United States Nationwide Inpatient Sample (NIS) database from 2006 until 2014. METHODS We conducted a weighted analysis on LVAD recipients during their index hospitalization. We compared those who had PCC with those who did not. We examined the trend in palliative care utilization and calculated adjusted odds ratios (aOR) to identify demographic, social, and hospital characteristics associated with PCC using multivariable logistic regression analysis. RESULTS We identified 20,675 admissions who had LVAD implantation, and of them 4% had PCC. PCC yearly rate increased from 0.6% to 7.2% (P < 0.001). DNR status (aOR 28.30), female sex (aOR 1.41), metastatic cancer (aOR: 3.53), Midwest location (aOR 1.33), and small-sized hospitals (aOR 2.52) were positive predictors for PCC along with in-hospital complications. Differently, Black (aOR 0.43) and Hispanic patients (aOR 0.25) were less likely to receive PCC. CONCLUSION There was an increasing trend for in-hospital PCC referral in LVAD admissions while the overall rate remained low. These findings suggest that integrative models to involve PCC early in advanced HF patients are needed to increase its generalized utilization.
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Affiliation(s)
- Karol Quelal
- Department of Internal Medicine, Cook County Health, Chicago, IL, USA
| | - Olankami Olagoke
- Division of Cardiovascular Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Anoj Shahi
- Department of Internal Medicine, Cook County Health, Chicago, IL, USA
| | - Andrea Torres
- Department of Internal Medicine, Cook County Health, Chicago, IL, USA
| | - Olisa Ezegwu
- Department of Internal Medicine, Cook County Health, Chicago, IL, USA
| | - Yasmeen Golzar
- Division of Cardiology, Cook County Health, Chicago, IL, USA
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13
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Godfrey S, Sahoo A, Sanchez J, Fried J, Masoumi A, Brodie D, Takayama H, Uriel N, Takeda K, Nakagawa S. The Role of Palliative Care in Withdrawal of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. J Pain Symptom Manage 2021; 61:1139-1146. [PMID: 33137423 DOI: 10.1016/j.jpainsymman.2020.10.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
CONTEXT As the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) increases, decisions regarding withdrawal from VA-ECMO increase. OBJECTIVES To evaluate the clinical characteristics of patients withdrawn from VA-ECMO and the role of palliative care consultation in the decision. METHODS We retrospectively reviewed adult patients with cardiogenic shock requiring VA-ECMO at our institution, who were withdrawn from VA-ECMO between January 1, 2014 and May 31, 2019. The relationship between clinical characteristics and palliative care visits was assessed, and documented reasons for withdrawal were identified. RESULTS Of 460 patients who received VA-ECMO, 91 deceased patients (19.8%) were included. Forty-two patients (44.8%) had a palliative care consultation. The median duration on VA-ECMO was 4.0 days (interquartile range 8.8), and it was significantly longer for patients with palliative care consultation than those without (8.8 days vs. 2.0 days, P < 0.001). Among those with palliative care consultation, those with early consultation (within three days) had significantly shorter duration of VA-ECMO compared with those with late consultation (7.6 days vs. 13.5 days, t = 2.022, P = 0.008). Twenty-two (24.2%) had evidence of brain injury, which was significantly associated with patient age, number of comorbidities, duration of VA-ECMO, number of life-sustaining therapies, and number of palliative care visits (Wilks lambda 0.8925, DF 5,121, P = 0.016). Presence of brain injury was associated with fewer palliative care visits (t = 2.82, P = 0.006). CONCLUSION Shorter duration of VA-ECMO support and presence of brain injury were associated with fewer palliative care visits. Decisions around withdrawal of VA-ECMO support might be less complicated when patient's medical conditions deteriorate quickly or when neurological prognosis seems poor.
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Affiliation(s)
- Sarah Godfrey
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Aradhana Sahoo
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Joseph Sanchez
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Justin Fried
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Amirali Masoumi
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel Brodie
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Hiroo Takayama
- Division of Cardiac, Vascular, and Thoracic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Nir Uriel
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Koji Takeda
- Division of Cardiac, Vascular, and Thoracic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Shunichi Nakagawa
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA; Adult Palliative Care Services, Columbia University Irving Medical Center, New York, New York, USA.
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14
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Palliative care for patients with advanced heart failure: When is the optimal timing of advanced care planning? Int J Cardiol 2020; 328:143-144. [PMID: 33301832 DOI: 10.1016/j.ijcard.2020.12.004] [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: 11/27/2020] [Accepted: 12/02/2020] [Indexed: 11/21/2022]
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15
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Prevalence of advanced heart failure and use of palliative care in admitted patients: Findings from the EPICTER study. Int J Cardiol 2020; 327:125-131. [PMID: 33171167 DOI: 10.1016/j.ijcard.2020.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/01/2020] [Accepted: 11/03/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION AND AIM Palliative care in patients with advanced heart failure is strongly recommended by Clinical Practice Guidelines. We aimed to calculate the prevalence of advanced heart failure in admitted patients, to describe their management, and to analyse the factors that influence their referral to specialised palliative care. PATIENTS AND METHODS Cross-sectional, multicentre study that consecutively included patients admitted for heart failure in 74 Spanish hospitals. If they met criteria for advanced heart failure, their treatment, complications and procedures were recorded. RESULTS A total of 3153 patients were included. Of them, 739 (23%) met criteria for advanced heart failure. They were more likely to be women, older and to have a history of anaemia, chronic kidney disease and cognitive impairment. For their management, furosemide infusions (30%) and vasodilators (21%) were used. Refractory symptoms were treated with opioids (47%) and benzodiazepines (44%). Palliative care was only provided in the last hours of life in 48% of them. A multidisciplinary approach, involving palliative care specialists was sought in 15% of these patients. Treatment with furosemide infusions, an advanced New York Heart Association functional class, to meet advanced HF criteria and the presence of cancer were associated with the referral to specialised palliative care. CONCLUSIONS Almost one in four patients admitted with HF met criteria of advanced disease. They were older and had more comorbidities. Specialist palliative care services were involved in only a minority of patients, mainly those who were highly symptomatic or had cancer.
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16
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Anand V, Vallabhajosyula S, Cheungpasitporn W, Frantz RP, Cajigas HR, Strand JJ, DuBrock HM. Inpatient Palliative Care Use in Patients With Pulmonary Arterial Hypertension: Temporal Trends, Predictors, and Outcomes. Chest 2020; 158:2568-2578. [PMID: 32800817 DOI: 10.1016/j.chest.2020.07.079] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a progressive disease associated with significant morbidity and mortality. Despite the negative impact of PAH on quality of life and survival, data on use of specialty palliative care services (PCS) is scarce. RESEARCH QUESTION We sought to evaluate the inpatient use of PCS in patients with PAH. STUDY DESIGN AND METHODS Using the National (Nationwide) Inpatient Sample, 30,495 admissions with a primary diagnosis of PAH were identified from 2001 through 2017. The primary outcome of interest was temporal trends and predictors of inpatient PCS use in patients with PAH. RESULTS The inpatient use of PCS was low (2.2%), but increased during the study period from 0.5% in 2001 to 7.6% in 2017, with a significant increase starting in 2009. White race, private insurance, higher socioeconomic status, hospital-specific factors, higher comorbidity burden (Charlson Comorbidity Index), cardiac and noncardiac organ failure, and use of extracorporeal membrane oxygenation and noninvasive mechanical ventilation were independent predictors of increased PCS use. PCS use was associated with a higher prevalence of do-not-resuscitate status, a longer length of stay, higher hospitalization costs, and increased in-hospital mortality with less frequent discharges to home, likely because these patients were also sicker (higher comorbidity index and illness acuity). INTERPRETATION The inpatient use of PCS in patients with PAH is low, but has been increasing over recent years. Despite increased PCS use over time, patient- and hospital-specific disparities in PCS use continue. Further studies evaluating these disparities and the role of PCS in the comprehensive care of PAH patients are warranted.
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Affiliation(s)
- Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi School of Medicine, Jackson, MS
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Hector R Cajigas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jacob J Strand
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
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17
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Robinson J, Frey R, Boyd M, McLeod H, Meehan B, Gott M. InterRAI assessments: opportunities to recognise need for and implementation of palliative care interventions in the last year of life? Australas J Ageing 2020; 40:e22-e28. [PMID: 33739596 DOI: 10.1111/ajag.12840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 06/21/2020] [Accepted: 07/06/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To explore how interRAI assessments could be used to identify opportunities to integrate palliative care into a plan of care. METHODS A population-based, cross-sectional design using unique identifiers to link deaths with a national interRAI database. Data were analysed using logistic regression models and chi-square tests. RESULTS A total of 4869 people died over a 12-month period in one district health board area; 50.9% (n = 2478) received one or more interRAI assessments in the year before death. Diagnosis impacted on the type and timing of interRAI assessments and the recognition of end-stage disease. CONCLUSION People in the last year of life experience frequent interRAI assessments. There are opportunities to identify people who might benefit from a palliative care approach. Future research is needed to understand how interRAI assessors can be supported in the application of assessment items related to palliative care.
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Affiliation(s)
- Jackie Robinson
- School of Nursing, University of Auckland, Auckland, New Zealand.,Auckland District Health Board, Auckland, New Zealand
| | - Rosemary Frey
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Michal Boyd
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Heather McLeod
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Brigette Meehan
- Technical Advisory Services Limited (TAS), interRAI New Zealand, Wellington, New Zealand
| | - Merryn Gott
- School of Nursing, University of Auckland, Auckland, New Zealand
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18
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Di Luca DG, Feldman M, Jimsheleishvili S, Margolesky J, Cordeiro JG, Diaz A, Shpiner DS, Moore HP, Singer C, Li H, Luca C. Trends of inpatient palliative care use among hospitalized patients with Parkinson's disease. Parkinsonism Relat Disord 2020; 77:13-17. [PMID: 32575002 DOI: 10.1016/j.parkreldis.2020.06.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/16/2020] [Accepted: 06/12/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Palliative care in Parkinson's Disease (PD) is an effective intervention to improve quality of life, although historically, access and availability have been very restricted. METHODS We performed a retrospective cohort study using the National Inpatient Sample (NIS) data from 2007 to 2014. Diagnostic codes were used to identify patients with PD and palliative care referral. Trends were calculated and logistic analysis performed to identify predictors of palliative care use. RESULTS We identified 397,963 hospitalizations from 2007 to 2014 for patients with PD. Of these, 10,639 (2.67%) were referred to palliative care. The rate of consultation increased from 0.85% in 2007 to 4.49% in 2014. For 1 unit in year increase, there was 1.23 time the odds of receiving palliative consultation (OR 1.23, CI 1.21-1.25, p < 0.0001). Hispanics (OR 0.90, CI 0.81-1.01, p = 0.0550), Black (OR 0.90, CI 0.81-1.01, p = 0.0747) and White patients had similar rates of referral after adjustment. Women were less likely to be referred to palliative care (OR 0.90, CI 0.87-0.94, p < 0.0001). Other factors strongly associated with a higher rate of referrals included private insurance when compared to Medicare (OR 2.14, CI 1.89-2.41, p < 0.0001) and higher income (OR 1.41, CI 1.30-1.53, p < 0.0001). CONCLUSION There has been a significant increase in palliative care referrals among hospitalized patients with PD in the US, although the overall rate remains low. After controlling for confounders, racial and ethnic disparities were not found. Women, patients with Medicare/Medicaid, and those with lower income were less likely to be referred to palliative care.
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Affiliation(s)
- Daniel G Di Luca
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Matthew Feldman
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Jason Margolesky
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Anthony Diaz
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Danielle S Shpiner
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Henry P Moore
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Carlos Singer
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hua Li
- Department of Public Health Sciences, Division of Biostatistics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Corneliu Luca
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
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19
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Wen Y, Jiang C, Koncicki HM, Horowitz CR, Cooper RS, Saha A, Coca SG, Nadkarni GN, Chan L. Trends and Racial Disparities of Palliative Care Use among Hospitalized Patients with ESKD on Dialysis. J Am Soc Nephrol 2019; 30:1687-1696. [PMID: 31387926 DOI: 10.1681/asn.2018121256] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 05/16/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Study findings show that although palliative care decreases symptom burden, it is still underused in patients with ESKD. Little is known about disparity in use of palliative care services in such patients in the inpatient setting. METHODS To investigate the use of palliative care consultation in patients with ESKD in the inpatient setting, we conducted a retrospective cohort study using the National Inpatient Sample from 2006 to 2014 to identify admitted patients with ESKD requiring maintenance dialysis. We compared palliative care use among minority groups (black, Hispanic, and Asian) and white patients, adjusting for patient and hospital variables. RESULTS We identified 5,230,865 hospitalizations of such patients from 2006 through 2014, of which 76,659 (1.5%) involved palliative care. The palliative care referral rate increased significantly, from 0.24% in 2006 to 2.70% in 2014 (P<0.01). Black and Hispanic patients were significantly less likely than white patients to receive palliative care services (adjusted odds ratio [aOR], 0.72; 95% confidence interval [95% CI], 0.61 to 0.84, P<0.01 for blacks and aOR, 0.46; 95% CI, 0.30 to 0.68, P<0.01 for Hispanics). These disparities spanned across all hospital subtypes, including those with higher proportions of minorities. Minority patients with lower socioeconomic status (lower level of income and nonprivate health insurance) were also less likely to receive palliative care. CONCLUSIONS Despite a clear increase during the study period in provision of palliative care for inpatients with ESKD, significant racial disparities occurred and persisted across all hospital subtypes. Further investigation into causes of racial and ethnic disparities is necessary to improve access to palliative care services for the vulnerable ESKD population.
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Affiliation(s)
- Yumeng Wen
- Department of Medicine, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, New York
| | - Changchuan Jiang
- Department of Medicine, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, New York
| | - Holly M Koncicki
- Division of Nephrology and.,Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Carol R Horowitz
- Department of Medicine, Mount Sinai Hospital, New York, New York.,Department of Population Health Science and Policy and
| | - Richard S Cooper
- Department of Public Health Sciences, Loyola University, Maywood, Illinois
| | - Aparna Saha
- Department of Public Health Sciences, Loyola University, Maywood, Illinois
| | - Steven G Coca
- Division of Nephrology and.,Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Girish N Nadkarni
- Division of Nephrology and .,Department of Medicine, Mount Sinai Hospital, New York, New York.,Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Lili Chan
- Division of Nephrology and .,Department of Medicine, Mount Sinai Hospital, New York, New York
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20
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Vallabhajosyula S, Prasad A, Dunlay SM, Murphree DH, Ingram C, Mueller PS, Gersh BJ, Holmes DR, Barsness GW. Utilization of Palliative Care for Cardiogenic Shock Complicating Acute Myocardial Infarction: A 15-Year National Perspective on Trends, Disparities, Predictors, and Outcomes. J Am Heart Assoc 2019; 8:e011954. [PMID: 31315497 PMCID: PMC6761657 DOI: 10.1161/jaha.119.011954] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background This study sought to evaluate the 15‐year national utilization, trends, predictors, disparities, and outcomes of palliative care services (PCS) use in cardiogenic shock complicating acute myocardial infarction. Methods and Results A retrospective cohort from January 1, 2000 through December 31, 2014 was analyzed using the National Inpatient Sample database. Administrative codes for acute myocardial infarction–cardiogenic shock and PCS were used to identify eligible admissions. The primary outcomes were the frequency, utilization trends, and predictors of PCS. Secondary outcomes included in‐hospital mortality and resources utilization. Multivariable regression and propensity‐matching analyses were used to control for confounding. In this 15‐year period, there were 444 253 acute myocardial infarction–cardiogenic shock admissions, of which 4.5% received PCS. The cohort receiving PCS was older, of white race, female sex, and with higher comorbidity and acute organ failure. The PCS cohort received fewer cardiac procedures, but more noncardiac organ support therapies. Older age, female sex, white race, higher comorbidity, higher socioeconomic status, admission to a larger hospital, and admission after 2008 were independent predictors of PCS use. Use of PCS was independently associated with higher in‐hospital mortality (odds ratio 6.59 [95% CI 6.37–6.83]; P<0.001). The cohort with PCS use had >2‐fold higher in‐hospital mortality, 12‐fold higher use of do‐not‐resuscitate status, lesser in‐hospital resource utilization, and fewer discharges to home. Similar findings were observed in the propensity‐matched cohort. Conclusions PCS use in patients with acute myocardial infarction–cardiogenic shock is low, though there is a trend towards increased adoption. There are significant patient and hospital‐specific disparities in the utilization of PCS.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Division of Pulmonary and Critical Care Medicine Department of Medicine Mayo Clinic Rochester MN
| | - Abhiram Prasad
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Department of Health Science Research Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Dennis H Murphree
- Department of Health Science Research Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Cory Ingram
- Division of General Internal Medicine Department of Medicine Mayo Clinic Rochester MN
| | - Paul S Mueller
- Division of General Internal Medicine Department of Medicine Mayo Clinic Rochester MN
| | - Bernard J Gersh
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - David R Holmes
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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21
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Heydari A, Sharifi H, Bagheri Moghaddam A. The Provision of Palliative Care for Noncancer Patients With Advanced Disease: Equity Does Matter. Am J Hosp Palliat Care 2019; 36:932-933. [PMID: 30836767 DOI: 10.1177/1049909119835225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
According to the World Health Organization, the main mission of palliative care is to optimize the quality of life of patients with serious chronic disease, as well as their caregivers, by providing biopsychosociospiritual care. However, historically, the primary focus of palliative care is on providing care only for cancer diseases. Based on the current literature, it is assumed that palliative care is not provided for many chronic diseases on a regular basis and in many cases, a clinical guideline does not exist for providing palliative care.
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Affiliation(s)
- Abbas Heydari
- 1 Nursing and Midwifery care research center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Sharifi
- 2 Department of Medical-Surgical Nursing, Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ahmad Bagheri Moghaddam
- 3 Department of Anesthesiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Abdullah AS, Salama A, Ibrahim H, Eigbire G, Hoefen R, Alweis R. Palliative Care in Myocardial Infarction: Patient Characteristics and Trends of Service Utilization in a National Inpatient Sample. Am J Hosp Palliat Care 2019; 36:722-726. [PMID: 30803244 DOI: 10.1177/1049909119832818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Myocardial infarction (MI) remains a leading cause of mortality. Palliative care (PC) has recently expanded in scope to include noncancer-related conditions. There is little data available regarding the use of PC in critical MI patients. METHODS We used discharge data from the National Inpatient Sample for the years 2012 to 2014. We examined discharges with a primary diagnosis of MI. We measured the rate of PC referral, trend in utilization during the study period and possible predictors of PC utilization. RESULTS Among 1 667 520 discharges of those patients ≥18 years of age and with a primary diagnosis of MI, use of PC was seen in 2.5% of all patients and in 24% of patients who died. In a multivariable logistic regression, we found the presence of cancer, cardiogenic shock, dementia, stroke, hemiplegia, the use of circulatory support, and mechanical ventilation were associated with higher likelihood of PC referral. Palliative care referral increased during the study period, odds ratio of 1.18 per year (95% confidence interval: 1.14-1.21; P value <.001). Palliative care was not associated with prolonged length of stay. CONCLUSION Several comorbidities were associated with the use of PC, most notably the use of mechanical ventilation and the presence of metastatic cancer. There was a trend of increasing use of PC during the study period.
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Affiliation(s)
| | - Amr Salama
- 1 Department of Medicine-Unity Hospital, Rochester Regional Health, Rochester, NY, USA
| | - Hisham Ibrahim
- 2 Department of Cardiology-University of Iowa Hospital and Clinics, Iowa city, IA, USA
| | - George Eigbire
- 1 Department of Medicine-Unity Hospital, Rochester Regional Health, Rochester, NY, USA
| | - Ryan Hoefen
- 3 Sands-Constellation Heart Institute, Rochester Regional health, Rochester, NY, USA
| | - Richard Alweis
- 1 Department of Medicine-Unity Hospital, Rochester Regional Health, Rochester, NY, USA.,4 Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,5 School of Health Sciences, Rochester Institute of Technology, Rochester, NY, USA
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Ando T, Adegbala O, Uemura T, Akintoye E, Ashraf S, Briasoulis A, Takagi H, Afonso L. Incidence, Trends, and Predictors of Palliative Care Consultation After Aortic Valve Replacement in the United States. J Palliat Care 2018; 34:111-117. [DOI: 10.1177/0825859718819433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Aim: Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have become a reasonably safe procedure with acceptable morbidity and mortality rate. However, little is known regarding the incidence, trends, and predictors of palliative care (PC) consult in aortic valve replacement (AVR) patients. The main purpose of this analysis was to assess the incidence, trends, and predictors of PC consultation in AVR recipients using the Nationwide Inpatient Sample (NIS) database. Materials and Methods: We queried the NIS database from 2005 to September 2015 to identify those who underwent TAVR or SAVR and had PC referral during the index hospitalization. Adjusted odds ratio (aOR) was calculated to identify patient demographic, social and hospital characteristics, and procedural characteristics associated with PC consult using multivariable regression analysis. We also reported the trends of PC referral in AVR recipients. Results: A total of 522 765 admissions (mean age: 75.3 ± 7.8 years, 40.3% female) who had TAVR (1.7% transapical and 9.2% endovascular approach) and SAVR (89.2%) were identified. Inpatient mortality was 3.96%, and 0.5% patients of the total admissions had PC consultation. The PC referral for SAVR increased from 0.90 to 7.2 per 1000 SAVR from 2005 to 2015 ( P = .011), while it remained stable ranging from 9.30 to 13.3 PC consults per 1000 TAVR ( P = .86). Age 80 to 89 (aOR: 1.93), age ≥90 years (aOR: 2.57), female sex (aOR: 1.36), electrolyte derangement (aOR: 1.90), weight loss (aOR: 1.88), and do not resuscitate status (aOR: 44.4) were associated with PC consult. West region (aOR: 1.46) and Medicaid (aOR: 3.05) were independently associated with PC consult. Endovascular (aOR: 1.88) and transapical TAVR (aOR: 2.80) had higher PC referral rates compared with SAVR. Conclusions: There was an increase in trends for utilization of PC service in SAVR admissions while it remained unchanged in TAVR cohort, but the overall PC referral rate was low in AVR recipients during the index hospitalization.
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Affiliation(s)
- Tomo Ando
- Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Oluwole Adegbala
- Department of Internal Medicine, Englewood Hospital and Medical Center, Seton Hall University–Hackensack Meridian School of Medicine, Englewood, NJ, USA
| | - Takeshi Uemura
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, NY, USA
| | - Emmanuel Akintoye
- Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Said Ashraf
- Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Alexandros Briasoulis
- Divison of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Luis Afonso
- Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
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