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Ahmad FS, Hu TL, Adler ED, Petito LC, Wehbe RM, Wilcox JE, Mutharasan RK, Nardone B, Tadel M, Greenberg B, Yagil A, Campagnari C. Performance of risk models to predict mortality risk for patients with heart failure: evaluation in an integrated health system. Clin Res Cardiol 2024:10.1007/s00392-024-02433-2. [PMID: 38565710 DOI: 10.1007/s00392-024-02433-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Referral of patients with heart failure (HF) who are at high mortality risk for specialist evaluation is recommended. Yet, most tools for identifying such patients are difficult to implement in electronic health record (EHR) systems. OBJECTIVE To assess the performance and ease of implementation of Machine learning Assessment of RisK and EaRly mortality in Heart Failure (MARKER-HF), a machine-learning model that uses structured data that is readily available in the EHR, and compare it with two commonly used risk scores: the Seattle Heart Failure Model (SHFM) and Meta-Analysis Global Group in Chronic (MAGGIC) Heart Failure Risk Score. DESIGN Retrospective, cohort study. PARTICIPANTS Data from 6764 adults with HF were abstracted from EHRs at a large integrated health system from 1/1/10 to 12/31/19. MAIN MEASURES One-year survival from time of first cardiology or primary care visit was estimated using MARKER-HF, SHFM, and MAGGIC. Discrimination was measured by the area under the receiver operating curve (AUC). Calibration was assessed graphically. KEY RESULTS Compared to MARKER-HF, both SHFM and MAGGIC required a considerably larger amount of data engineering and imputation to generate risk score estimates. MARKER-HF, SHFM, and MAGGIC exhibited similar discriminations with AUCs of 0.70 (0.69-0.73), 0.71 (0.69-0.72), and 0.71 (95% CI 0.70-0.73), respectively. All three scores showed good calibration across the full risk spectrum. CONCLUSIONS These findings suggest that MARKER-HF, which uses readily available clinical and lab measurements in the EHR and required less imputation and data engineering than SHFM and MAGGIC, is an easier tool to identify high-risk patients in ambulatory clinics who could benefit from referral to a HF specialist.
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Affiliation(s)
- Faraz S Ahmad
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 600, Chicago, IL, 60611, USA.
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA.
- Institute for Augmented Intelligence in Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Ted Ling Hu
- Institute for Augmented Intelligence in Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric D Adler
- Division of Cardiology, Department of Medicine, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Lucia C Petito
- Division of Biostatistics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ramsey M Wehbe
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jane E Wilcox
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 600, Chicago, IL, 60611, USA
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA
| | - R Kannan Mutharasan
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 600, Chicago, IL, 60611, USA
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA
| | - Beatrice Nardone
- Institute for Augmented Intelligence in Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Matevz Tadel
- Physics Department, UC San Diego, La Jolla, CA, USA
| | - Barry Greenberg
- Division of Cardiology, Department of Medicine, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Avi Yagil
- Physics Department, UC San Diego, La Jolla, CA, USA
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2
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Bailey J, Lavelle B, Miller J, Jimenez M, Lim PH, Orban ZS, Clark JR, Tomar R, Ludwig A, Ali ST, Lank GK, Zielinski A, Mylvaganam R, Kalhan R, Muayed ME, Mutharasan RK, Liotta EM, Sznajder JI, Davidson C, Koralnik IJ, Sala MA. Multidisciplinary Center Care for Long COVID Syndrome - a Retrospective Cohort Study. Am J Med 2023:S0002-9343(23)00328-5. [PMID: 37220832 DOI: 10.1016/j.amjmed.2023.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/17/2023] [Accepted: 05/17/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Persistent multi-organ symptoms after COVID-19 have been termed "long COVID" or "post-acute sequelae of SARS-CoV-2 infection" (PASC). The complexity of these clinical manifestations posed challenges early in the pandemic as different ambulatory models formed out of necessity to manage the influx of patients. Little is known about the characteristics and outcomes of patients seeking care at multidisciplinary post-COVID centers. METHODS We performed a retrospective cohort study of patients evaluated at our multidisciplinary Comprehensive COVID-19 Center (CCC) in Chicago, IL, between May 2020 and February 2022. We analyzed specialty clinic utilization and clinical test results according to severity of acute COVID-19. RESULTS We evaluated 1802 patients a median of 8 months from acute COVID-19 onset, including 350 post-hospitalization and 1452 non-hospitalized patients. Patients were seen in 2361 initial visits in 12 specialty clinics, with 1151 (48.8%) in neurology, 591 (25%) in pulmonology, and 284 (12%) in cardiology. Among patients tested, 742/878(85%) reported decreased quality of life, 284/553(51%) had cognitive impairment, 195/434(44.9%) had alteration of lung function, 249/299(83.3%) had abnormal CT chest scans, and 14/116(12.1%) had elevated heart rate on rhythm monitoring. Frequency of cognitive impairment and pulmonary dysfunction was associated with severity of acute COVID-19. Non-hospitalized patients with positive SARS-CoV-2 testing had similar findings than those with negative or no test results. CONCLUSIONS The CCC experience shows common utilization of multiple specialists by long COVID patients, who harbor frequent neurologic, pulmonary, and cardiologic abnormalities. Differences in post-hospitalization and non-hospitalized groups suggest distinct pathogenic mechanisms of long COVID in these populations.
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Affiliation(s)
- Joseph Bailey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University.
| | - Bianca Lavelle
- McGaw Medical Center, Northwestern University Feinberg School of Medicine
| | - Janet Miller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Millenia Jimenez
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University
| | - Patrick H Lim
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University
| | - Zachary S Orban
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University
| | - Jeffrey R Clark
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University
| | - Ria Tomar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Amy Ludwig
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Sareen T Ali
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University
| | - Grace K Lank
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University
| | - Allison Zielinski
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Ruben Mylvaganam
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Ravi Kalhan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Malek El Muayed
- Division of Endocrinology, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - R Kannan Mutharasan
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Eric M Liotta
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University
| | - Jacob I Sznajder
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Charles Davidson
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Igor J Koralnik
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University
| | - Marc A Sala
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University
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3
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Shah KS, Reyes-Miranda AE, Bradley SM, Breathett K, Das SR, Gluckman TJ, Gupta D, Leung DT, Mutharasan RK, Peterson PN, Spivak ES, Shah RU. Clinical Trial Participation and COVID-19: a Descriptive Analysis from the American Heart Association's Get With The Guidelines Registry. J Racial Ethn Health Disparities 2023; 10:892-898. [PMID: 35380371 PMCID: PMC8982302 DOI: 10.1007/s40615-022-01277-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/13/2022] [Accepted: 02/28/2022] [Indexed: 10/31/2022]
Abstract
As COVID-19 cases begin to decrease in the USA, learning from the pandemic experience will provide insights regarding disparities of care delivery. We sought to determine if specific populations hospitalized with COVID-19 are equally likely to be enrolled in clinical trials. We examined patients hospitalized with COVID-19 at centers participating in the American Heart Association's COVID-19 CVD Registry. The primary outcome was odds of enrollment in a clinical trial, according to sex, race, and ethnicity. Among 14,397 adults hospitalized with COVID-19, 9.5% (n = 1,377) were enrolled in a clinical trial. The proportion of enrolled patients was the lowest for Black patients (8%); in multivariable analysis, female and Black patients were less likely to be enrolled in a clinical trial related to COVID-19 compared to men and other racial groups, respectively. Determination of specific reasons for the disparities in trial participation related to COVID-19 in these populations should be further investigated.
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Affiliation(s)
- Kevin S Shah
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. 1900 E, Room 4A100, UT, 84132, Salt Lake City, USA.
| | - Adriana E Reyes-Miranda
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. 1900 E, Room 4A100, UT, 84132, Salt Lake City, USA
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ, USA
| | - Sandeep R Das
- Department of Internal Medicine, Cardiology Division, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Portland, OR, USA
| | - Divya Gupta
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel T Leung
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - R Kannan Mutharasan
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pamela N Peterson
- Denver Health Medical Center, Denver, CO, USA
- University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Emily S Spivak
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. 1900 E, Room 4A100, UT, 84132, Salt Lake City, USA
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4
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Gay HC, Yu J, Persell SD, Linder JA, Srivastava A, Isakova T, Huffman MD, Khan SS, Mutharasan RK, Petito LC, Feinstein MJ, Shah SJ, Yancy CW, Kho AN, Ahmad FS. Comparison of Sodium-Glucose Cotransporter-2 Inhibitor and Glucagon-Like Peptide-1 Receptor Agonist Prescribing in Patients With Diabetes Mellitus With and Without Cardiovascular Disease. Am J Cardiol 2023; 189:121-130. [PMID: 36424193 PMCID: PMC9908071 DOI: 10.1016/j.amjcard.2022.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP1-RAs) reduce cardiovascular events and mortality in patients with type 2 diabetes mellitus (T2DM). We sought to describe trends in prescribing for SGLT2is and GLP1-RAs in diverse care settings, including (1) the outpatient clinics of a midwestern integrated health system and (2) small- and medium-sized community-based primary care practices and health centers in 3 midwestern states. We included adults with T2DM and ≥1 outpatient clinic visit. The outcomes of interest were annual active prescription rates for SGLT2is and GLP1-RAs (separately). In the integrated health system, 22,672 patients met the case definition of T2DM. From 2013 to 2019, the overall prescription rate for SGLT2is increased from 1% to 15% (absolute difference [AD] 14%, 95% confidence interval [CI] 13% to 15%, p <0.01). The GLP1-RA prescription rate was stable at 10% (AD 0%, 95% CI -1% to 1%, p = 0.9). In community-based primary care practices, 43,340 patients met the case definition of T2DM. From 2013 to 2017, the SGLT2i prescription rate increased from 3% to 7% (AD 4%, 95% CI 3% to 6%, p <0.01), whereas the GLP1-RA prescription rate was stable at 2% to 3% (AD 1%, 95% CI -1 to 1%, p = 0.40). In a fully adjusted regression model, non-Hispanic Black patients had lower odds of SGLT2i or GLP1-RA prescription (odds ratio 0.56, 95% CI 0.34 to 0.89, p = 0.016). In conclusion, the increase in prescription rates was greater for SGLT2is than for GLP1-RAs in patients with T2DM in a large integrated medical center and community primary care practices. Overall, prescription rates for eligible patients were low, and racial disparities were observed.
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Affiliation(s)
- Hawkins C Gay
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois
| | - Jingzhi Yu
- Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois
| | - Stephen D Persell
- Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois; Department of Medicine-General Internal Medicine, Northwestern University, Chicago, Illinois
| | - Jeffrey A Linder
- Department of Medicine-General Internal Medicine, Northwestern University, Chicago, Illinois
| | - Anand Srivastava
- Department of Medicine-Nephrology, and Northwestern University, Chicago, Illinois
| | - Tamara Isakova
- Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois; Department of Medicine-Nephrology, and Northwestern University, Chicago, Illinois
| | - Mark D Huffman
- Department of Medicine-Cardiology, Washington University in St. Louis, St. Louis, Missouri; Global Health Center, Washington University in St. Louis, St. Louis, Missouri; The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Sadiya S Khan
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - R Kannan Mutharasan
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois
| | - Lucia C Petito
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matthew J Feinstein
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois
| | - Sanjiv J Shah
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois
| | - Clyde W Yancy
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois
| | - Abel N Kho
- Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois; Department of Medicine-General Internal Medicine, Northwestern University, Chicago, Illinois
| | - Faraz S Ahmad
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois; Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois.
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5
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Cheema B, Mutharasan RK, Sharma A, Jacobs M, Powers K, Lehrer S, Wehbe FH, Ronald J, Pifer L, Rich JD, Ghafourian K, Tibrewala A, McCarthy P, Luo Y, Pham DT, Wilcox JE, Ahmad FS. Augmented Intelligence to Identify Patients With Advanced Heart Failure in an Integrated Health System. JACC Adv 2022; 1:100123. [PMID: 36643021 PMCID: PMC9838119 DOI: 10.1016/j.jacadv.2022.100123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Timely referral for specialist evaluation in patients with advanced heart failure (HF) is a Class 1 recommendation. However, the transition from stage C HF to advanced or stage D HF often goes undetected in routine care, resulting in delayed referral and higher mortality rates. OBJECTIVES The authors sought to develop an augmented intelligence-enabled workflow using machine learning to identify patients with stage D HF and streamline referral. METHODS We extracted data on HF patients with encounters from January 1, 2007, to November 30, 2020, from a HF registry within a regional, integrated health system. We created an ensemble machine learning model to predict stage C or stage D HF and integrated the results within the electronic health record. RESULTS In a retrospective data set of 14,846 patients, the model had a good positive predictive value (60%) and low sensitivity (25%) for identifying stage D HF in a 100-person, physician-reviewed, holdout test set. During prospective implementation of the workflow from April 1, 2021, to February 15, 2022, 416 patients were reviewed by a clinical coordinator, with agreement between the model and the coordinator in 50.3% of stage D predictions. Twenty-four patients have been scheduled for evaluation in a HF clinic, 4 patients started an evaluation for advanced therapies, and 1 patient received a left ventricular assist device. CONCLUSIONS An augmented intelligence-enabled workflow was integrated into clinical operations to identify patients with advanced HF. Endeavors such as this require a multidisciplinary team with experience in design thinking, informatics, quality improvement, operations, and health information technology, as well as dedicated resources to monitor and improve performance over time.
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Affiliation(s)
- Baljash Cheema
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA,Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - R. Kannan Mutharasan
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA,Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Aditya Sharma
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA,Northwestern Medicine, Chicago, Illinois, USA
| | - Maia Jacobs
- Department of Computer Science, Northwestern University McCormick School of Engineering, Evanston, Illinois, USA
| | | | | | - Firas H. Wehbe
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA,Division of Cardiac Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | - Jonathan D. Rich
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kambiz Ghafourian
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anjan Tibrewala
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick McCarthy
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA,Division of Cardiac Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Yuan Luo
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Duc T. Pham
- Division of Cardiac Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jane E. Wilcox
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Faraz S. Ahmad
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA,Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA,Division of Health and Biomedical Informatics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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6
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Hughes Z, Simkowski J, Mendapara P, Fink N, Gupta S, Youmans Q, Khan S, Wilcox J, Mutharasan RK. Racial and Socioeconomic Differences in Heart Failure Hospitalizations and Telemedicine Follow-up During the COVID-19 Pandemic: A Retrospective Cohort Study (Preprint). JMIR Cardio 2022; 6:e39566. [DOI: 10.2196/39566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 10/13/2022] [Accepted: 11/13/2022] [Indexed: 11/15/2022] Open
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7
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Bradley SM, Adusumalli S, Amin AP, Borden WB, Das SR, Downey WE, Ebinger JE, Gelbman J, Gluckman TJ, Goyal A, Gupta D, Khot UN, Levy AE, Mutharasan RK, Rush P, Strauss CE, Shreenivas S, Ho PM. The Cardiovascular Quality Improvement and Care Innovation Consortium: Inception of a Multicenter Collaborative to Improve Cardiovascular Care. Circ Cardiovasc Qual Outcomes 2021; 14:e006753. [PMID: 33430610 DOI: 10.1161/circoutcomes.120.006753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite decades of improvement in the quality and outcomes of cardiovascular care, significant gaps remain. Existing quality improvement strategies are often limited in scope to specific clinical conditions and episodic care. Health services and outcomes research is essential to inform gaps in care but rarely results in the development and implementation of care delivery solutions. Although individual health systems are engaged in projects to improve the quality of care delivery, these efforts often lack a robust study design or implementation evaluation that can inform generalizability and further dissemination. Aligning the work of health care systems and health services and outcomes researchers could serve as a strategy to overcome persisting gaps in cardiovascular quality and outcomes. We describe the inception of the Cardiovascular Quality Improvement and Care Innovation Consortium that seeks to rapidly improve cardiovascular care by (1) developing, implementing, and evaluating multicenter quality improvement projects using innovative care designs; (2) serving as a resource for quality improvement and care innovation partners; and (3) establishing a presence within existing quality improvement and care innovation structures. Success of the collaborative will be defined by projects that result in changes to care delivery with demonstrable impacts on the quality and outcomes of care across multiple health systems. Furthermore, insights gained from implementation of these projects across sites in Cardiovascular Quality Improvement and Care Innovation Consortium will inform and promote broad dissemination for greater impact.
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Affiliation(s)
| | - Steven M Bradley
- Healthcare Delivery Innovation Center, Minneapolis Heart Institute, MN (S.M.B., P.R., C.E.S.)
| | - Srinath Adusumalli
- Center for Healthcare Innovation, Hospital of the University of Pennsylvania, Philadelphia (S.A.)
| | - Amit P Amin
- Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, MO (A.P.A.)
| | | | - Sandeep R Das
- University of Texas Southwestern Medical Center and Center for Innovation and Value at Parkland, Dallas (S.R.D.)
| | - William E Downey
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC (W.E.D.)
| | | | - Joy Gelbman
- New York Presbyterian Hospital, Weill Cornell Medicine (J.G.)
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, OR (T.J.G.)
| | - Abhinav Goyal
- Emory Heart and Vascular Center and the Department of Medicine, Emory University School of Medicine (A.G., D.G.)
| | - Divya Gupta
- Emory Heart and Vascular Center and the Department of Medicine, Emory University School of Medicine (A.G., D.G.)
| | - Umesh N Khot
- Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation, Cleveland Clinic, OH (U.N.K.)
| | - Andrew E Levy
- University of Colorado School of Medicine, Aurora, CO (A.E.L.).,Denver Health and Hospital Authority, CO (A.E.L.)
| | | | - Pam Rush
- Healthcare Delivery Innovation Center, Minneapolis Heart Institute, MN (S.M.B., P.R., C.E.S.)
| | - Craig E Strauss
- Healthcare Delivery Innovation Center, Minneapolis Heart Institute, MN (S.M.B., P.R., C.E.S.)
| | - Satya Shreenivas
- Lindner Center for Research, The Christ Hospital, Cincinnati, OH (S.S.)
| | - P Michael Ho
- University of Colorado School of Medicine, Aurora (P.M.H.).,VA Eastern Colorado Health Care System, Aurora (P.M.H.)
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8
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Shah RU, Mutharasan RK, Ahmad FS, Rosenblatt AG, Gay HC, Steinberg BA, Yandell M, Tristani-Firouzi M, Klewer J, Mukherjee R, Lloyd-Jones DM. Development of a Portable Tool to Identify Patients With Atrial Fibrillation Using Clinical Notes From the Electronic Medical Record. Circ Cardiovasc Qual Outcomes 2020; 13:e006516. [PMID: 33079591 DOI: 10.1161/circoutcomes.120.006516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The electronic medical record contains a wealth of information buried in free text. We created a natural language processing algorithm to identify patients with atrial fibrillation (AF) using text alone. METHODS AND RESULTS We created 3 data sets from patients with at least one AF billing code from 2010 to 2017: a training set (n=886), an internal validation set from site no. 1 (n=285), and an external validation set from site no. 2 (n=276). A team of clinicians reviewed and adjudicated patients as AF present or absent, which served as the reference standard. We trained 54 algorithms to classify each patient, varying the model, number of features, number of stop words, and the method used to create the feature set. The algorithm with the highest F-score (the harmonic mean of sensitivity and positive predictive value) in the training set was applied to the validation sets. F-scores and area under the receiver operating characteristic curves were compared between site no. 1 and site no. 2 using bootstrapping. Adjudicated AF prevalence was 75.1% at site no. 1 and 86.2% at site no. 2. Among 54 algorithms, the best performing model was logistic regression, using 1000 features, 100 stop words, and term frequency-inverse document frequency method to create the feature set, with sensitivity 92.8%, specificity 93.9%, and an area under the receiver operating characteristic curve of 0.93 in the training set. The performance at site no. 1 was sensitivity 92.5%, specificity 88.7%, with an area under the receiver operating characteristic curve of 0.91. The performance at site no. 2 was sensitivity 89.5%, specificity 71.1%, with an area under the receiver operating characteristic curve of 0.80. The F-score was lower at site no. 2 compared with site no. 1 (92.5% [SD, 1.1%] versus 94.2% [SD, 1.1%]; P<0.001). CONCLUSIONS We developed a natural language processing algorithm to identify patients with AF using text alone, with >90% F-score at 2 separate sites. This approach allows better use of the clinical narrative and creates an opportunity for precise, high-throughput cohort identification.
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Affiliation(s)
- Rashmee U Shah
- Division of Cardiovascular Medicine, Department of Internal Medicine (R.U.S., B.A.S., R.M.), University of Utah School of Medicine, Salt Lake City
| | - R Kannan Mutharasan
- Division of Cardiology, Department of Medicine (R.K.M., F.S.A., H.C.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Faraz S Ahmad
- Division of Cardiology, Department of Medicine (R.K.M., F.S.A., H.C.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anna G Rosenblatt
- Division of Cardiology (A.G.R.), The University of Texas Southwestern Medical Center, Dallas
| | - Hawkins C Gay
- Division of Cardiology, Department of Medicine (R.K.M., F.S.A., H.C.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Benjamin A Steinberg
- Division of Cardiovascular Medicine, Department of Internal Medicine (R.U.S., B.A.S., R.M.), University of Utah School of Medicine, Salt Lake City
| | - Mark Yandell
- Eccles Institute of Human Genetics (M.Y.), University of Utah, Salt Lake City.,USTAR Center for Genetic Discovery (M.Y.), University of Utah, Salt Lake City
| | - Martin Tristani-Firouzi
- Division of Pediatric Cardiology (M.T.-F.), University of Utah School of Medicine, Salt Lake City.,Nora Eccles Harrison Cardiovascular Research and Training Institute (M.T.-F.), University of Utah, Salt Lake City
| | - Jake Klewer
- Department of Internal Medicine (J.K.), University of Utah School of Medicine, Salt Lake City
| | - Rebeka Mukherjee
- Division of Cardiovascular Medicine, Department of Internal Medicine (R.U.S., B.A.S., R.M.), University of Utah School of Medicine, Salt Lake City
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine (D.M.L.-J.), Northwestern University Feinberg School of Medicine, Chicago, IL
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9
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Yancy CW, Mutharasan RK, Bossone E. The Critical Need for Process Improvement in Heart Failure. Heart Fail Clin 2020; 16:xiii-xv. [PMID: 32888644 PMCID: PMC7462474 DOI: 10.1016/j.hfc.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Chicago, IL 60611, USA.
| | - R Kannan Mutharasan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, 676 North Saint Clair Street, Chicago, IL 60611, USA.
| | - Eduardo Bossone
- Division of Cardiology, Cardarelli Hospital, Via A. Cardarelli, 9, Naples 80131, Italy.
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10
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Gurvich I, Mutharasan RK, Van Mieghem JA. Approaching Process Improvement. Heart Fail Clin 2020; 16:369-377. [PMID: 32888633 DOI: 10.1016/j.hfc.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Process improvement begins with the process view: understanding patient care from the patient's point of view. Organizations must also clearly articulate for themselves how they define operational excellence so that the tradeoffs taken in process improvement can be clearly made. Constructing a process map allows application of powerful analytical tools, such as Little's law, which in turn uncovers targets for process improvement from the patient's point of view. Often tradeoffs among process performance metrics, such as quality, cost, time, personalization, and innovation, must be made when deciding upon improvements to be made in certain processes.
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Affiliation(s)
- Itai Gurvich
- Cornell School of Operations Research and Information Engineering, Cornell Tech, 2 West Loop Road, New York, NY 10044, USA
| | - R Kannan Mutharasan
- Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Arkes Pavilion, Suite 6-071, Chicago, IL 60611, USA
| | - Jan Albert Van Mieghem
- Kellogg School of Management at Northwestern University, GLOBAL HUB 2211 Campus Dr, Evanston, IL 60201, USA.
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11
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Mutharasan RK. Transitioning Patients with Heart Failure to Outpatient Care. Heart Fail Clin 2020; 16:421-431. [PMID: 32888637 DOI: 10.1016/j.hfc.2020.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The transition from hospitalization to outpatient care is a vulnerable time for patients with heart failure. This requires specific focus on the transitional care period. Here the authors propose a framework to guide process improvement in the transitional care period. The authors extend this framework by (1) examining the role new technology might play in transitional care, and (2) offering practical advice for teams building transitional care programs.
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Affiliation(s)
- R Kannan Mutharasan
- Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Arkes Pavilion, Suite 6-071, Chicago, IL 60611, USA.
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12
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Affiliation(s)
- Andrew T Peters
- Department of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
| | - R Kannan Mutharasan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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13
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Nassif ME, Windsor SL, Tang F, Khariton Y, Husain M, Inzucchi SE, McGuire DK, Pitt B, Scirica BM, Austin B, Drazner MH, Fong MW, Givertz MM, Gordon RA, Jermyn R, Katz SD, Lamba S, Lanfear DE, LaRue SJ, Lindenfeld J, Malone M, Margulies K, Mentz RJ, Mutharasan RK, Pursley M, Umpierrez G, Kosiborod M. Dapagliflozin Effects on Biomarkers, Symptoms, and Functional Status in Patients With Heart Failure With Reduced Ejection Fraction: The DEFINE-HF Trial. Circulation 2019; 140:1463-1476. [PMID: 31524498 DOI: 10.1161/circulationaha.119.042929] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Outcome trials in patients with type 2 diabetes mellitus have demonstrated reduced hospitalizations for heart failure (HF) with sodium-glucose co-transporter-2 inhibitors. However, few of these patients had HF, and those that did were not well-characterized. Thus, the effects of sodium-glucose co-transporter-2 inhibitors in patients with established HF with reduced ejection fraction, including those with and without type 2 diabetes mellitus, remain unknown. METHODS DEFINE-HF (Dapagliflozin Effects on Biomarkers, Symptoms and Functional Status in Patients with HF with Reduced Ejection Fraction) was an investigator-initiated, multi-center, randomized controlled trial of HF patients with left ventricular ejection fraction ≤40%, New York Heart Association (NYHA) class II-III, estimated glomerular filtration rate ≥30 mL/min/1.73m2, and elevated natriuretic peptides. In total, 263 patients were randomized to dapagliflozin 10 mg daily or placebo for 12 weeks. Dual primary outcomes were (1) mean NT-proBNP (N-terminal pro b-type natriuretic peptide) and (2) proportion of patients with ≥5-point increase in HF disease-specific health status on the Kansas City Cardiomyopathy Questionnaire overall summary score, or a ≥20% decrease in NT-proBNP. RESULTS Patient characteristics reflected stable, chronic HF with reduced ejection fraction with high use of optimal medical therapy. There was no significant difference in average 6- and 12-week adjusted NT-proBNP with dapagliflozin versus placebo (1133 pg/dL (95% CI 1036-1238) vs 1191 pg/dL (95% CI 1089-1304), P=0.43). For the second dual-primary outcome of a meaningful improvement in Kansas City Cardiomyopathy Questionnaire overall summary score or NT-proBNP, 61.5% of dapagliflozin-treated patients met this end point versus 50.4% with placebo (adjusted OR 1.8, 95% CI 1.03-3.06, nominal P=0.039). This was attributable to both higher proportions of patients with ≥5-point improvement in Kansas City Cardiomyopathy Questionnaire overall summary score (42.9 vs 32.5%, adjusted OR 1.73, 95% CI 0.98-3.05), and ≥20% reduction in NT-proBNP (44.0 vs 29.4%, adjusted OR 1.9, 95% CI 1.1-3.3) by 12 weeks. Results were consistent among patients with or without type 2 diabetes mellitus, and other prespecified subgroups (all P values for interaction=NS). CONCLUSIONS In patients with heart failure and reduced ejection fraction, use of dapagliflozin over 12 weeks did not affect mean NT-proBNP but increased the proportion of patients experiencing clinically meaningful improvements in HF-related health status or natriuretic peptides. Benefits of dapagliflozin on clinically meaningful HF measures appear to extend to patients without type 2 diabetes mellitus. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02653482.
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Affiliation(s)
- Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., F.T., Y.K., B.A., M.K.).,University of Missouri-Kansas City, MO (M.E.N., Y.K., B.A., M.K.)
| | - Sheryl L Windsor
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., F.T., Y.K., B.A., M.K.)
| | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., F.T., Y.K., B.A., M.K.)
| | - Yevgeniy Khariton
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., F.T., Y.K., B.A., M.K.).,University of Missouri-Kansas City, MO (M.E.N., Y.K., B.A., M.K.)
| | - Mansoor Husain
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada (M.H.).,Ted Rogers Centre for Heart Research, Toronto, Canada (M.H.).,University of Toronto, Canada (M.H.).,Peter Munk Cardiac Centre, Toronto, Canada (M.H)
| | | | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas (D.K.M., M.H.D.)
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Benjamin M Scirica
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.M.S., M.M.G.)
| | - Bethany Austin
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., F.T., Y.K., B.A., M.K.).,University of Missouri-Kansas City, MO (M.E.N., Y.K., B.A., M.K.)
| | - Mark H Drazner
- University of Texas Southwestern Medical Center, Dallas (D.K.M., M.H.D.)
| | - Michael W Fong
- Keck School of Medicine of USC, University of Southern California, Los Angeles (M.W.F.)
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.M.S., M.M.G.)
| | | | | | - Stuart D Katz
- New York University Langone Health, New York (S.D.K.)
| | - Sumant Lamba
- First Coast Cardiovascular Institute, Jacksonville, FL (S.L.)
| | | | - Shane J LaRue
- Washington University School of Medicine, St. Louis, MO (S.J.L.)
| | | | - Michael Malone
- Charlotte Heart Group Research Center, Port Charlotte, FL (M.M.)
| | | | | | | | | | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., F.T., Y.K., B.A., M.K.).,University of Missouri-Kansas City, MO (M.E.N., Y.K., B.A., M.K.).,The George Institute for Global Health, Sydney, Australia (M.K.).,University of New South Wales, Sydney, Australia (M.K.)
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14
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Chandler AE, Mutharasan RK, Amelia L, Carson MB, Scholtens DM, Soulakis ND. Risk Adjusting Health Care Provider Collaboration Networks. Methods Inf Med 2019; 58:71-78. [PMID: 31514208 DOI: 10.1055/s-0039-1694990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The quality of hospital discharge care and patient factors (health and sociodemographic) impact the rates of unplanned readmissions. This study aims to measure the effects of controlling for the patient factors when using readmission rates to quantify the weighted edges between health care providers in a collaboration network. This improved understanding may inform strategies to reduce hospital readmissions, and facilitate quality-improvement initiatives. METHODS We extracted 4 years of patient, provider, and activity data related to cardiology discharge workflow. A Weibull model was developed to predict the risk of unplanned 30-day readmission. A provider-patient bipartite network was used to connect providers by shared patient encounters. We built collaboration networks and calculated the Shared Positive Outcome Ratio (SPOR) to quantify the relationship between providers by the relative rate of patient outcomes, using both risk-adjusted readmission rates and unadjusted readmission rates. The effect of risk adjustment on the calculation of the SPOR metric was quantified using a permutation test and descriptive statistics. RESULTS Comparing the collaboration networks consisting of 2,359 provider pairs, we found that SPOR values with risk-adjusted outcomes are significantly different than unadjusted readmission as an outcome measure (p-value = 0.025). The two networks classified the same provider pairs as high-scoring 51.5% of the time, and the same low scoring provider pairs 85.6% of the time. The observed differences in patient demographics and disease characteristics between high-scoring and low-scoring provider pairs were reduced by applying the risk-adjusted model. The risk-adjusted model reduced the average variation across each individual's SPOR scored provider connections. CONCLUSIONS Risk adjusting unplanned readmission in a collaboration network has an effect on SPOR-weighted edges, especially on classifying high-scoring SPOR provider pairs. The risk-adjusted model reduces the variance of providers' connections and balances shared patient characteristics between low- and high-scoring provider pairs. This indicates that the risk-adjusted SPOR edges better measure the impact of collaboration on readmissions by accounting for patients' risk of readmission.
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Affiliation(s)
- Ariel E Chandler
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - R Kannan Mutharasan
- Department of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Lia Amelia
- Chapin Hall at the University of Chicago, Chicago, Illinois, United States
| | - Matthew B Carson
- Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Denise M Scholtens
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Nicholas D Soulakis
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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15
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Waase MP, Mutharasan RK, Whang W, DiTullio MR, DiFiori JP, Callahan L, Mancell J, Phelan D, Schwartz A, Homma S, Engel DJ. Electrocardiographic Findings in National Basketball Association Athletes. JAMA Cardiol 2019; 3:69-74. [PMID: 29214319 DOI: 10.1001/jamacardio.2017.4572] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance While it is known that long-term intensive athletic training is associated with cardiac structural changes that can be reflected on surface electrocardiograms (ECGs), there is a paucity of sport-specific ECG data. This study seeks to clarify the applicability of existing athlete ECG interpretation criteria to elite basketball players, an athlete group shown to develop significant athletic cardiac remodeling. Objective To generate normative ECG data for National Basketball Association (NBA) athletes and to assess the accuracy of athlete ECG interpretation criteria in this population. Design, Setting, and Participants The NBA has partnered with Columbia University Medical Center to annually perform a review of policy-mandated annual preseason ECGs and stress echocardiograms for all players and predraft participants. This observational study includes the preseason ECG examinations of NBA athletes who participated in the 2013-2014 and 2014-2015 seasons, plus all participants in the 2014 and 2015 NBA predraft combines. Examinations were performed from July 2013 to May 2015. Data analysis was performed between December 2015 and March 2017. Exposures Active roster or draft status in the NBA and routine preseason ECGs and echocardiograms. Main Outcomes and Measures Baseline quantitative ECG variables were measured and ECG data qualitatively analyzed using 3 existing, athlete-specific interpretation criteria: Seattle (2012), refined (2014), and international (2017). Abnormal ECG findings were compared with matched echocardiographic data. Results Of 519 male athletes, 409 (78.8%) were African American, 96 (18.5%) were white, and the remaining 14 (2.7%) were of other races/ethnicities; 115 were predraft combine participants, and the remaining 404 were on active rosters of NBA teams. The mean (SD) age was 24.8 (4.3) years. Physiologic, training-related changes were present in 462 (89.0%) athletes in the study. Under Seattle criteria, 131 (25.2%) had abnormal findings, compared with 108 (20.8%) and 81 (15.6%) under refined and international criteria, respectively. Increased age and increased left ventricular relative wall thickness (RWT) on echocardiogram were highly associated with abnormal ECG classifications; 17 of 186 athletes (9.1%) in the youngest age group (age 18-22 years) had abnormal ECGs compared with 36 of the 159 athletes (22.6%) in the oldest age group (age 27-39 years) (odds ratio, 2.9; 95% CI, 1.6-5.4; P < .001). Abnormal T-wave inversions (TWI) were present in 32 athletes (6.2%), and this was associated with smaller left ventricular cavity size and increased RWT. One of the 172 athletes (0.6%) in the lowest RWT group (range, 0.24-0.35) had TWIs compared with 24 of the 163 athletes (14.7%) in the highest RWT group (range, 0.41-0.57) (odds ratio, 29.5; 95% CI, 3.9-221.0; P < .001). Conclusions and Relevance Despite the improved specificity of the international recommendations over previous athlete-specific ECG criteria, abnormal ECG classification rates remain high in NBA athletes. The development of left ventricular concentric remodeling appears to have a significant influence on the prevalence of abnormal ECG classification and repolarization abnormalities in this athlete group.
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Affiliation(s)
- Marc P Waase
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - R Kannan Mutharasan
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William Whang
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Marco R DiTullio
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - John P DiFiori
- National Basketball Association, New York, New York.,Department of Family Medicine, David Geffen School of Medicine at University of California, Los Angeles.,Department of Orthopedics, David Geffen School of Medicine at University of California, Los Angeles
| | - Lisa Callahan
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Jimmie Mancell
- Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Dermot Phelan
- Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Allan Schwartz
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Shunichi Homma
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - David J Engel
- Division of Cardiology, Columbia University Medical Center, New York, New York
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16
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Mutharasan RK, Ahmad FS, Gurvich I, Alphs Jackson H, Van Mieghem JA, Yancy CW. Buffer or Suffer: Redesigning Heart Failure Postdischarge Clinic Using Queuing Theory. Circ Cardiovasc Qual Outcomes 2019; 11:e004351. [PMID: 29970363 DOI: 10.1161/circoutcomes.117.004351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- R Kannan Mutharasan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (R.K.M., F.S.A., C.W.Y.).
| | - Faraz S Ahmad
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (R.K.M., F.S.A., C.W.Y.)
| | - Itai Gurvich
- School of Operations Research and Information Engineering, Cornell University, New York, NY (I.G.)
| | - Hannah Alphs Jackson
- Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL (H.A.J.)
| | - Jan A Van Mieghem
- Department of Operations, Northwestern University Kellogg School of Management, Evanston, IL (J.A.V.M.)
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (R.K.M., F.S.A., C.W.Y.)
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17
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Eivazi M, Mutharasan RK, Cleveland E, Fine M. Outcome of Titrating Guideline Directed Medical Therapy in Heart Failure Patients at 90-Day Post-Hospital Discharge. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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18
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Ahmad FS, Wehbe RM, Kansal P, Jackson HA, Anderson AS, Yancy CW, Mutharasan RK. Targeting the Correct Population When Designing Transitional Care Programs for Medicare Patients Hospitalized With Heart Failure. JAMA Cardiol 2019; 2:1274-1275. [PMID: 28975198 DOI: 10.1001/jamacardio.2017.3089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Faraz S Ahmad
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Division of Epidemiology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ramsey M Wehbe
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Preeti Kansal
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hannah A Jackson
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Value-Based Delivery, Northwestern Memorial HealthCare, Chicago, Illinois
| | - Allen S Anderson
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Deputy Editor
| | - R Kannan Mutharasan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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19
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Seckler HDS, Fornelli L, Mutharasan RK, Thaxton CS, Fellers R, Daviglus M, Sniderman A, Rader D, Kelleher NL, Lloyd-Jones DM, Compton PD, Wilkins JT. A Targeted, Differential Top-Down Proteomic Methodology for Comparison of ApoA-I Proteoforms in Individuals with High and Low HDL Efflux Capacity. J Proteome Res 2018; 17:2156-2164. [PMID: 29649363 DOI: 10.1021/acs.jproteome.8b00100] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Top-down proteomics (TDP) allows precise determination/characterization of the different proteoforms derived from the expression of a single gene. In this study, we targeted apolipoprotein A-I (ApoA-I), a mediator of high-density-lipoprotein cholesterol efflux (HDL-E), which is inversely associated with coronary heart disease risk. Absolute ApoA-I concentration and allelic variation only partially explain interindividual HDL-E variation. Therefore, we hypothesize that differences in HDL-E are associated with the abundances of different ApoA-I proteoforms. Here, we present a targeted TDP methodology to characterize ApoA-I proteoforms in serum samples and compare their abundances between individuals. We characterized 18 ApoA-I proteoforms using selected-ion monitoring coupled to electron-transfer dissociation mass spectrometry. We then compared the abundances of these proteoforms between two groups of four participants, representing the individuals with highest and lowest HDL-E values within the Chicago Healthy Aging Study ( n = 420). Six proteoforms showed significantly ( p < 0.0005) higher intensity in high HDL-E individuals: canonical ApoA-I [fold difference (fd) = 1.17], carboxymethylated ApoA-I (fd = 1.24) and, with highest difference, four fatty acylated forms: palmitoylated (fd = 2.16), oleoylated (fd = 2.08), arachidonoylated (fd = 2.31) and one bearing two modifications: palmitoylation and truncation (fd = 2.13). These results demonstrate translational potential for targeted TDP in revealing, with high sensitivity, associations between interindividual proteoform variation and physiological differences underlying disease risk.
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Affiliation(s)
| | | | - R Kannan Mutharasan
- Bluhm Cardiovascular Institute , Northwestern Memorial Hospital , Chicago , Illinois 60611 , United States
| | | | | | - Martha Daviglus
- Institute for Minority Health Research , University of Illinois at Chicago , Chicago , Illinois 60607 , United States
| | - Allan Sniderman
- Royal Victoria Hospital-McGill University Health Centre , Montreal , QC H4A 3J1 , Canada
| | | | | | - Donald M Lloyd-Jones
- Bluhm Cardiovascular Institute , Northwestern Memorial Hospital , Chicago , Illinois 60611 , United States
| | | | - John T Wilkins
- Bluhm Cardiovascular Institute , Northwestern Memorial Hospital , Chicago , Illinois 60611 , United States
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20
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Rosenblatt A, Gravenor S, Gurvich I, Van Mieghem J, Mutharasan RK. Abstract 5: Optimizing Emergency Room Throughput for Cardiac Telemetry Patients: A Queuing Theory Approach. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The capacity of telemetry monitoring in hospitalized patients is constrained due to limited equipment and personnel. Electing for telemetry monitoring may pose a bottleneck for patients admitted through the Emergency Department (ED). This can result in increased length of stays in the ED, a parameter that is correlated with decreased quality of care due to crowding and delay in treatment. Queuing theory is the mathematical study of waiting times. We opted to use queuing theory to analyze system performance before and after an expansion of telemetry capacity.
Objective:
To retrospectively analyze the impact of telemetry capacity on ED wait times using enterprise data warehouse (EDW) data and queuing theory.
Methods:
Unused telemetry boxes were used as a proxy metric for available cardiac telemetry monitoring. The number of telemetry boxes in use at a large urban academic medical center was determined by daily manual count. The number of telemetry admissions, average length of telemetry use, and length of stay in the ED were obtained from EDW data. Using queuing theory, system parameters including expected wait time and percent of patients who will wait were calculated for scenarios to simulate before and after the expansion of telemetry capacity. These modeled system behaviors were compared to observed data from before and after the intervention to understand the utility of the mathematical model.
Results:
Over the study period of 365 days, a total of 13,515 inpatient non-critical care hospital encounters had orders for telemetry monitoring. Prior to the increase in telemetry capacity, there were 144 telemetry boxes, which were utilized at 96.7% of capacity. Using these parameters, the model predicts a 5.8-hour average wait time and a 42.1% chance that a patient will have to wait for a telemetry box. Increasing telemetry capacity modestly by 10 boxes (144 to154 boxes) results in a dramatic system improvement, reducing utilization to 88.6%, average wait time for a telemetry bed to 34 minutes, and percent of patients waiting for a telemetry slot to 9.4%. These predicted results compared well to the observed data. After the intervention, there was a decrease in utilization to 86.9%, and a statistically significant reduction in time waiting in the ED for an inpatient bed by 1.24 (p<0.05) hours per telemetry patient, representing a total savings of ED boarding time of 11.2 bed-days per week.
Conclusions:
Queuing theory allows for modeling of healthcare system behavior to predict needed clinical capacity for achieving system goals. Our simplified model demonstrates that a modest increase in capacity can drive significant system improvements. Utilizing queuing theory and understanding the behavior of the healthcare system can improve the predicted impact of interventions on cost-effectiveness and quality of care.
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Cleveland ER, Berkowitz C, Pissaris A, Valencia V, Mutharasan RK. Abstract 251: Gender Equity in Rates of Guideline-Directed Medical Therapy Prescription at Discharge for Hospitalized Heart Failure Patients. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Heart failure (HF) is an increasingly prevalent condition with significant morbidity and mortality. Guideline-directed medical therapy (GDMT) reduces morbidity and mortality in heart failure with reduced ejection fraction, but continues to be under-prescribed. There is a paucity of data on the impact of patient gender on the quality of HF care, although it has previously been shown that women with other cardiovascular conditions, such as coronary artery disease, receive less intensive treatment. We sought to determine whether there is a difference in rates of prescription of GDMT for patients hospitalized with heart failure by gender with the hypothesis that rates of GDMT prescription in women would be lower than that in men.
Methods:
Over a six month study window, we identified 246 patients discharged from an urban academic medical center with a primary discharge diagnosis of systolic heart failure. Systematic chart review was performed to identify whether patients were discharged with the following medications: angiotensin converting enzyme inhibitor (ACE-I), angiotensin receptor blocker (ARB), beta blocker (BB), mineralocorticoid receptor antagonist (MRA), hydralazine and a nitrate, and neprilysin inhibitor/ARB. Statistical analysis was performed to evaluate for an association between rates of GDMT prescription and gender. Regression analysis was then performed to adjust for age, weight, serum potassium, and 1/(discharge creatinine).
Results:
At the time of discharge, there was no statistically significant difference in the rate of GDMT prescription for females compared to males in either the unadjusted or adjusted models. ACE-I or ARB prescription rates were 59% in females and 50% in males (p=0.11); BB prescription rates were 89% in females and 84% in males (p=0.27); MRA prescription rates were 43% in females and 52% in males (p=0.19). Prescription rates of combination therapy of ACE-I or ARB with BB and MRA were 30% in females and 31% in males (p=0.78). There was a significant difference in 30 day all-cause unadjusted readmission rates in females (22%) compared to males (37%) (p<0.05).
Conclusions:
In this sample of hospitalized heart failure patients, no difference was found in rates of GDMT prescription for women as compared to men. Readmission rates were significantly higher for men than women, consistent with national data. Further investigation will determine the extent to which equity in prescription rates translates into improved outcomes for women hospitalized with heart failure.
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Sandison K, Marsh M, Lizza B, Yancy CW, Mutharasan RK. Pharmacist Education at Discharge Correlates with Reduced 30-Day Readmissions in Heart Failure Patients. J Card Fail 2017. [DOI: 10.1016/j.cardfail.2017.07.333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Albaghdadi MS, Wang Z, Gao Y, Mutharasan RK, Wilkins J. High-Density Lipoprotein Subfractions and Cholesterol Efflux Capacity Are Not Affected by Supervised Exercise but Are Associated with Baseline Interleukin-6 in Patients with Peripheral Artery Disease. Front Cardiovasc Med 2017; 4:9. [PMID: 28303243 PMCID: PMC5332379 DOI: 10.3389/fcvm.2017.00009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 02/15/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To quantify the association between high-density lipoprotein (HDL) subfractions, efflux capacity, and inflammatory markers at baseline and the effect of supervised exercise on these HDL parameters in patients with peripheral artery disease (PAD). METHODS The study to improve leg circulation (SILC) was a randomized trial of supervised treadmill exercise, leg resistance training, or control in individuals with PAD. In a post hoc cross-sectional analysis, we quantified the associations between baseline HDL subfraction concentrations (HDL2 and HDL3), HDL-C efflux capacity, and inflammatory markers [C-reactive protein (CRP) and interleukin-6 (IL-6)]. We then examined the effect of supervised exercise on changes in these lipoprotein parameters and inflammatory markers in 88 patients from SILC. RESULTS Baseline HDL-C efflux capacity was associated with baseline concentrations of HDL2 (β = 0.008, p = 0.0106), HDL3 (β = 0.013, p < 0.0001), and IL-6 (β = -0.019, p = 0.03). Baseline HDL3 concentration was inversely associated with IL-6 concentration (β = -0.99, p = 0.008). Compared to control, changes in HDL2, HDL3, normalized HDL-C efflux capacity, CRP, or IL-6 were not significantly different at 6 months following the structured exercise intervention. CONCLUSION HDL efflux and HDL3 were inversely associated with IL-6 in PAD patients. Structured exercise was not associated with changes in HDL subfractions, HDL-C efflux capacity, CRP, and IL-6 in PAD patients. Our preliminary findings support the theory that inflammation may adversely affect HDL structure and function; however, further studies are needed to evaluate these findings.
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Affiliation(s)
- Mazen S Albaghdadi
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine , Chicago, IL , USA
| | - Zheng Wang
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine , Chicago, IL , USA
| | - Ying Gao
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine , Chicago, IL , USA
| | - R Kannan Mutharasan
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine , Chicago, IL , USA
| | - John Wilkins
- Department of Preventive Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Youmans Q, Kansal P, Alphs Jackson H, Fortman R, Navarro D, Abecassis M, Noskin G, Anderson A, Davidson C, Yancy C, Mutharasan RK. Abstract 077: Hospitalized Heart Failure Epidemiology: Active Surveillance to Enhance Inpatient Cardiology Consultation Rates. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Co-management of hospitalized heart failure (HHF) patients by hospitalists and cardiologists may enhance care quality. Aided by an enterprise data warehouse (EDW) screen for HHF patients, we implemented a house surveillance model of heart failure consultation, whereby cardiology consultation and multidisciplinary heart failure intervention was offered for patients meeting criteria.
Objective:
To analyze the impact of house surveillance for HHF on cardiology consultation rates for patients coding into heart failure diagnosis-related groups (DRGs) on medicine units.
Methods:
An EDW screen for HHF was deployed, and services with HHF patients were offered cardiology consultation. The intervention was deployed 7/2015; chart review for patients 6 months pre- and post-intervention was conducted to ascertain consultation rate.
Results:
There were 386 patient discharges from a non-cardiac service with a heart failure DRG. In the six months prior to intervention, 40% of patients had cardiology consultation. This figure rose to 69% post-intervention, a highly statistically significant result.
Conclusions:
EDW-enabled active surveillance for HHF increases cardiology consultation rate, allowing for multidisciplinary intervention, co-management, and potentially improved outcomes for HHF patients.
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Kricke GS, Carson MB, Lee YJ, Benacka C, Mutharasan RK, Ahmad FS, Kansal P, Yancy CW, Anderson AS, Soulakis ND. Leveraging electronic health record documentation for Failure Mode and Effects Analysis team identification. J Am Med Inform Assoc 2017; 24:288-294. [PMID: 27589944 PMCID: PMC5391722 DOI: 10.1093/jamia/ocw083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 04/26/2016] [Accepted: 04/30/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Using Failure Mode and Effects Analysis (FMEA) as an example quality improvement approach, our objective was to evaluate whether secondary use of orders, forms, and notes recorded by the electronic health record (EHR) during daily practice can enhance the accuracy of process maps used to guide improvement. We examined discrepancies between expected and observed activities and individuals involved in a high-risk process and devised diagnostic measures for understanding discrepancies that may be used to inform quality improvement planning. METHODS Inpatient cardiology unit staff developed a process map of discharge from the unit. We matched activities and providers identified on the process map to EHR data. Using four diagnostic measures, we analyzed discrepancies between expectation and observation. RESULTS EHR data showed that 35% of activities were completed by unexpected providers, including providers from 12 categories not identified as part of the discharge workflow. The EHR also revealed sub-components of process activities not identified on the process map. Additional information from the EHR was used to revise the process map and show differences between expectation and observation. CONCLUSION Findings suggest EHR data may reveal gaps in process maps used for quality improvement and identify characteristics about workflow activities that can identify perspectives for inclusion in an FMEA. Organizations with access to EHR data may be able to leverage clinical documentation to enhance process maps used for quality improvement. While focused on FMEA protocols, findings from this study may be applicable to other quality activities that require process maps.
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Affiliation(s)
- Gayle Shier Kricke
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Matthew B Carson
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Young Ji Lee
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Corrine Benacka
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL, 60611, USA
| | - R. Kannan Mutharasan
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL, 60611, USA
| | - Faraz S Ahmad
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL, 60611, USA
| | - Preeti Kansal
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL, 60611, USA
| | - Clyde W Yancy
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL, 60611, USA
| | - Allen S Anderson
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL, 60611, USA
| | - Nicholas D Soulakis
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
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Mutharasan RK, Thaxton CS, Berry J, Daviglus ML, Yuan C, Sun J, Ayers C, Lloyd-Jones DM, Wilkins JT. HDL efflux capacity, HDL particle size, and high-risk carotid atherosclerosis in a cohort of asymptomatic older adults: the Chicago Healthy Aging Study. J Lipid Res 2017; 58:600-606. [PMID: 28049656 DOI: 10.1194/jlr.p069039] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 12/30/2016] [Indexed: 11/20/2022] Open
Abstract
HDL efflux capacity and HDL particle size are associated with atherosclerotic CVD (ASCVD) events in middle-aged individuals; however, it is unclear whether these associations are present in older adults. We sampled 402 Chicago Healthy Aging Study participants who underwent a dedicated carotid MRI assessment for lipid-rich necrotic core (LRNC) plaque. We measured HDL particle size, HDL particle number, and LDL particle number with NMR spectroscopy, as well as HDL efflux capacity. We quantified the associations between HDL particle size and HDL efflux using adjusted linear regression models. We quantified associations between the presence of LRNC and HDL and LDL particle number, HDL particle size, and HDL efflux capacity using adjusted logistic regression models. HDL efflux capacity was directly associated with large (β = 0.037, P < 0.001) and medium (β = 0.0065, P = 0.002) HDL particle concentration and inversely associated with small (β = -0.0049, P = 0.018) HDL particle concentration in multivariable adjusted models. HDL efflux capacity and HDL particle number were inversely associated with prevalent LRNC plaque in unadjusted models (odds ratio: 0.5; 95% confidence interval: 0.26, 0.96), but not after multivariable adjustment. HDL particle size was not associated with prevalent LRNC. HDL particle size was significantly associated with HDL efflux capacity, suggesting that differences in HDL efflux capacity may be due to structural differences in HDL particles. Future research is needed to determine whether HDL efflux is a marker of ASCVD risk in older populations.
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Affiliation(s)
- R Kannan Mutharasan
- Department of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611
| | - C Shad Thaxton
- Department of Urology and Institute of BioNanotechnology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611
| | - Jarett Berry
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX 75390
| | - Martha L Daviglus
- Institute for Minority Health Research, University of Illinois College of Medicine, Chicago, IL 60612
| | - Chun Yuan
- University of Washington College of Engineering and University of Washington School of Medicine, University of Washington, Seattle, WA 98195
| | - Jie Sun
- University of Washington College of Engineering and University of Washington School of Medicine, University of Washington, Seattle, WA 98195
| | - Colby Ayers
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX 75390
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611
| | - John T Wilkins
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611
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Carson MB, Scholtens DM, Frailey CN, Gravenor SJ, Powell ES, Wang AY, Kricke GS, Ahmad FS, Mutharasan RK, Soulakis ND. Characterizing Teamwork in Cardiovascular Care Outcomes: A Network Analytics Approach. Circ Cardiovasc Qual Outcomes 2016; 9:670-678. [PMID: 28051772 DOI: 10.1161/circoutcomes.116.003041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 10/10/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The nature of teamwork in healthcare is complex and interdisciplinary, and provider collaboration based on shared patient encounters is crucial to its success. Characterizing the intensity of working relationships with risk-adjusted patient outcomes supplies insight into provider interactions in a hospital environment. METHODS AND RESULTS We extracted 4 years of patient, provider, and activity data for encounters in an inpatient cardiology unit from Northwestern Medicine's Enterprise Data Warehouse. We then created a provider-patient network to identify healthcare providers who jointly participated in patient encounters and calculated satisfaction rates for provider-provider pairs. We demonstrated the application of a novel parameter, the shared positive outcome ratio, a measure that assesses the strength of a patient-sharing relationship between 2 providers based on risk-adjusted encounter outcomes. We compared an observed collaboration network of 334 providers and 3453 relationships to 1000 networks with shared positive outcome ratio scores based on randomized outcomes and found 188 collaborative relationships between pairs of providers that showed significantly higher than expected patient satisfaction ratings. A group of 22 providers performed exceptionally in terms of patient satisfaction. Our results indicate high variability in collaboration scores across the network and highlight our ability to identify relationships with both higher and lower than expected scores across a set of shared patient encounters. CONCLUSIONS Satisfaction rates seem to vary across different teams of providers. Team collaboration can be quantified using a composite measure of collaboration across provider pairs. Tracking provider pair outcomes over a sufficient set of shared encounters may inform quality improvement strategies such as optimizing team staffing, identifying characteristics and practices of high-performing teams, developing evidence-based team guidelines, and redesigning inpatient care processes.
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Affiliation(s)
- Matthew B Carson
- From the Departments of Preventive Medicine (M.B.C., D.M.S., C.N.F., A.Y.W., G.S.K., F.S.A., N.D.S.), Emergency Medicine (S.J.G., E.S.P.), Family and Community Medicine (A.Y.W.), and Medicine (F.S.A., R.K.M.), Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Denise M Scholtens
- From the Departments of Preventive Medicine (M.B.C., D.M.S., C.N.F., A.Y.W., G.S.K., F.S.A., N.D.S.), Emergency Medicine (S.J.G., E.S.P.), Family and Community Medicine (A.Y.W.), and Medicine (F.S.A., R.K.M.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Conor N Frailey
- From the Departments of Preventive Medicine (M.B.C., D.M.S., C.N.F., A.Y.W., G.S.K., F.S.A., N.D.S.), Emergency Medicine (S.J.G., E.S.P.), Family and Community Medicine (A.Y.W.), and Medicine (F.S.A., R.K.M.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Stephanie J Gravenor
- From the Departments of Preventive Medicine (M.B.C., D.M.S., C.N.F., A.Y.W., G.S.K., F.S.A., N.D.S.), Emergency Medicine (S.J.G., E.S.P.), Family and Community Medicine (A.Y.W.), and Medicine (F.S.A., R.K.M.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Emilie S Powell
- From the Departments of Preventive Medicine (M.B.C., D.M.S., C.N.F., A.Y.W., G.S.K., F.S.A., N.D.S.), Emergency Medicine (S.J.G., E.S.P.), Family and Community Medicine (A.Y.W.), and Medicine (F.S.A., R.K.M.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Amy Y Wang
- From the Departments of Preventive Medicine (M.B.C., D.M.S., C.N.F., A.Y.W., G.S.K., F.S.A., N.D.S.), Emergency Medicine (S.J.G., E.S.P.), Family and Community Medicine (A.Y.W.), and Medicine (F.S.A., R.K.M.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gayle Shier Kricke
- From the Departments of Preventive Medicine (M.B.C., D.M.S., C.N.F., A.Y.W., G.S.K., F.S.A., N.D.S.), Emergency Medicine (S.J.G., E.S.P.), Family and Community Medicine (A.Y.W.), and Medicine (F.S.A., R.K.M.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Faraz S Ahmad
- From the Departments of Preventive Medicine (M.B.C., D.M.S., C.N.F., A.Y.W., G.S.K., F.S.A., N.D.S.), Emergency Medicine (S.J.G., E.S.P.), Family and Community Medicine (A.Y.W.), and Medicine (F.S.A., R.K.M.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - R Kannan Mutharasan
- From the Departments of Preventive Medicine (M.B.C., D.M.S., C.N.F., A.Y.W., G.S.K., F.S.A., N.D.S.), Emergency Medicine (S.J.G., E.S.P.), Family and Community Medicine (A.Y.W.), and Medicine (F.S.A., R.K.M.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Nicholas D Soulakis
- From the Departments of Preventive Medicine (M.B.C., D.M.S., C.N.F., A.Y.W., G.S.K., F.S.A., N.D.S.), Emergency Medicine (S.J.G., E.S.P.), Family and Community Medicine (A.Y.W.), and Medicine (F.S.A., R.K.M.), Feinberg School of Medicine, Northwestern University, Chicago, IL
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Mutharasan RK, Kansal P, Jackson HA, Benacka C, Fortman R, Navarro D, Ahmad F, Abecassis MM, Anderson AS, Davidson C, Gurvich I, Noskin G, Soulakis ND, Van Mieghem J, Yancy CW. Heart Failure Care Transitions: A Queuing Theory Approach to Quantify the Impact of Vacation Periods on Discharge Clinic Wait Times. J Card Fail 2016. [DOI: 10.1016/j.cardfail.2016.06.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Finch JAM, Chiampas G, Mutharasan RK, Contursi M, D’Hemecourt P, Dyer S, Troyanos C, Baggish A. ELECTROCARDIOGRAM UTILIZATION IN THE MARATHON MEDICAL TENT. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)31639-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kricke GS, Carson M, Lee YJ, Benacka C, Ahmad F, Mutharasan RK, Kansal P, Yancy C, Anderson A, Soulakis N. Abstract 215: Leveraging Electronic Health Record Documentation for Failure Mode and Effects Analysis Team Identification on an Inpatient Cardiology Unit. Circ Cardiovasc Qual Outcomes 2016. [DOI: 10.1161/circoutcomes.9.suppl_2.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives:
Failure Mode and Effects Analysis (FMEA) is a frequently-used approach for prospective risk assessment and quality improvement in healthcare, particularly for high-risk care processes such as hospital discharge planning. Our goal was to evaluate whether secondary use of metadata collected by the electronic health record (EHR) during daily practice can inform assembly of a comprehensive FMEA team by showing: 1) discrepancies between expected and observed process activities and individuals involved, and 2) the presence of individuals who may be appropriate to include in an FMEA based on their variable familiarity with a process.
Methods:
We extracted discharge planning data for an inpatient cardiology unit from the Enterprise Data Warehouse (EDW) and compared it to a hand-drawn map (HDM) indicating clinicians’ understanding of discharge activities and providers expected to complete each activity. We assessed the presence of providers highly experienced in the process, the diversity of involved disciplines, and the accuracy of the HDM compared to observation from EDW data.
Findings:
Over 500 providers completed nearly 35,000 discharge-related activities across 18 activity types over 2,000 encounters. Experience was skewed such that 90% (510 of 569) of providers completed between 0 and 99 activities while the remaining 10% (59 of 569) performed up to 1,200 activities. Frequent performers completed similar activities to their peers, but did so as many as 12 times more frequently than average for their discipline. Expectation of who performed an activity closely matched observation for 11 discipline-specific activities, such as case management assessment. However, providers from up to 10 different disciplines performed the remaining 7 activities, such as scheduling a follow-up visit or ordering a therapy consult. Overall, 35% (12,183 of 34,939) of activities were performed by an unexpected provider.
Conclusions:
Analyzing metadata from EHRs is a novel method to inform FMEA of high-risk processes. This study provides a framework for assessing process activities and the providers involved. In the discharge planning process, there appears to be significant discrepancy between clinicians’ understanding and the actual discharge process and team, which suggests the presence of providers who could be overlooked during typical FMEA team construction. This methodology can empirically enrich the FMEA team and highlight quality improvement target areas.
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Affiliation(s)
- Gayle S Kricke
- Northwestern Univ Div of Health and Biomedical Informatics, Chicago, IL
| | - Matthew Carson
- Northwestern Univ Div of Health and Biomedical Informatics, Chicago, IL
| | | | - Corrine Benacka
- Northwestern Memorial Hosp Bluhm Cardiovascular Institute, Chicago, IL
| | - Faraz Ahmad
- Northwestern Memorial Hosp Bluhm Cardiovascular Institute, Chicago, IL
| | | | - Preeti Kansal
- Northwestern Memorial Hosp Bluhm Cardiovascular Institute, Chicago, IL
| | - Clyde Yancy
- Northwestern Memorial Hosp Bluhm Cardiovascular Institute, Chicago, IL
| | - Allen Anderson
- Northwestern Memorial Hosp Bluhm Cardiovascular Institute, Chicago, IL
| | - Nicholas Soulakis
- Northwestern Univ Div of Health and Biomedical Informatics, Chicago, IL
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Mutharasan RK, Kansal P, Abecassis MM, Alphs Jackson H, Anderson AS, Benacka C, Berry Jaeker JA, Davidson C, Gurvich I, Navarro D, Noskin GA, Schaeffer-Pettigrew C, Soulakis ND, Van Mieghem J, Yancy CW. Abstract 161: Heart Failure Care Transitions: A Queuing Theory Approach to Match Variable Hospital Discharge Rate With Outpatient Clinic Capacity. Circ Cardiovasc Qual Outcomes 2016. [DOI: 10.1161/circoutcomes.9.suppl_2.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Heart failure (HF) readmissions remain a major driver of cost and health care utilization. Timely follow-up of patients post-discharge represents an evidence-based intervention proven to reduce readmission rates. A previously unexplored characteristic of hospital discharges is variability in discharge caseload. This variability thwarts the timeliness of follow-up, negates the benefit of transition care planning and may lead to a higher risk of HF readmissions. Queuing theory is the mathematical study of waiting times. We opted to use queuing theory to determine if caseload can be determined more precisely in a manner that sufficiently accommodates HF discharge variability.
Objective:
To analyze the impact of hospital discharge rate variability on outpatient clinic capacity needs using HF hospitalization discharge data and operations management approaches.
Methods:
Higher risk hospitalizations requiring active transitional care heart failure management were detected using an enterprise data warehouse-supported process over the study period. Queuing theory approaches were used to model the impact of HF discharge clinic capacity on wait time to an appointment. Discharge clinic was modeled as a single 7-day follow-up appointment, with an acceptable scheduling window of 5 to 9 days post-discharge.
Results:
During the study period of 100 days, 566 HF discharges were made, for a median of 5.66 discharges daily, or 39.6 discharges weekly. The distribution of daily discharges was skewed rightward (mode = 3, range = 0 to 18, standard deviation = 3.3, coefficient of variation = 0.58). Current clinic design: Providing one discharge slot for every hospital discharge (100% utilization) leads to an average wait of 18.3 days prior to an appointment, with only 31.9% of appointments scheduled within 7 days, and 38.9% of appointments scheduled within 9 days. Clinic re-design (queuing theory): Providing five extra discharge appointment slots per week (88% utilization or 13.6% excess capacity) reduces the expected waiting period to 1.1 days, with 99.8% of patients seen within 7 days, and virtually all patients seen within 9 days of discharge.
Conclusions:
Deployment of queuing theory allows for a more precise quantification of needed clinical capacity to accomplish appropriate HF follow-up with a reasonable degree of certainty. Our simplified model demonstrates that variability in hospital discharge rates leads to excessive clinic wait times in the absence of a modest capacity buffer and consequently exposes patients to a higher risk of HF readmission. We show using single center HF discharge data that a 10-15% increase in capacity is needed to ensure an adequate follow-up service level. Ongoing process of care work will demonstrate if optimization of clinic load yields a significant reduction in HF readmissions.
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Soulakis ND, Carson MB, Frailey C, Kricke GS, Scholtens DM, Anderson AS, Benacka C, Kansal P, Mutharasan RK, Gurvich I, Van Mieghem JA, Yancy CW. Abstract 136: Complexity and Collaboration in Discharge Planning for Inpatient Cardiology. Circ Cardiovasc Qual Outcomes 2016. [DOI: 10.1161/circoutcomes.9.suppl_2.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Multidisciplinary, collaborative care improves outcomes and reduces costs but may unintentionally increase the operational overhead to manage the complexity of increasingly sophisticated teamwork.
Objective:
To quantify complexity of a standardized discharge planning process by closely examining team continuity, composition, and experience for both explicitly defined, deliberately organized teams and implicitly defined, organically assembled teams.
Methods:
We examined discharge planning team membership for inpatient cardiology encounters with a length of stay (LOS) greater than 48 hours for a three-year period from 2012-2014 in a large academic medical center. By constructing a co-affiliation graph from transactional EHR data, we determined the frequency of team occurrence and size. We then calculated the shared experience of teammates using a pairwise similarity metric and identified modularity, groups of healthcare personnel with dense connections, within the graph by applying a community detection algorithm.
Results:
We identified 52,254 transactions for 3,213 encounters with an average LOS of 8.7 days for the time period. The standard discharge planning team accounted for 41,101 (79%) transactions, consisted of 7 team member types, and comprised 709 individual providers performing 36 activities. We identified 569 additional discharge planning team members, consisting of 22 additional provider types. When constrained to only explicitly defined teams, 404 unique teams with an average size of 5.9 members occurred with a mean of 8 (min=1, max=118) shared encounters. When unconstrained, organically assembled teams with no explicit definition occurred 3,209 times (mean=1; min=1, max=3) with an average size of 7.3 members. Single-encounters accounted for 21,107 (62%) of all provider pairs. However, over 50% of all discharges had at least 1 pair sharing over 99 encounters (median=4 pairs). Community detection found 9 modules (range: 12-275 members) among pairs with more than 5 shared encounters.
Conclusions:
We have shown by deconstructing digital interactions via the EHR, a core group of providers, defined by role and activity, anchor most discharge planning teams. However, the EHR can also identify identify the 20% of teams with constantly recombining membership due to situational care; this can impose overhead when targeting team-wide process improvements, communication strategies, or educational initiatives.
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Affiliation(s)
| | | | - Conor Frailey
- Northwestern Univ Clinical and Translational Sciences Institute, Chicago, IL
| | | | | | | | | | - Preeti Kansal
- Northwestern Univ Feinberg Sch of Medicine, Chicago, IL
| | | | - Itai Gurvich
- Northwestern Univ Kellogg Sch of Management, Chicago, IL
| | | | - Clyde W Yancy
- Northwestern Univ Feinberg Sch of Medicine, Chicago, IL
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Carson MB, Scholtens DM, Frailey CN, Kricke GS, Benacka C, Ahmad F, Mutharasan RK, Kansal P, Anderson AS, Yancy CW, Soulakis ND. Abstract 15: Quantifying Teamwork at Hospital Discharge for Readmissions Reduction: A Network Analytics Approach. Circ Cardiovasc Qual Outcomes 2016. [DOI: 10.1161/circoutcomes.9.suppl_2.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The vulnerable period for hospital readmission begins upon hospital discharge, a complex, interdisciplinary process that necessitates close teamwork for accurate execution of the discharge plan. Thus, better understanding of the quality of teamwork throughout the discharge process may inform strategies to reduce hospital readmissions rates. Novel methods using a network analytics approach to quantify teamwork may better characterize this critical clinical process, facilitate quality improvement (QI), and become an important tool in learning healthcare systems.
Methods:
We extracted three years of patient, provider, and activity data related to discharge planning for an inpatient cardiology unit from Northwestern Medicine’s Enterprise Data Warehouse. We then created a provider-patient network to identify providers who shared patients and calculated readmissions rates for provider pairs. Using these data, we calculated a novel parameter, the
Shared Positive Outcome Ratio
(SPOR), an objective composite measure that quantifies the concentration of positive outcomes over a set of shared patients. To identify significant low-readmission and high-readmission collaborative relationships, we compared the observed network to 1000 sample networks containing randomized readmission values.
Results:
We identified 133,927 actions distributed among 38 discharge activity types performed during 13,720 patient encounters. The collaborative network was composed of 1,542 providers including 503 nurses, 432 residents, 207 physicians, 111 physical and occupational therapists, 59 medical students, 32 dieticians, and other medical and administrative staff. The average encounter involved 4 providers performing 10 discharge-related actions. After pruning the network to include only provider pairs with 6 or more shared patients, we found that 6% of collaborative interactions had a significantly low SPOR, indicating lower than expected readmission rates. Conversely, 12% of collaborative interactions had a significantly high SPOR, indicating higher than expected readmission rates. We identified 21 providers who had a low SPOR for a significant percentage of their collaborations, indicating potential top performers in the teamwork domain.
Conclusions:
Readmission rates appear to vary across different teams of providers. Team collaboration can be quantified using a composite measure of collaboration across provider pairs. Tracking provider pair outcomes over a sufficient set of shared encounters may inform various QI strategies, such as optimizing team staffing, identifying high-performing teams who can share their best practices, and redesigning discharge care processes. Ongoing work on this model is focused on accurately risk-adjusting outcomes, which will increase the robustness of this method.
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Mutharasan RK, Kansal P, Benacka C, Navarro D, Abecassis MM, Alphs Jackson H, Anderson AS, Berry Jaeker JA, Davidson C, Gurvich I, Noskin G, Schaeffer-Pettigrew C, Soulakis ND, Van Mieghem J, Yancy CW. Abstract 152: Enterprise Data Warehouse-Supported Early Identification of Acute Decompensated Heart Failure Admissions for Efficient and Multidisciplinary Transitional Care Team Interventions. Circ Cardiovasc Qual Outcomes 2016. [DOI: 10.1161/circoutcomes.9.suppl_2.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Multidisciplinary transitional care teams represent a model for reducing heart failure readmissions. Within this context, early identification of patients hospitalized with acute decompensated heart failure (ADHF) permits meaningful transitional care plan development. Improving the efficiency of early identification of the higher risk ADHF patient represents an area not well studied in hospitalized heart failure (HF).
Objective:
To validate the sensitivity and specificity of an enterprise data warehouse (EDW)-based strategy for early identification of patients with ADHF.
Methods:
An EDW query was constructed to identify patients with ADHF based on clinical and diagnosis-related parameters, including BNP level and administration of intravenous diuretics. The EDW query was run daily; expert clinicians verified the diagnosis of ADHF based on comprehensive chart review. This classification was used to determine specificity of the query for ADHF. We computed the sensitivity of the EDW-based approach by matching query results to heart failure diagnosis related group (DRG) data and primary discharge diagnosis data from separate hospital systems.
Results:
During the study period of 70 days, a total of 2354 charts were screened (33.6 charts per day). A total of 410 patients were identified by chart review as having heart failure requiring active management, for a specificity of 17.4%. Sensitivity was computed using both heart failure DRG data and primary discharge diagnosis data. Of the 114 patients discharged with a heart failure DRG (291, 292, or 293), all 114 were detected a priori by the admission EDW screen, for a sensitivity of 100%. A similar analysis conducted using HF principal diagnoses, which includes cardiac surgery-related admissions, yielded a sensitivity of 97.2%.
Conclusions:
EDW-based screening of patients based on simple clinical parameters early in the hospitalization is highly sensitive for detection of ADHF hospitalizations, but specificity is low. Brief chart review by expert clinicians is rapid, and identifies a specific cohort of patients that can be targeted for multidisciplinary HF transitional care. A better delineation of risk has broad outpatient workflow implications. Ongoing process improvements will demonstrate if early identification of at-risk patients yields significant reduction in HF readmissions.
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Abstract
High-density lipoproteins (HDL) are a class of natural nanostructures found in the blood and are composed of lipids, proteins, and nucleic acids (e.g. microRNA). Their size, which appears to be well-suited for both tissue penetration/retention as well as payload delivery, long circulation half-life, avoidance of endosomal sequestration, and potential low toxicity are all excellent properties to model in a drug delivery vehicle. In this review, we consider high-density lipoproteins for therapeutic delivery systems. First we discuss the structure and function of natural HDL, describing in detail its biogenesis and transformation from immature, discoidal forms, to more mature, spherical forms. Next we consider features of HDL making them suitable vehicles for drug delivery. We then describe the use of natural HDL, discoidal HDL analogs, and spherical HDL analogs to deliver various classes of drugs, including small molecules, lipids, and oligonucleotides. We briefly consider the notion that the drug delivery vehicles themselves are therapeutic, constituting entities that exhibit "theralivery." Finally, we discuss challenges and future directions in the field.
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Affiliation(s)
- R. Kannan Mutharasan
- Feinberg Cardiovascular Research Institute, 303 E. Chicago Ave., Tarry 14-725, Chicago, IL 60611 United States
| | - Linda Foit
- Feinberg School of Medicine, Department of Urology, Northwestern University, Tarry 16-703, 303 E. Chicago Ave, Chicago, IL 60611, USA
| | - C. Shad Thaxton
- Feinberg School of Medicine, Department of Urology, Northwestern University, Tarry 16-703, 303 E. Chicago Ave, Chicago, IL 60611, USA
- Simpson Querrey Institute for BioNanotechnology, Northwestern University, 303 E. Superior St, Chicago, IL 60611, USA
- International Institute for Nanotechnology (IIN), 2145 Sheridan Road, Evanston, IL 60208, USA
- Robert H Lurie Comprehensive Cancer Center (RHLCCC), Northwestern University, Feinberg School of Medicine, 303 E Superior, Chicago, IL 60611, USA
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Kim K, Compton PD, Toby TK, Thomas PM, Wilkins JT, Mutharasan RK, Kelleher NL. Reducing protein oxidation in low-flow electrospray enables deeper investigation of proteoforms by top down proteomics. EuPA Open Proteom 2015; 8:40-47. [PMID: 26753126 PMCID: PMC4704458 DOI: 10.1016/j.euprot.2015.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Enabling the implementation of top down proteomic techniques within clinical workflows requires a dramatic increase in sensitivity. It has been previously demonstrated that electrospray ionization (ESI) becomes more efficient with decreasing volumetric flow rates at the emitter. Therefore, narrow inner diameter (I.D.) columns used in front-end chromatographic separations yield increased sensitivity. However, the smaller cross-sectional area of a narrow I.D. column places a larger fraction of the eluent in fluid communication with the electrode within the high voltage union that facilitates electrospray ionization (ESI), leading to increased oxidation of solution-phase proteins. Oxidation of proteins alters their chemical state of the protein, complicates data analysis, and reduces the depth of proteome coverage attained in a typical top-down proteomics experiment. Excessive protein oxidation results in poor deconvolution and exact mass calculations from MS1 spectra, interferes with peak isolation for MS/MS fragmentation, and effectively reduces sensitivity by splitting ion current. All of these factors deteriorate top down mass spectral data quality, an effect that becomes more pronounced as column diameter decreases. Artificial protein oxidation can also mislead investigations of in vivo protein oxidation. All of these effects are accentuated in comparison to bottom up proteomics due to the increased probability of having oxidizable residues within a particular species with increasing mass. Herein, we describe a configuration (which we term "Low Protein Oxidation (LPOx)") for proteomics experiments created by re-arranging liquid chromatography (LC) plumbing and present its application to artificial protein oxidation and show a marked improvement in detection sensitivity. Using a standard mixture of five intact proteins, we demonstrate that the LPOx configuration reduces protein oxidation up to 90% using 50 μm I.D. columns when compared to a conventional LC plumbing configuration with 50 μm I.D. column. As a proof-of-concept study, at least 11 distinct proteoforms of serum Apolipoprotein A1 were detected with the LPOx configuration. This innovative LC configuration can be applied to the top down identification and characterization of proteoforms obscured by abundant artificial protein oxidation at low flowrates, all while using reduced amounts of valuable protein samples.
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Affiliation(s)
- Kyunggon Kim
- Departments of Chemistry, Molecular Biosciences and the Proteomics Center of Excellence, Northwestern University, 2145 N. Sheridan Road, Evanston, IL 60208, United States
| | - Philip D. Compton
- Departments of Chemistry, Molecular Biosciences and the Proteomics Center of Excellence, Northwestern University, 2145 N. Sheridan Road, Evanston, IL 60208, United States
| | - Timothy K. Toby
- Departments of Chemistry, Molecular Biosciences and the Proteomics Center of Excellence, Northwestern University, 2145 N. Sheridan Road, Evanston, IL 60208, United States
| | - Paul M. Thomas
- Departments of Chemistry, Molecular Biosciences and the Proteomics Center of Excellence, Northwestern University, 2145 N. Sheridan Road, Evanston, IL 60208, United States
| | - John T. Wilkins
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive., Chicago, IL 60611, United States
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair Street, Chicago, IL 60611, United States
| | - R. Kannan Mutharasan
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair Street, Chicago, IL 60611, United States
| | - Neil L. Kelleher
- Departments of Chemistry, Molecular Biosciences and the Proteomics Center of Excellence, Northwestern University, 2145 N. Sheridan Road, Evanston, IL 60208, United States
- Corresponding author. Tel.: +1 847 467 4362; fax: +1 847 467 3276. (N.L. Kelleher)
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Mutharasan RK, Singh AT, McMahon KM, Thaxton CS. Abstract 631: Lipid Composition of Gold Nanoparticle-Templated High-Density Lipoprotein Analogs Dictates Cholesterol Efflux Function. Arterioscler Thromb Vasc Biol 2014. [DOI: 10.1161/atvb.34.suppl_1.631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Reverse cholesterol transport, the process by which cholesterol is effluxed from cells to high-density lipoproteins (HDL) and is delivered to the liver for clearance, is a promising pathway to augment for treatment of atherosclerosis. Though structure-function relationships for nascent, discoidal HDL and cholesterol efflux have been well studied, how the lipid composition of spherical HDL species - which varies in pathophysiological conditions - impacts their ability to mediate cholesterol efflux has not been investigated.
Methods and Results:
Spherical gold nanoparticles (5 nm) were used to synthesize spherical HDL analogs (HDL-NP) by adding ApoAI protein, and various lipids. With this strategy a panel of HDL-NP varying in lipid content was generated. HDL-NP designs tested include: dipalmitylphosphatidylcholine (DPPC, saturated fatty acid), dioleoylphosphatidylcholine (DOPC, unsaturated fatty acid), sphingomyelin, lysophosphatidylcholine (LPC), and mixtures thereof. All of these species are found in natural HDL. After characterizing protein and lipid stoichiometry of the purified HDL-NP, these HDL-NP designs were tested in the cellular reverse cholesterol transport assay using J774 mouse macrophages. These studies demonstrate that all HDL-NP designs mediate more efflux than equimolar amounts of ApoAI protein control, and further demonstrate that HDL-NP designs incorporating unsaturated phospholipid (DOPC), sphingomyelin, and LPC - each of which can increase disorder in the lipid membrane and thus give rise to opportunity for cholesterol to intercalate and bind - enhance cholesterol efflux compared to saturated phospholipid (DPPC) design.
Conclusion:
In summary, these results demonstrate that lipid content of HDL-NP - analogs of spherical HDL - dictates cholesterol efflux function, a finding which sheds light on the functional importance of lipid content variation seen in mature, spherical HDL species.
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Ichikawa Y, Ghanefar M, Bayeva M, Wu R, Khechaduri A, Naga Prasad SV, Mutharasan RK, Naik TJ, Ardehali H. Cardiotoxicity of doxorubicin is mediated through mitochondrial iron accumulation. J Clin Invest 2014; 124:617-30. [PMID: 24382354 DOI: 10.1172/jci72931] [Citation(s) in RCA: 589] [Impact Index Per Article: 58.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 10/17/2013] [Indexed: 01/19/2023] Open
Abstract
Doxorubicin is an effective anticancer drug with known cardiotoxic side effects. It has been hypothesized that doxorubicin-dependent cardiotoxicity occurs through ROS production and possibly cellular iron accumulation. Here, we found that cardiotoxicity develops through the preferential accumulation of iron inside the mitochondria following doxorubicin treatment. In isolated cardiomyocytes, doxorubicin became concentrated in the mitochondria and increased both mitochondrial iron and cellular ROS levels. Overexpression of ABCB8, a mitochondrial protein that facilitates iron export, in vitro and in the hearts of transgenic mice decreased mitochondrial iron and cellular ROS and protected against doxorubicin-induced cardiomyopathy. Dexrazoxane, a drug that attenuates doxorubicin-induced cardiotoxicity, decreased mitochondrial iron levels and reversed doxorubicin-induced cardiac damage. Finally, hearts from patients with doxorubicin-induced cardiomyopathy had markedly higher mitochondrial iron levels than hearts from patients with other types of cardiomyopathies or normal cardiac function. These results suggest that the cardiotoxic effects of doxorubicin develop from mitochondrial iron accumulation and that reducing mitochondrial iron levels protects against doxorubicin-induced cardiomyopathy.
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Damiano MG, Mutharasan RK, Tripathy S, McMahon KM, Thaxton CS. Templated high density lipoprotein nanoparticles as potential therapies and for molecular delivery. Adv Drug Deliv Rev 2013; 65:649-62. [PMID: 22921597 DOI: 10.1016/j.addr.2012.07.013] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 07/13/2012] [Accepted: 07/23/2012] [Indexed: 01/04/2023]
Abstract
High density lipoproteins (HDLs) are dynamic natural nanoparticles best known for their role in cholesterol transport and the inverse correlation that exists between blood HDL levels and the risk of developing coronary heart disease. In addition, enhanced HDL-cholesterol uptake has been demonstrated in several human cancers. As such, the use of HDL as a therapeutic and as a vehicle for systemic delivery of drugs and as imaging agents is increasingly important. HDLs exist on a continuum from the secreted HDL-scaffolding protein, apolipoprotein A-1 (Apo A1), to complex, spherical "mature" HDLs. Aspects of HDL particles including their size, shape, and surface chemical composition are being recognized as critical to their diverse biological functions. Here we review HDL biology; strategies for synthesizing HDLs; data supporting the clinical use and benefit of directly administered HDL; a rationale for developing synthetic methods for spherical, mature HDLs; and, the potential to employ HDLs as therapies, imaging agents, and drug delivery vehicles. Importantly, methods that utilize nanoparticle templates to control synthetic HDL size, shape, and surface chemistry are highlighted.
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Affiliation(s)
- Marina G Damiano
- Department of Chemistry, Northwestern University, 2145 Sheridan Road, Evanston, IL 60208, USA
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Abstract
Background MicroRNA‐210 (miR‐210) increases in hypoxia and regulates mitochondrial respiration through modulation of iron‐sulfur cluster assembly proteins (ISCU1/2), a protein that is involved in Fe/S cluster synthesis. However, it is not known how miR‐210 affects cellular iron levels or production of heme, another iron containing molecule that is also needed for cellular and mitochondrial function. Methods and Results To screen for micro‐ribonucleic acids (miRNAs) regulated by iron, we performed a miRNA gene array in neonatal rat cardiomyocytes treated with iron chelators. Levels of miR‐210 are significantly increased with iron chelation, however, this response was mediated entirely through the hypoxia‐inducible factor (HIF) pathway. Furthermore, miR‐210 reduced cellular heme levels and the activity of mitochondrial and cytosolic heme‐containing proteins by modulating ferrochelatase (FECH), the last enzyme in heme biosynthesis. Mutation of the 2 miR‐210 binding sites in the 3′ untranslated region (UTR) of FECH reversed the miR‐210 response, while mutation of either binding site in isolation did not exert any effects. Changes mediated by miR‐210 in heme and FECH were independent of ISCU, as overexpression of an ISCU construct lacking the 3′ UTR does not alter miR‐210 regulation of heme and FECH. Finally, FECH levels increased in hypoxia, and this effect was not reversed by miR‐210 knockdown, suggesting that the effects of miR‐210 on heme are restricted to normoxic conditions, and that the pathway is overriden in hypoxia. Conclusions Our results identify a role for miR‐210 in the regulation of heme production by targeting and inhibiting FECH under normoxic conditions.
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Affiliation(s)
- Aijun Qiao
- Feinberg Cardiovascular Research Institute, Northwestern University, Chicago,IL 60611, USA
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Mutharasan RK, Nagpal V, Ichikawa Y, Ardehali H. microRNA-210 is upregulated in hypoxic cardiomyocytes through Akt- and p53-dependent pathways and exerts cytoprotective effects. Am J Physiol Heart Circ Physiol 2011; 301:H1519-30. [PMID: 21841015 DOI: 10.1152/ajpheart.01080.2010] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
microRNA-210 (miR-210) is upregulated in hypoxia, but its function in cardiomyocytes and its regulation in response to hypoxia are not well characterized. The purpose of this study was to identify upstream regulators of miR-210, as well as to characterize miR-210's function in cardiomyocytes. We first showed miR-210 is upregulated through both hypoxia-inducible factor (HIF)-dependent and -independent pathways, since aryl hydrocarbon nuclear translocator (ARNT) knockout mouse embryonic fibroblasts (MEF), lacking intact HIF signaling, still displayed increased miR-210 levels in hypoxia. To determine the mechanism for HIF-independent regulation of miR-210, we focused on p53 and protein kinase B (Akt). Overexpression of p53 in wild-type MEFs induced miR-210, whereas p53 overexpression in ARNT knockout MEFs did not, suggesting p53 regulates miR-210 in a HIF-dependent mechanism. Akt inhibition reduced miR-210 induction by hypoxia, whereas Akt overexpression increased miR-210 levels in both wild-type and ARNT knockout MEFs, indicating Akt regulation of miR-210 is HIF-independent. We then studied the effects of miR-210 in cardiomyocytes. Overexpression of miR-210 reduced cell death in response to oxidative stress and reduced reactive oxygen species (ROS) production both at baseline and after treatment with antimycin A. Furthermore, downregulation of miR-210 increased ROS after hypoxia-reoxygenation. To determine a mechanism for the cytoprotective effects of miR-210, we focused on the predicted target, apoptosis-inducing factor, mitochondrion-associated 3 (AIFM3), known to induce cell death. Although miR-210 reduced AIFM3 levels, overexpression of AIFM3 in the presence of miR-210 overexpression did not reduce cellular viability either at baseline or after hydrogen peroxide treatment, suggesting AIFM3 does not mediate miR-210's cytoprotective effects. Furthermore, HIF-3α, a negative regulator of HIF signaling, is targeted by miR-210, but miR-210 does not modulate HIF activity. In conclusion, we demonstrate a novel role for p53 and Akt in regulating miR-210 and demonstrate that, in cardiomyocytes, miR-210 exerts cytoprotective effects, potentially by reducing mitochondrial ROS production.
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Affiliation(s)
- R Kannan Mutharasan
- Feinberg Cardiovascular Research Institute, Northwestern University, Chicago, Illinois 60611, USA
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McMahon KM, Mutharasan RK, Tripathy S, Veliceasa D, Bobeica M, Shumaker DK, Luthi AJ, Helfand BT, Ardehali H, Mirkin CA, Volpert O, Thaxton CS. Biomimetic high density lipoprotein nanoparticles for nucleic acid delivery. Nano Lett 2011; 11:1208-14. [PMID: 21319839 PMCID: PMC4077779 DOI: 10.1021/nl1041947] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
We report a gold nanoparticle-templated high density lipoprotein (HDL AuNP) platform for gene therapy that combines lipid-based nucleic acid transfection strategies with HDL biomimicry. For proof-of-concept, HDL AuNPs are shown to adsorb antisense cholesterylated DNA. The conjugates are internalized by human cells, can be tracked within cells using transmission electron microscopy, and regulate target gene expression. Overall, the ability to directly image the AuNP core within cells, the chemical tailorability of the HDL AuNP platform, and the potential for cell-specific targeting afforded by HDL biomimicry make this platform appealing for nucleic acid delivery.
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Affiliation(s)
- Kaylin M. McMahon
- Northwestern University, Feinberg School of Medicine, Department of Urology, 303 E. Chicago Ave., Tarry 16-703, Chicago, IL 60611
- Institute for BioNanotechnology and Medicine (IBNAM), 303 E. Superior Ave., 11 Floor, Chicago, IL 60611
| | - R. Kannan Mutharasan
- Feinberg Cardiovascular Research Institute, 303 E. Chicago Ave., Tarry 14-725, Chicago, IL 60611
| | - Sushant Tripathy
- Northwestern University, Feinberg School of Medicine, Department of Urology, 303 E. Chicago Ave., Tarry 16-703, Chicago, IL 60611
- Institute for BioNanotechnology and Medicine (IBNAM), 303 E. Superior Ave., 11 Floor, Chicago, IL 60611
| | - Dorina Veliceasa
- Northwestern University, Feinberg School of Medicine, Department of Urology, 303 E. Chicago Ave., Tarry 16-703, Chicago, IL 60611
| | - Mariana Bobeica
- Northwestern University, Feinberg School of Medicine, Department of Urology, 303 E. Chicago Ave., Tarry 16-703, Chicago, IL 60611
- Institute for BioNanotechnology and Medicine (IBNAM), 303 E. Superior Ave., 11 Floor, Chicago, IL 60611
| | - Dale K. Shumaker
- Northwestern University, Feinberg School of Medicine, Department of Urology, 303 E. Chicago Ave., Tarry 16-703, Chicago, IL 60611
- Robert H. Lurie Comprehensive Cancer Center, 303 E. Superior Ave., Chicago, IL 60611
| | - Andrea J. Luthi
- Northwestern University, Department of Chemistry, 2145 Sheridan Road, Evanston, IL 60208
- Northwestern University, International Institute for Nanotechnology, 2145 Sheridan Road, Evanston, IL 60208
| | - Brian T. Helfand
- Northwestern University, Feinberg School of Medicine, Department of Urology, 303 E. Chicago Ave., Tarry 16-703, Chicago, IL 60611
| | - Hossein Ardehali
- Feinberg Cardiovascular Research Institute, 303 E. Chicago Ave., Tarry 14-725, Chicago, IL 60611
| | - Chad A. Mirkin
- Robert H. Lurie Comprehensive Cancer Center, 303 E. Superior Ave., Chicago, IL 60611
- Northwestern University, Department of Chemistry, 2145 Sheridan Road, Evanston, IL 60208
- Northwestern University, International Institute for Nanotechnology, 2145 Sheridan Road, Evanston, IL 60208
| | - Olga Volpert
- Northwestern University, Feinberg School of Medicine, Department of Urology, 303 E. Chicago Ave., Tarry 16-703, Chicago, IL 60611
| | - C. Shad Thaxton
- Northwestern University, Feinberg School of Medicine, Department of Urology, 303 E. Chicago Ave., Tarry 16-703, Chicago, IL 60611
- Robert H. Lurie Comprehensive Cancer Center, 303 E. Superior Ave., Chicago, IL 60611
- Institute for BioNanotechnology and Medicine (IBNAM), 303 E. Superior Ave., 11 Floor, Chicago, IL 60611
- Northwestern University, International Institute for Nanotechnology, 2145 Sheridan Road, Evanston, IL 60208
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Luthi AJ, Patel PC, Ko CH, Mutharasan RK, Mirkin CA, Thaxton CS. Nanotechnology for synthetic high-density lipoproteins. Trends Mol Med 2010; 16:553-60. [PMID: 21087901 PMCID: PMC4076051 DOI: 10.1016/j.molmed.2010.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 10/12/2010] [Accepted: 10/12/2010] [Indexed: 01/04/2023]
Abstract
Atherosclerosis is the disease mechanism responsible for coronary heart disease (CHD), the leading cause of death worldwide. One strategy to combat atherosclerosis is to increase the amount of circulating high-density lipoproteins (HDL), which transport cholesterol from peripheral tissues to the liver for excretion. The process, known as reverse cholesterol transport, is thought to be one of the main reasons for the significant inverse correlation observed between HDL blood levels and the development of CHD. This article highlights the most common strategies for treating atherosclerosis using HDL. We further detail potential treatment opportunities that utilize nanotechnology to increase the amount of HDL in circulation. The synthesis of biomimetic HDL nanostructures that replicate the chemical and physical properties of natural HDL provides novel materials for investigating the structure-function relationships of HDL and for potential new therapeutics to combat CHD.
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Affiliation(s)
- Andrea J. Luthi
- Department of Chemistry, Northwestern University, 2145 Sheridan Road, Evanston, IL 60208, USA
| | - Pinal C. Patel
- Interdepartmental Biological Sciences, Northwestern University, 2145 Sheridan Road, Evanston, Il 60203, USA
| | - Caroline H. Ko
- Department of Chemistry, Northwestern University, 2145 Sheridan Road, Evanston, IL 60208, USA
| | - R. Kannan Mutharasan
- Feinberg Cardiovascular Research Institute, Northwestern University, 303 E. Chicago Avenue, Chicago, IL 60611
| | - Chad A. Mirkin
- Department of Chemistry, Northwestern University, 2145 Sheridan Road, Evanston, IL 60208, USA
- International Institute for Nanotechnology, Northwestern University, 2145 Sheridan Road, Evanston, IL 60208, USA
| | - C. Shad Thaxton
- International Institute for Nanotechnology, Northwestern University, 2145 Sheridan Road, Evanston, IL 60208, USA
- Feinberg School of Medicine, Department of Urology, 303 E. Chicago Avenue, Tarry 16-703, Chicago, IL 60611, USA
- Institute for BioNanotechnology and Medicine, Northwestern University, 303 E. Superior, Suite 11-131, Chicago, IL 60611, USA
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Affiliation(s)
- Michael A. Burke
- From the Division of Cardiology, Feinberg Cardiovascular Institute, Northwestern University, Chicago, Ill
| | - R. Kannan Mutharasan
- From the Division of Cardiology, Feinberg Cardiovascular Institute, Northwestern University, Chicago, Ill
| | - Hossein Ardehali
- From the Division of Cardiology, Feinberg Cardiovascular Institute, Northwestern University, Chicago, Ill
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Kobayashi M, Mutharasan RK, Feng J, Roberts MF, Lomasney JW. Identification of Hydrophobic Interactions between Proteins and Lipids: Free Fatty Acids Activate Phospholipase C δ1 via Allosterism. Biochemistry 2004; 43:7522-33. [PMID: 15182194 DOI: 10.1021/bi035966c] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Lipids are well recognized ligands that bind to proteins in a specific manner and regulate their function. Most attention has been placed on the headgroup of phospholipids, and little is known about the role of the acyl chains in mediating any effects of lipids on proteins. In this report, free fatty acids (FFA) were found to bind and activate phospholipase C delta1(PLC delta1). The unsaturated FFA arachidonic acid (AA) and oleic acid were able to stimulate PLC delta1 up to 30-fold in a dose-dependent manner. The saturated FFA stearic acid and palmitic acid were less efficacious than unsaturated FFA, activating the enzyme up to 8-fold. The mechanism of activation appears to be due to a change in K(m) for substrate; 50 microM arachidonate reduced the K(m) for the soluble PLC substrate diC(4)PI from 1.7 +/- 0.6 mM to 0.24 +/- 0.04 mM (7-fold reduction). V(max) was not significantly altered. PLC delta1 bound to sucrose-loaded vesicles that contained AA in a concentration-dependent manner. A fragment of PLC delta1 that encompasses the EF-hand domain also bound to micelles containing AA using nondenaturing PAGE. This same fragment also inhibited AA activation of PLC delta1 in a competition assay. These results suggest that the function of the EF-hand domain of PLC delta1 is to bind lipid and to allosterically regulate catalysis. These results also suggest that esterified and nonesterified fatty acids can bind to and regulate protein function, identifying a functional role for hydrophobic interactions between lipids and proteins.
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Affiliation(s)
- Minae Kobayashi
- Department of Pathology, Northwestern University, The Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, Illinios 60611, USA
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