Search

Introduction: The global pandemic caused by coronavirus (COVID-19) sped up the adoption of telemedicine. We aimed to assess whether factors associated with no-show differed between in-person and telemedicine visits. The focus is on understanding how social economic factors affect patient no-show for the two modalities of visits. Methods: We utilized electronic health records data for outpatient internal medicine visits at a large urban academic medical center, from February 1, 2020 to December 31, 2020. A mixed-effect logistic regression was used. We performed stratified analysis for each modality of visit and a combined analysis with interaction terms between exposure variables and visit modality. Results: A total of 111,725 visits for 72,603 patients were identified. Patient demographics (age, gender, race, income, partner), lead days, and primary insurance were significantly different between the two visit modalities. Our multivariable regression analyses showed that the impact of sociodemographic factors, such as Medicaid insurance (OR 1.23, p < 0.01 for in-person; OR 1.03, p = 0.57 for telemedicine; p < 0.01 for interaction), Medicare insurance (OR 1.11, p = 0.04 for in-person; OR 0.95, p = 0.32 for telemedicine; p = 0.03 for interaction) and Black race (OR 1.36, p < 0.01 for in-person; OR 1.20, p < 0.01 for telemedicine; p = 0.03 for interaction), on increased odds of no-show was less for telemedicine visits than for in-person visits. In addition, inclement weather and younger age had less impact on no-show for telemedicine visits. Discussion: Our findings indicated that if adopted successfully, telemedicine had the potential to reduce no-show rate for vulnerable patient groups and reduce the disparity between patients from different socioeconomic backgrounds. [ABSTRACT FROM AUTHOR]

To satisfy the requirement of low power consumption vehicle computing platform for lane detection, this paper proposes a low computing power dependent real-time lane recognition method. Considering the variation of illumination during vehicle driving, a color separation method based on adaptive illumination to extract lane characteristics is proposed. The effective edge point form is defined and the lane lines are determined by edge point voting based on the classical edge detection and Hough transform algorithm. The lane lines are used to filter and supplement the edge points and the lane curve equation is obtained by using the random sample consensus algorithm. The results show that the proposed method achieves a recognition accuracy of over 98% and computation speed of 38 frames per second on a low power processor. Furthermore, the method has proven to be stable and robust in a variety of scenarios. [ABSTRACT FROM AUTHOR]

Introduction: Telemedicine is increasing in popularity but the impact of this shift on patient outcomes has not been well described. Prior data has shown that early post-discharge office visits can reduce readmissions. However, it is unknown if routine use of telemedicine visits for this purpose is similarly beneficial. Materials and methods: We conducted a retrospective observational study using electronic health records data to assess if the rate of 30-day hospital readmissions differed between modality of visit for primary care or cardiology post-discharge follow-up visits. Results: Compared to discharges with completed in-person follow-up visits, the adjusted odds of readmission for those with telemedicine follow-up visits was not significantly different (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.61 to 1.51, P = 0.86). Conclusions: Our study showed that 30-day readmission rate did not differ significantly according to the modality of visit. These results provide reassurance that telemedicine visits are a safe and viable alternative for primary care or cardiology post-hospitalization follow-up. [ABSTRACT FROM AUTHOR]

Background Depression after acute coronary syndrome (ACS) is common and increases risks of adverse outcomes, but it remains unclear which depression features are most associated with major adverse cardiac events (MACE) and all-cause mortality (ACM). Purpose To examine whether a subtype of depression characterized by anhedonia and major depressive disorder (MDD) predicts 1-year MACE/ACM occurrence in ACS patients compared to no MDD history. We also consider other depression features in the literature as predictors. Methods Patients (N = 1,087) presenting to a hospital with ACS completed a self-report measure of current depressive symptoms in-hospital and a diagnostic interview assessing MDD within 1 week post-hospitalization. MACE/ACM events were assessed at 1-, 6-, and 12-month follow-ups. Cox regression models were used to examine the association of the anhedonic depression subtype and MDD without anhedonia with time to MACE/ACM, adjusting for sociodemographic and clinical covariates. Results There were 142 MACE/ACM events over the 12-month follow-up. The 1-year MACE/ACM in patients with anhedonic depression, compared to those with no MDD, was somewhat higher in an age-adjusted model (hazard ratio [HR] = 1.63, p =.08), but was not significant after further covariate adjustment (HR = 1.24, p =.47). Of the additional depression features, moderate-to-severe self-reported depressive symptoms significantly predicted the risk of MACE/ACM, even in covariate-adjusted models (HR = 1.72, p =.04), but the continuous measure of self-reported depressive symptoms did not. Conclusion The anhedonic depression subtype did not uniquely predict MACE/ACM as hypothesized. Moderate-to-severe levels of total self-reported depressive symptoms, however, may be associated with increased MACE/ACM risk, even after accounting for potential sociodemographic and clinical confounders. [ABSTRACT FROM AUTHOR]

Background: New York State (NYS) has approximately 4.7 million Medicaid beneficiaries with 75% having at least one or more chronic conditions. An estimated 10% of Medicaid beneficiaries seek emergency department (ED) services for nonurgent matters. It is unclear if an increased supply of nurse practitioners (NPs) and physician assistants (PAs) impact utilization of ED and subsequent hospitalizations for chronic conditions. Purpose: To investigate the relationship between NYS workforce supply (physicians, NPs, and PAs) and 1) ED use and 2) in-patient hospitalizations for chronically ill Medicaid beneficiaries. Methods: A cross-sectional study design was employed by calculating total workforce supply per NYS county and the proportion of physicians, NPs, and PAs per total number of Medicaid beneficiaries. We extracted the frequencies of all NYS Medicaid beneficiary chronic condition–related ED visits and in-patient admissions. Medicaid beneficiaries were considered to have a chronic condition if there was a claim indicating that the beneficiary received a service or treatment for this specific condition. We calculated the proportion of ED visits/beneficiary for each chronic disease category and the proportion of category-specific in-patient hospitalizations per the number of beneficiaries with that diagnosis. Results: As the NP/beneficiary proportion increased, ED visits for dual and nondual eligible beneficiaries decreased (p =.007; β = −2.218; 95% confidence interval [CI]: −3.79 to −0.644 and p =.04; β = −2.698; 95% CI: −5.268 to −0.127, respectively). Implications for practice: Counties with a higher proportion of NPs and PAs had significantly lower numbers of ED visits and hospitalizations for Medicaid beneficiaries. [ABSTRACT FROM AUTHOR]

The coronavirus pandemic catalyzed a digital health transformation, placing renewed focus on using remote monitoring technologies to care for patients outside of hospitals. At NewYork-Presbyterian, the authors expanded remote monitoring infrastructure and developed a COVID-19 Hypoxia Monitoring program-a critical means through which discharged COVID-19 patients were followed and assessed, enabling the organization to maximize inpatient capacity at a time of acute bed shortage. The pandemic tested existing remote monitoring efforts, revealing numerous operating challenges including device management, centralized escalation protocols, and health equity concerns. The continuation of these programs required addressing these concerns while expanding monitoring efforts in ambulatory and transitions of care settings. Building on these experiences, this article offers insights and strategies for implementing remote monitoring programs at scale and improving the sustainability of these efforts. As virtual care becomes a patient expectation, the authors hope hospitals recognize the promise that remote monitoring holds in reenvisioning health care delivery. [ABSTRACT FROM AUTHOR]

Legumain, a lysosomal cysteine protease, is critical for pathological progression and has been found to play an important role in the occurrence and development of several cancers. However, its biological functions remain few recognized. To further understand the role of legumain activity in tumor progression, a legumain protease‐responsive fluorescent probe was developed in the present study. The probe 1 was synthesized by conjugating an aminoluciferin fluorophore with an alanine–alanine–asparagine (AAN) peptide sequence. The successful synthesis of probe 1 was validated by NMR and MS spectra as well as HPLC analysis. The probe 1 was non‐toxic and exhibited great stability in the physiological solutions. More importantly, compared with the aminoluciferin fluorophore, the peptide conjugation may dramatically increase the targeting specificity. Probe 1 was able to effectively detect the legumain activity in living HCT116 cells through fluorescence imaging. All these results implied that probe 1 could act as a promising fluorescent probe specialized for the monitoring of legumain activity in living cells. [ABSTRACT FROM AUTHOR]

Current demand for primary care services will soon exceed the primary care provider (PCP) workforce capacity. As patient panel sizes increase, it has become difficult for a single PCP to deliver all recommended care. As a result, provider comanagement of the same patient has emerged in practice. Provider comanagement is defined as two or more PCPs sharing care management responsibilities for the same patient. While physician–physician comanagement of patients has been widely investigated, there is little evidence about nurse practitioner (NP)–physician comanagement. Given the large number of NPs that are practicing in primary care, more evidence is warranted about the PCP perspectives of physicians and NPs comanaging patient care. The purpose of this study was to explore NP–physician comanagement in primary care from the perspectives of PCPs. We conducted in-person qualitative interviews of 26 PCPs, including NPs and physicians, that lasted 25 to 45 minutes, were audio recorded, and then professionally transcribed. Transcripts were deidentified and checked for accuracy prior to a deductive and inductive data analysis. Physicians and NPs reported that comanagement increases adherence to recommended care guidelines, improves quality of care, and increases patient access to care. Effective communication, mutual respect and trust, and a shared philosophy of care are essential attributes of NP–physician comanagement. Physicians and NPs are optimistic about comanagement care delivery and find it a promising approach to improve the quality of care and alleviate primary care delivery strain. Efforts to promote effective NP–physician comanagement should be supported in clinical practice. [ABSTRACT FROM AUTHOR]

The article discusses a study on the increased staffing of registered nurses (RN) within primary care in the U.S. The study obtained perspectives of primary care providers (PCPs) about the use of RNs in primary care. It examined the implementation of team-based care models to expand the access to primary care, reduce cost and improve health care quality.

Background: Medication nonadherence contributes to hospitalizations in recently discharged patients with heart failure (HF). We aimed to test the feasibility of telemonitoring medication adherence in patients with HF.Methods and Results: We randomized 40 patients (1:1) hospitalized for HF to 30 days of loop diuretic adherence monitoring with telephonic support or to passive adherence monitoring alone. Eighty-three percent of eligible patients agreed to participate. The median age of patients was 64 years, 25% were female, and 45% were Hispanic. Overall, 67% of patients were nonadherent (percentage of days that the correct number of doses were taken <88%). There were no differences between intervention and passive monitoring group patients, respectively, in adherence (median correct dosing adherence 82% vs 73%; P = .41) or in the proportion readmitted within 30 days (30% vs 20%; P = .72). Eighty-eight percent of patients rated the wireless electronic adherence device as somewhat or very easy to use, and 88% agreed to use it again.Conclusions: Adherence telemonitoring was acceptable to most patients with HF. Diuretic nonadherence was common even when patients knew they were being monitored. Future studies should assess whether adherence telemonitoring can improve adherence and reduce readmissions among patients with HF. [ABSTRACT FROM AUTHOR]

Objective: Shared decision-making (SDM) is increasingly promoted in the primary care setting, but depressive symptoms, which are associated with cognitive changes, may influence decision-making preferences. We sought to assess whether elevated depressive symptoms are associated with decision-making preference in patients with comorbid chronic illness.Methods: We enrolled 195 patients ≥18years old with uncontrolled hypertension from two urban, academic primary care clinics. Depressive symptoms were assessed using the 8-item Patient Health Questionnaire. Clinician-directed decision-making preference was assessed according to the Control Preference Scale. The impact of depressive symptoms on decision-making preference was assessed using generalized linear mixed models adjusted for age, gender, race, ethnicity, education, Medicaid status, Charlson Comorbidity Index, partner status, and clustering within clinicians.Results: The mean age was 64.2years; 72% were women, 77% Hispanic, 38% Black, and 33% had elevated depressive symptoms. Overall, 35% of patients preferred clinician-directed decision-making, 19% mostly clinician-directed, 39% shared, and 7% some or little clinician-input. Patients with (vs. without) elevated depressive symptoms were more likely to prefer clinician-directed decision-making (46% versus 29%; p=0.02; AOR 2.51, 95% CI 1.30-4.85, p=0.005). Remitted depressive symptoms (vs. never depressed) were not associated with preference.Conclusions: Elevated depressive symptoms are associated with preference for clinician-directed decision-making. We suggest that clinicians should be aware of this effect when incorporating preference into their communication styles and take an active role in eliciting patient values and exchanging information about treatment choice, all important components of shared decision-making, particularly when patients are depressed. [ABSTRACT FROM AUTHOR]

Background: Depression leads to poor health outcomes in patients with coronary heart disease (CHD). Despite guidelines recommending screening and treatment of depressed patients with CHD, few patients receive optimal care. We applied behavioral and implementation science methods to (1) identify generalizable, multilevel barriers to depression screening and treatment in patients with CHD and (2) develop a theory-informed, multilevel implementation strategy for promoting guideline adoption.Methods: We conducted a narrative review of barriers to depression screening and treatment in patients with CHD (ie, medications, exercise, cardiac rehabilitation, or therapy) comprising data from 748 study participants. Informed by the behavior change wheel framework and Expert Recommendations for Implementing Change, we defined multilevel target behaviors, characterized determinants (capability, opportunity, motivation), and mapped barriers to feasible, acceptable, and equitable intervention functions and behavior change techniques to develop a multilevel implementation strategy, targeting health care systems/providers and patients.Results: We identified implementation barriers at the system/provider level (eg, Capability: knowledge; Opportunity: workflow integration; Motivation: ownership) and patient level (eg, Capability: knowledge; Opportunity: mobility; Motivation: symptom denial). Acceptable, feasible, and equitable intervention functions included education, persuasion, environmental restructuring, and enablement. Expert Recommendations for Implementing Change strategies included learning collaborative, audit, feedback, and educational materials. The final multicomponent strategy (iHeart DepCare) for promoting depression screening/treatment included problem-solving meetings with clinic staff (system); educational/motivational videos, electronic health record reminders/decisional support (provider); and a shared decision-making (electronic shared decision-making) tool with several functions for patients, for example, patient activation, patient treatment selection support.Conclusions: We applied implementation and behavioral science methods to identify implementation barriers and to develop a multilevel implementation strategy for increasing uptake of depression screening and treatment in patients with CHD as a use case. The multilevel implementation strategy will be evaluated in a future hybrid II effectiveness-implementation trial. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to determine whether the CHA2 DS2 -VASc score can predict adverse outcomes such as death, ischaemic stroke, and major haemorrhage, in patients with systolic heart failure in sinus rhythm.Methods and Results: CHA2 DS2 -VASc scores were calculated for 1101 patients randomized to warfarin and 1123 patients randomized to aspirin. Adverse outcomes were defined as death or ischaemic stroke, death alone, ischaemic stroke alone, and major haemorrhage. Using proportional hazards models, we found that each 1-point increase in the CHA2 DS2 -VASc score was associated with increased hazard of death or ischaemic stroke events [hazard ratio (HR) for the warfarin arm = 1.21, 95% confidence interval (CI) 1.13-1.30, P < 0.001; for aspirin, HR = 1.20, 95% CI 1.11-1.29, P < 0.001]. Similar increased hazards for higher CHA2 DS2 -VASc scores were observed for death alone, ischaemic stroke alone, and major haemorrhage. Overall performance of the CHA2 DS2 -VASc score was assessed using c-statistics for full models containing the risk score, treatment assignment, and score-treatment interaction, with the c-statistics for the full models ranging from 0.57 for death to 0.68 for major haemorrhage.Conclusions: The CHA2 DS2 -VASc score predicted adverse outcomes in patients with systolic heart failure in sinus rhythm, with modest prediction accuracy. [ABSTRACT FROM AUTHOR]

We sought to determine whether cognitive function in stable outpatients with heart failure (HF) is affected by HF severity. A retrospective, cross-sectional analysis was performed using data from 2, 043 outpatients with systolic HF and without prior stroke enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) Trial. Multivariable regression analysis was used to assess the relationship between cognitive function measured using the Mini-Mental Status Exam (MMSE) and markers of HF severity (left ventricular ejection fraction [LVEF], New York Heart Association [NYHA] functional class, and 6-minute walk distance). The mean (SD) for the MMSE was 28.6 (2.0), with 64 (3.1%) of the 2,043 patients meeting the cut-off of MMSE <24 that indicates need for further evaluation of cognitive impairment. After adjustment for demographic and clinical covariates, 6-minute walk distance (β-coefficient 0.002, p<0.0001), but not LVEF or NYHA functional class, was independently associated with the MMSE as a continuous measure. Age, education, smoking status, body mass index, and hemoglobin level were also independently associated with the MMSE. In conclusion, six-minute walk distance, but not LVEF or NYHA functional class, was an important predictor of cognitive function in ambulatory patients with systolic heart failure. [ABSTRACT FROM AUTHOR]

Background The Coronary Psychosocial Evaluation Studies trial demonstrated promising results for enhanced depression treatment to reduce cardiovascular risk of patients with acute coronary syndrome and comorbid depression, but the long-term effectiveness of this intervention is unclear. Methods A total of 157 participants with persistent depression after hospitalization for acute coronary syndromes were enrolled in the Coronary Psychosocial Evaluation Studies trial. A total of 80 participants were allocated to 6 months of enhanced depression treatment, and 77 participants were allocated to usual care. We report on an additional 12 months of observational follow-up for the composite outcome of death or first hospitalization for myocardial infarction or unstable angina. Results Although the intervention was previously shown to have favorable cardiovascular effects during the treatment period, we observed a significant time-by-treatment group interaction during extended follow-up ( P = .008). Specifically, during the 6-month treatment period, death or hospitalization for myocardial infarction/unstable angina occurred in 3 participants (4%) in the treatment group compared with 11 participants (14%) in the usual care group (hazard ratio, 0.25; 95% confidence interval, 0.07-0.90; P = .03). In contrast, during 12 months of additional observational follow-up, 11 participants (14%) in the treatment group experienced the composite outcome of death or hospitalization for myocardial infarction/unstable angina compared with 3 participants (4%) in the usual care group (hazard ratio, 2.91; 95% confidence interval, 0.80-10.56; P = .10). Conclusions Enhanced depression treatment was associated with a reduced risk of death or hospitalization for myocardial infarction/unstable angina during active treatment, but this effect did not persist after treatment ceased. Future research is needed to confirm our findings and to determine the optimal duration of depression treatment in patients with depression after acute coronary syndromes. [ABSTRACT FROM AUTHOR]

Background: Many acute coronary syndrome (ACS; myocardial infarction and unstable angina) patients are rehospitalized within 30 days of discharge, and recent US health policy initiatives have tied hospital Medicare reimbursement to 30-day readmission rates. Patient-perceived psychological stress is thought to impact prognosis after ACS. A recently offered “posthospital syndrome” model of 30-day readmissions posits that the stress level at the time of the index hospitalization itself may increase 30-day risk for readmission in ACS patients. We tested whether self-reported stress in the days surrounding the ACS hospitalization was associated with increased risk for readmission within 30 days. Methods: A mean of 8.5 days after discharge, 342 consecutively hospitalized ACS patients reported on how often they felt stress during the past two weeks. Readmission within 30 days of hospital discharge for any cause was determined by follow-up telephone calls to patients and confirmed by hospital records. Results: Overall, 40 (11.7%) participants were readmitted within 30 days, and 22 (6.4%) reported high stress. Readmission within 30 days was more common in patients with high stress (5 admissions, 23%) than in patients with low stress (35 admissions, 11%). After adjustment for demographic and clinical factors, as well as depression, high stress was associated with a 3-fold increased risk of 30-day readmission (HR = 3.21, 95% CI = 1.13, 9.10). Conclusions: Previous research has shown that stress in the days surrounding a hospitalization can mark long-term cardiovascular risk, but this is the first study to test a hypothesis of the posthospital syndrome model of early readmission. Further research is needed to confirm the association between stress and readmission risk, and to identify the processes of hospitalization that could be modified to both reduce the stress experienced and that would also be effective for reducing readmissions. [ABSTRACT FROM AUTHOR]

Abstract: Approximately 50% of patients with cardiovascular disease and/or its major risk factors have poor adherence to their prescribed medications. Finding novel methods to help patients improve their adherence to existing evidence-based cardiovascular drug therapies has enormous potential to improve health outcomes while potentially reducing health care costs. The goal of this report is to provide a review of the current understanding of adherence to cardiovascular medications from the point of view of prescribing clinicians and cardiovascular researchers. Key topics addressed include: 1) definitions of medication adherence; 2) prevalence and impact of non-adherence; 3) methods for assessing medication adherence; 4) reasons for poor adherence; and 5) approaches to improving adherence to cardiovascular medications. For each of these topics, the report seeks to identify important gaps in knowledge and opportunities for advancing the field of cardiovascular adherence research. [Copyright &y& Elsevier]

Objectives: The aim of this study was to determine whether behavioral mechanisms explain the association between depressive symptoms and myocardial infarction (MI) or death in individuals with coronary heart disease (CHD). Background: Depressive symptoms are associated with increased morbidity and mortality in individuals with CHD, but it is unclear how much behavioral mechanisms contribute to this association. Methods: The study included 4,676 participants with a history of CHD. Elevated depressive symptoms were defined as scores ≥4 on the Center for Epidemiologic Studies Depression 4-item Scale. The primary outcome was definite/probable MI or death from any cause. Incremental proportional hazards models were constructed by adding demographic data, comorbidities, and medications and then 4 behavioral mechanisms (alcohol use, smoking, physical inactivity, and medication non-adherence). Results: At baseline, 638 (13.6%) participants had elevated depressive symptoms. Over a median 3.8 years of follow up, 125 of 638 (19.6%) participants with and 657 of 4,038 (16.3%) without elevated depressive symptoms had events. Higher risk of MI or death was observed for elevated depressive symptoms after adjusting for demographic data (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.15 to 1.72) but was no longer significant after adjusting for behavioral mechanisms (HR: 1.14, 95% CI: 0.93 to 1.40). The 4 behavioral mechanisms together significantly attenuated the risk for MI or death conveyed by elevated depressive symptoms (−36.9%, 95% CI: −18.9 to −119.1%), with smoking (−17.6%, 95% CI: −6.5% to −56.0%) and physical inactivity (−21.0%, 95% CI: −9.7% to −61.1%) having the biggest explanatory roles. Conclusions: Our findings suggest potential roles for behavioral interventions targeting smoking and physical inactivity in patients with CHD and comorbid depression. [ABSTRACT FROM AUTHOR]

Coronary heart disease (CHD) and depression are both highly prevalent in women. Importantly, depression is associated with significantly elevated morbidity and mortality in women with CHD. There are intriguing speculations about biological mechanisms underlying this association, such as endothelial dysfunction, subclinical atherosclerosis, inflammation, and autonomic dysregulation. Social and behavioral mechanisms, such as lack of social support and physical inactivity, have also been shown to play important roles. Unfortunately, many randomized clinical trials of counseling and pharmacologic interventions for depression in patients with CHD have failed to improve cardiovascular outcomes, and in fact have raised the possibility that interventions might be harmful in women. Several recent trials of new treatment strategies, however, have been more effective in improving depressive symptoms and quality of life and deserve further investigation. In this review, we summarize recent findings with regards to the epidemiology, etiology, diagnosis, and management of depression in women diagnosed with CHD. [ABSTRACT FROM AUTHOR]