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Background: The United States lacks a timely and accurate nationwide surveillance system for acute ischemic stroke (AIS). We use the Get With The Guidelines-Stroke registry to apply poststratification survey weights to generate national assessment of AIS epidemiology, hospital care quality, and in-hospital outcomes. Methods: Clinical data from the Get With The Guidelines-Stroke registry were weighted using a Bayesian interpolation method anchored to observations from the national inpatient sample. To generate a US stroke forecast for 2019, we linearized time trend estimates from the national inpatient sample to project anticipated AIS hospital volume, distribution, and race/ethnicity characteristics for the year 2019. Primary measures of AIS epidemiology and clinical care included patient and hospital characteristics, stroke severity, vital and laboratory measures, treatment interventions, performance measures, disposition, and clinical outcomes at discharge. Results: We estimate 552 476 patients with AIS were admitted in 2019 to US hospitals. Median age was 71 (interquartile range, 60–81), 48.8% female. Atrial fibrillation was diagnosed in 22.6%, 30.2% had prior stroke/transient ischemic attack, and 36.4% had diabetes. At baseline, 46.4% of patients with AIS were taking antiplatelet agents, 19.2% anticoagulants, and 46.3% cholesterol-reducers. Mortality was 4.4%, and only 52.3% were able to ambulate independently at discharge. Performance nationally on AIS achievement measures were generally higher than 95% for all measures but the use of thrombolytics within 3 hours of early stroke presentations (81.9%). Additional quality measures had lower rates of receipt: dysphagia screening (84.9%), early thrombolytics by 4.5 hours (79.7%), and statin therapy (80.6%). Conclusions: We provide timely, reliable, and actionable US national AIS surveillance using Bayesian interpolation poststratification weights. These data may facilitate more targeted quality improvement efforts, resource allocation, and national policies to improve AIS care and outcomes.

Author(s): Seo, Young-Ji; Sareh, Sohail; Hadaya, Joseph; Sanaiha, Yas; Ziaeian, Boback; Shemin, Richard J; Benharash, Peyman | Abstract: BackgroundLack of consensus remains about factors that may be associated with high resource use (HRU) in adult cardiac surgical patients. This study aimed to identify patient-related, hospital, and perioperative characteristics associated with HRU admissions involving elective cardiac operations.MethodsData from the National Inpatient Sample was used to identify patients who underwent coronary artery bypass graft, valve replacement, and valve repair operations between 2005 and 2016. Admissions with HRU were defined as those in the highest decile for total hospital costs. Multivariable regressions were used to identify factors associated with HRU.ResultsAn estimated 1,750,253 hospitalizations coded for elective cardiac operations. The median hospitalization cost was $34,700 (interquartile range, $26,800- to $47,100), with the HRU (Nn= 175,025) cutoff at $66,029. Although HRU patients comprised 10% of admissions, they accounted for 25% of cumulative costs. On multivariable regression, patient-related characteristics predictive of HRU included female sex, older age, higher comorbidity burden, non-White race, and highest income quartile. Hospital factors associated with HRU were low-volume hospitals for both coronary artery bypass graft and valvular operations. Among postoperative outcomes, mortality, infectious complications, extracorporeal membrane oxygenation use, and hospitalization for more than 8 days were associated with greater odds of HRU.ConclusionsIn this nationwide study of elective cardiac surgical patients, several important patient-related and hospital factors, including patients' race, comorbidities, postoperative infectious complications, and low hospital operative volume were identified as predictors of HRU. These highly predictive factors may be used for benchmarking purposes and improvement in surgical planning.

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Background The objective of this study was to characterize practical use trends and outcomes for intraaortic balloon pump (IABP) and percutaneous left ventricular assist device (pVAD) use in cardiogenic shock at a national level. Methods An analysis of all adult patients admitted nonelectively for cardiogenic shock from January 2008 through December 2017 was performed using the National Inpatient Sample. Trends of inpatient IABP and pVAD use were analyzed using survey-weighted estimates and the modified Cochran-Armitage test for significance. Multivariable regression models and inverse probability of treatment weights were used to perform risk-adjusted analyses of pVAD mortality, a composite of adverse events (AE), and resource use, with IABP as reference. Results Of an estimated 774,310 patients admitted with cardiogenic shock, 143,051 received a device: IABP, 127,792 (16.5%); or pVAD, 15,259 (2.0%). IABP use decreased (23.8% to 12.7%; P for trend Conclusions Over the study period, the rate of pVAD use for cardiogenic shock significantly increased. Compared with IABP, pVAD use was associated with increased mortality, higher costs, and several AEs. Multi-institutional clinical trials with rigorous inclusion criteria are warranted to evaluate the clinical utility of pVADs in the modern era.

Objective: To analyze the cardiovascular disease (CVD) burden in hospitalized patients with a diagnosis of coronavirus from the pre–coronavirus disease 2019 era in the United States. Patients and Methods: We identified hospitalized adults with a diagnosis of coronavirus in a large US administrative database, the National (Nationwide) Inpatient Sample, from January 1, 2016, to December 3, 2017, to study patient demographic characteristics, clinical comorbidities, and outcomes (in-hospital mortality and health care resource utilization) based on the presence or absence of CVD. Results: A total of 21,300 hospitalized adults with a diagnosis of coronavirus in 2016 and 2017 from all across the United States were included in the final analysis; the mean age was 63.6 years, 11,033 (51.8%) were female, and 15,911 (74.7%) had public insurers. Among these hospitalized patients, 11,930 (56.0%) had a diagnosis of CVD. Compared with those without CVD, the patients with CVD were older (70.1 vs 55.4 years) and had higher Charlson comorbidity index scores (2.5 vs 1.6) and Elixhauser comorbidity index scores (4.3 vs 2.4) (all P

Heart failure is a leading diagnosis for hospitalization with a high risk of readmission. Despite robust data and recommendations by professional societies, there is a well-documented gap in delivering guideline-directed medical therapy (GDMT) known to reduce hospitalizations and improve mortality for patients with heart failure with reduced ejection fraction (HFrEF). The Dashboard Activated Services and Telehealth for HF (DASH-HF) is a quality improvement initiative to evaluate the effectiveness of proactive population management clinics to optimize use and dosing of GDMT for patients with HFrEF relative to usual care. The study utilizes the existing Veterans Affairs Academic Detailing HF Dashboard to target actionable patients (n=300) with a low optimization potential score (OPS) (Table 1). The intervention clinics utilize multidisciplinary providers (e.g., physicians, pharmacists) to perform chart review and telemedicine visits to address opportunities to optimize GDMT. The primary outcome of the study is the OPS 6 months after the end of the intervention, defined by active prescriptions and prescribed doses for each class of GDMT. Secondary outcomes include differences in hospitalizations and mortality and measures of health service efficiency such as patients contacted per clinic. The intervention duration was September to December 2021, and analysis is planned for June 2022. This is a unique study to systematically identify HFrEF patients with the largest gaps in GDMT and proactively engage with this group. We describe the study design for identifying target patients, logistics of the intervention, patient characteristics, and an overview of barriers faced during the intervention. The Coronavirus disease 2019 pandemic has led to a marked increase in telehealth services. If successful, this study may serve as a key pilot trial for more robust telehealth delivery, targeting patients at highest risk for HF-related hospitalizations and mortality.

BackgroundThe sex differences in use, safety outcomes, and health-care resource use of patients with pulmonary embolism (PE) undergoing percutaneous pulmonary artery thrombectomy are not well characterized.Research questionWhat are the sex differences in outcomes for patients diagnosed with PE who undergo percutaneous pulmonary artery thrombectomy?Study design and methodsThis retrospective cross-sectional study used national inpatient claims data to identify patients in the United States with a discharge diagnosis of PE who underwent percutaneous thrombectomy between January 2016 and December 2018. We evaluated the demographics, comorbidities, safety outcomes (in-hospital mortality), and health-care resource use (discharge to home, length of stay, and hospital charges) of patients with PE undergoing percutaneous thrombectomy.ResultsAmong 1,128,904 patients with a diagnosis of PE between 2016 and 2018, 5,160 patients (0.5%) underwent percutaneous pulmonary artery thrombectomy. When compared with male patients, female patients showed higher procedural bleeding (16.9%vs11.2%; P< .05), required more blood transfusions (11.9%vs5.7%; P< .05), and experienced more vascular complications (5.0%vs1.5%; P< .05). Women experienced higher in-hospital mortality (16.9%vs9.3%; adjusted OR, 1.9; 95%CI, 1.2-3.0; P= .003) when compared with men. Although length of stay and hospital charges were similar to those of men, women were less likely to be discharged home after surviving hospitalization (47.9%vs60.3%; adjusted OR, 0.7; 95%CI, 0.50-0.99; P= .04).InterpretationIn this large nationwide cohort, women with PE who underwent percutaneous thrombectomy showed higher morbidity and in-hospital mortality compared with men.

Author(s): Heidenreich, Paul A; Fonarow, Gregg C; Breathett, Khadijah; Jurgens, Corrine Y; Pisani, Barbara A; Pozehl, Bunny J; Spertus, John A; Taylor, Kenneth G; Thibodeau, Jennifer T; Yancy, Clyde W; Ziaeian, Boback

Takotsubo cardiomyopathy (TC) is associated with significant short-term morbidity and mortality. Several risk factors for poor outcomes have been identified; however, the prognostic implications of pre-existing comorbidity in TC are poorly delineated. We sought to assess the association of aggregate pre-existing comorbidity with short-term outcomes in TC. We performed a retrospective observational study of adult subjects diagnosed with TC at two academic tertiary care hospitals between 2005 and 2018. Overall burden of medical comorbidity was estimated using the Charlson comorbidity index (CCI). Multivariable logistic regression was used to test for independent association of CCI with 30-day mortality and severe shock at index presentation. Multivariable poisson regression was performed to assess the association of CCI with duration of hospitalization. Five-hundred and thirty-eight subjects were diagnosed with TC during the study period. The median CCI score of all subjects was 2 (IQR 1-4). Among subjects with physical triggers of TC, the median CCI score was 2 (IQR 1-4) compared to a median CCI score of 1 (IQR 0-1) in subjects with non-physical triggers of TC (P

Author(s): Wong, Michelle S; Steers, W Neil; Hoggatt, Katherine J; Ziaeian, Boback; Washington, Donna L | Abstract: ObjectiveTo examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation.Data sourcesElectronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census.Study designRacial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions.Principal findingsMortality disparities existed for AI/ANs (HRn=n1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (Pn=n.047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations.ConclusionsNeighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention.

ObjectiveTo evaluate the adoption and discontinuation of four broadly used non-pharmaceutical interventions on shifts in the covid-19 burden among US states.DesignRetrospective, observational cohort study.SettingUS state data on covid-19 between 19 January 2020 and 7 March 2021.ParticipantsUS population with a diagnosis of covid-19.Main outcome measuresEmpirically derived breakpoints in case and mortality velocities (ie, rate of change) were used to identify periods of stable, decreasing, or increasing covid-19 burden. Associations between adoption of non-pharmaceutical interventions and subsequent decreases in case or death rates were estimated by use of generalised linear models accounting for weekly variability across US states. State level case and mortality counts per day were obtained from the Covid-19 Tracking Project. State level policies on non-pharmaceutical interventions included stay-at-home orders, indoor public gathering bans (mild >10 or severe ≤10 people), indoor restaurant dining bans, and public mask mandates. National policies were not included in statistical models.Results28 602 830 cases and 511 899 deaths were recorded during the study. Odds of a reduction in covid-19 case velocity increased for stay-at-home orders (odds ratio 2.02, 95% confidence interval 1.63 to 2.52), indoor dining bans (1.62, 1.25 to 2.10), public mask mandates (2.18, 1.47 to 3.23), and severe indoor public gathering bans (1.68, 1.31 to 2.16) in univariate analysis. In mutually adjusted models, odds remained elevated for orders to stay at home (adjusted odds ratio 1.47, 95% confidence interval 1.04 to 2.07) and public mask mandates (2.27, 1.51 to 3.41). Stay-at-home orders (odds ratio 2.00, 95% confidence interval 1.53 to 2.62; adjusted odds ratio 1.89, 95% confidence interval 1.25 to 2.87) was also associated with a greater likelihood of decrease in death velocity in unadjusted and adjusted models.ConclusionsState level non-pharmaceutical interventions used in the US during the covid-19 pandemic, in particular stay-at-home orders, were associated with a decreased covid-19 burden.

With rising United States health care expenditure, estimating current spending for patients with heart failure (HF) informs the value of preventative health interventions.The purpose of this study was to estimate current health care expenditure growth for patients with HF in the United States.The authors pooled MEPS (Medical Expenditure Panel Survey) data from 2009-2018 to calculate total HF-related expenditure across clinical settings in the United States. A 2-part model adjusted for demographics, comorbidities, and year was used to estimate annual mean and incremental expenditures associated with HF.In the United States, an average of $28,950 (2018 inflation-adjusted dollars) is spent per year for health care-related expenditure for individuals with HF compared with $5,727 for individuals without HF. After adjusting for demographics and comorbidities, a diagnosis of HF was associated with $3,594 in annual incremental expenditure compared with those without HF. HF-related expenditure increased from $26,864 annual per person in 2009-2010 to $32,955 in 2017-2018, representing a 23% rise over 10 years. In comparison, expenditure on myocardial infarction, type 2 diabetes mellitus, and cancer grew by 16%, 28%, and 16%, respectively. Most of the cost was related to hospitalization: $12,569 per year. Outpatient office-based care and prescription medications saw the greatest growth in cost over the period, 41% and 24%, respectively. Estimated incremental national expenditure for HF per year was $22.3 billion; total annual expenditure for adults with HF was $179.5 billion.HF is a costly condition for which expenditure is growing faster than that of other chronic conditions.

There are gaps in the use of therapies that save lives and improve quality of life for patients with heart failure with reduced ejection fraction, both in the US and abroad. The evidence is clear that initiation and titration of guideline-directed medical therapy (GDMT) and comprehensive disease-modifying medical therapy (CDMMT) to maximally tolerated doses improves patient-focused outcomes, yet observational data suggest this does not happen. The purpose of this review is to describe the gap in the use of optimal treatment worldwide and discuss the benefits of newer heart failure therapies including angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter 2 inhibitors. It will also cover the efficacy and safety of such treatments and provide potential pathways for the initiation and rapid titration of GDMT/CDMMT.

Background: Little data exists describing the national burden of supraventricular tachycardia (SVT) related hospitalizations on US healthcare system. The objectives of this study are to examine the temporal trends of SVT-related hospitalizations in the United States and to compare patient characteristics, outcomes, and comorbid diagnoses. Methods: Using the Nationwide Readmission Database from 2010 through 2017, we identified adult (age >17 years) SVT-related hospitalizations using International Classification of Diseases, 9 th /10th Revision, Clinical Modification codes- 427.0/I47.1 as the principal discharge diagnosis. Results: There were 192,853 adult hospitalizations for SVT from 2010 to 2017 across United States. The number of hospitalizations increased from 22,313 in 2010 to 39,216 in 2017. Mean age was 63.9 years, 56.8% females and 55.8% Medicare insured. The proportion of comorbid diagnoses in overall cohort: hypertension 66.4%, diabetes 26.9%, hyperlipidemia 42.8%, coronary artery disease 31.6%, atrial fibrillation 30.0%, cerebrovascular disease 3.4%, renal disease 18.8%, liver disease 4.2% and chronic pulmonary disease 14.7%. From 2010 to 2017, following trends were observed: mean age (63.7 years to 64.1 years), females (59.5% to 54.4%), Medicare insured (53.8% to 57.0%), hypertension (62.2% to 70.0%), diabetes (25.3% to 27.5%), hyperlipidemia (39.6% to 45.0%), coronary artery disease (28.6% to 34.8%), cerebrovascular disease (3.0% to 3.3%), renal disease (12.9% to 23.0%), liver disease (4.5% to 2.8%) and chronic pulmonary disease (13.0% to 16.4%). The overall unadjusted in-hospital mortality was 0.6% and mean length of stay was 3.0 days. The trends of mortality and length of stay changed as follows: 0.5% in 2010 to 0.6% in 2017 and 2.9 days to 3.1 days respectively. Mean hospital charges (in USD) were 40,943 and increased from 31,755 in 2010 to 47,830 in 2017. Conclusions: The number of hospitalizations for SVT have increased among US adults from 2010 to 2017. The proportion of comorbid chronic diseases, in-hospital mortality and the hospitalization charges also increased during the period of analysis.

BackgroundCOVID-19 rapidly accelerated the implementation of telemedicine in U.S. Department of Veterans Affairs (VA) specialty care clinics. This mixed-methods study was conducted at a VA medical center to understand the use of telemedicine, and the barriers and facilitators to its implementation, in cardiology outpatient clinics.MethodsQuantitative analyses modeled monthly trends of telemedicine use over 24-months (March 2019-March 2021) with segmented logistic regression and adjusted for socio-demographic predictors of patient-level telemedicine use. Qualitative interviews were conducted (July-October 2020) with eight cardiology clinicians.ResultsAt the onset of COVID-19, likelihood of telemedicine use was ∼12 times higher than it was pre-COVID-19 (p

Author(s): Turgeon, Ricky D; Althouse, Andrew D; Cohen, Jordana B; Enache, Bogdan; Hogenesch, John B; Johansen, Michael E; Mehta, Raj; Meyerowitz-Katz, Gideon; Ziaeian, Boback; Hiremath, Swapnil

BackgroundGaps in the receipt and dosing of guideline-directed medical therapy (GDMT) persist for patients with heart failure with reduced ejection fraction (HFrEF) [1]. In 2020, the Veterans Affairs (VA) developed a heart failure (HF) specific population dashboard to monitor care quality and performance on standard HFrEF performance measures [2].MethodsThe Dashboard Activated Services and Telehealth for HF (DASH-HF) study is a pragmatic randomized quality improvement study designed to evaluate the utility of proactive population management clinics using the VA's HF dashboard to optimize GDMT for patients with HFrEF. Panel management telemedicine clinics incorporated multidisciplinary clinicians to perform chart review and impromptu telephone encounters to evaluate current HFrEF management and opportunities to optimize GDMT. The study will evaluate the efficacy of proactive panel management to usual care at 6months as quantified by the GDMT optimization potential score. Secondary outcomes include hospitalizations, mortality, and clinician time per intervention. The study completed enrollment and randomization of 300 participants. The intervention was performed from September to December 2021.ConclusionDASH-HF will contribute to the literature by evaluating use of the existing VA dashboard to identify HF patients with the lowest adherence to GDMT and proactively target this group for the intervention.Registrationhttps://clinicaltrials.gov/. Unique identifier: NCT05001165.

Gregg C. Fonarow, MD, FACC, FAHA, Chair [∗][1] Biykem Bozkurt, MD, PhD, FACC[∗][1] Sandeep Das, MD, MPH[∗][1] Michael E. Hall, MD, MS, FAHA, FACC[∗][1] Hani Jneid, MD, FACC, FAHA[∗][1] Corrine Y. Jurgens, PhD, RN, ANP-BC, FAHA[∗][1],[†][2] Patricia Keegan, DNP, APRN, NP-C[‡][3

Cardiac beriberi, or heart failure due to thiamine deficiency, is considered rare in the developed world. The diagnosis is often only considered in limited populations such as those with chronic alcoholism. Alternatively, the disease can be mislabeled as “alcoholic cardiomyopathy” or “nonischemic cardiomyopathy.” The following 2 cases illustrate the need to expand our vigilance to other at-risk populations.

Patients with renal dysfunction are at increased risk for developing aortic valve pathology. In the present era of value-based healthcare delivery, a comparison of transcatheter and surgical aortic valve replacement (SAVR) readmission performance in this population is warranted. All adult patients who underwent transcatheter or SAVR from 2011 to 2014 were identified using the Nationwide Readmissions Database, containing data for nearly 50% of US hospitalizations. Patients were further stratified as chronic kidney disease stage 1 to 5 as well as end-stage renal disease requiring dialysis. Kaplan-Meier, Cox Hazard, and multivariable regression models were generated to identify predictors of readmission and costs. Of the 350,609 isolated aortic valve replacements, 4.7% of patients suffered from chronic kidney disease stages 1 to 5 or end-stage renal disease. Transcatheter aortic valve patients with chronic kidney disease stages 1 to 5/or end-stage renal disease were older (81.9 vs 72.9 years, p

Background Cardiovascular electronic consultation is a new service line in consultative medicine and enables care without in-person office visits. We aimed to evaluate accessibility and time saved as measures of efficiency, determine the safety of cardiology electronic consultations, and assess satisfaction by responding cardiologists. Methods Using a mixed-methods approach and a modified time-driven, activity-based, costing framework, we retrospectively analysed cardiology electronic consultations. A random subset of 500 electronic consultations referred between 2013–2017 were reviewed. Accessibility was determined based upon increased number of patients served without the need for an in-person clinic visit. To assess safety, medical records were reviewed for emergency room visits or hospital admission at six months from the initial electronic consultation date. Responding cardiologist satisfaction was assessed by voluntary completion of an online survey. Results The majority of electronic consultations were related to medication advice, clearance for surgery, evaluation of images, or guidance after abnormal testing. Recommendations included echo (10.8%), stress testing (5.0%), other imaging (4.0%) and other subspecialist referrals (3.8%). Electronic consultations were completed within 0.7±0.5 days of the request, with a time to completion of 5–30 min. Over a six-month follow-up, 13.9% of patients had an in-person visit and 2.2% of patients were hospitalised, but none were directly related to the electronic consultation question. Satisfaction by responding cardiologists was modest. Conclusion In conclusion, within a single-payer system, cardiology electronic consultations represent a convenient and safe alternative for providing consultative cardiovascular care, but further optimization is necessary to minimise electronic consultation fatigue experienced by cardiologists.

BackgroundPatients admitted with cardiogenic shock (CS) have high mortality rates, readmission rates, and healthcare costs. Palliative care services (PCS) may be underused, and the association with 30-day readmission and other predictive factors is unknown. We studied the frequency, etiologies, and predictors of 30-day readmission in CS admissions with and without PCS in the United States.Methods and resultsUsing the 2017 Nationwide Readmissions Database, we identified admissions for (1) CS, (2) CS with PCS, and (3) CS without PCS. We compared differences in outcomes and predictors of readmission using multivariable logistic regression analysis accounting for survey design. Of 133,738 CS admissions nationally in 2017, 36.3% died inpatient. Among those who survived, 8.6% used PCS and 21% were readmitted within 30 days. Difference between CS with and without PCS groups included mortality (72.8% vs 27%), readmission rate (11.6% vs 21.9%), most frequent discharge destination (50.2% skilled nursing facilities vs 36.4% home), hospitalization cost per patient ($51,083 ± $2,629 vs $66,815 ± $1,729). The primary readmission diagnoses for both groups were heart failure (32.1% vs 24.4%). PCS use was associated with lower rates of readmission (odds ratio, 0.462; 95% confidence interval, 0.408-0.524; P < .001). Do-not-resuscitate status, private pay, self-pay, and cardiac arrest were negative predictors, and multiple comorbidities was a positive predictor of readmission.ConclusionsThe use of PCS in CS admissions remains low at 8.6% in 2017. PCS use was associated with lower 30-day readmission rates and hospitalization costs. PCS are associated with a decrease in future acute care service use for critically ill cardiac patients but underused for high-risk cardiac patients.

Author(s): Dixit, Neal M; Shah, Shivani; Ziaeian, Boback; Fonarow, Gregg C; Hsu, Jeffrey J | Abstract: Heart failure remains a huge societal concern despite medical advancement, with an annual direct cost of over $30 billion. While guideline-directed medical therapy (GDMT) is proven to reduce morbidity and mortality, many eligible patients with heart failure with reduced ejection fraction (HFrEF) are not receiving one or more of the recommended medications, often due to suboptimal initiation and titration in the outpatient setting. Hospitalization serves as a key point to initiate and titrate GDMT. Four evidence-based therapies have clinical benefit within 30 days of initiation and form a crucial foundation for HFrEF therapy: renin-angiotensin-aldosterone system inhibitors with or without a neprilysin inhibitor, β-blockers, mineralocorticoid-receptor-antagonists, and sodium-glucose cotransporter-2 inhibitors. The authors present a practical guide for the implementation of these four pillars of GDMT during a hospitalization for acute heart failure.

BACKGROUND At the onset of the COVID-19 pandemic, there was a rapid increase in the use of telehealth services at the US Department of Veterans Affairs (VA), which was accelerated by state and local policies mandating stay-at-home orders and restricting nonurgent in-person appointments. Even though the VA was an early adopter of telehealth in the late 1990s, the vast majority of VA outpatient care continued to be face-to-face visits through February 2020. OBJECTIVE We compared telehealth service use at a VA Medical Center, Greater Los Angeles across 3 clinics (primary care [PC], cardiology, and home-based primary care [HBPC]) 12 months before and 12 months after the onset of COVID-19 (March 2020). METHODS We used a parallel mixed methods approach including simultaneous quantitative and qualitative approaches. The distribution of monthly outpatient and telehealth visits, as well as telephone and VA Video Connect encounters were examined for each clinic. Semistructured telephone interviews were conducted with 34 staff involved in telehealth services within PC, cardiology, and HBPC during COVID-19. All audiotaped interviews were transcribed and analyzed by identifying key themes. RESULTS Prior to COVID-19, telehealth use was minimal at all 3 clinics, but at the onset of COVID-19, telehealth use increased substantially at all 3 clinics. Telephone was the main modality of patient choice. Compared with PC and cardiology, video-based care had the greatest increase in HBPC. Several important barriers (multiple steps for videoconferencing, creation of new scheduling grids, and limited access to the internet and internet-connected devices) and facilitators (flexibility in using different video-capable platforms, technical support for patients, identification of staff telehealth champions, and development of workflows to help incorporate telehealth into treatment plans) were noted. CONCLUSIONS Technological issues must be addressed at the forefront of telehealth evolution to achieve access for all patient populations with different socioeconomic backgrounds, living situations and locations, and health conditions. The unprecedented expansion of telehealth during COVID-19 provides opportunities to create lasting telehealth solutions to improve access to care beyond the pandemic.

Author(s): Basir, Mir B; Pinto, Duane S; Ziaeian, Boback; Khandelwal, Akshay; Cowger, Jennifer; Suh, William; Althouse, Andrew | Abstract: BackgroundAcute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is associated with significant morbidity and mortality.MethodsWe provide an overview of previously conducted studies on the use of mechanical circulatory support (MCS) devices in the treatment of AMI-CS and difficulties which may be encountered in conducting such trials in the United States.ResultsWell powered randomized control trials are difficult to conduct in a critically ill patient population due to physician preferences, perceived lack of equipoise and challenges obtaining informed consent.ConclusionsWith growth in utilization of MCS devices in patients with AMI-CS, efforts to perform well-powered, randomized control trials must be undertaken.

Author(s): Agarwal, Manyoo A; Fonarow, Gregg C; Ziaeian, Boback | Abstract: ImportancePrevious studies have described the secular trends of overall heart failure (HF) hospitalizations, but the literature describing the national trends of unique index hospitalizations and readmission visits for the primary management of HF is lacking.ObjectivesTo examine contemporary overall and sex-specific trends of unique primary HF (grouped by number of visits for the same patient in a given year) and 30-day readmission visits in a large national US administrative database from 2010 to 2017.Design, setting, and participantsThis cohort study used data from all adult hospitalizations in the Nationwide Readmission Database from January 1, 2010, to December 31, 2017, with a primary diagnosis of HF. Data analyses were conducted from March to November 2020.ExposuresAdmission for a primary diagnosis of HF at discharge.Main outcomes and measuresUnique and overall hospitalizations with a primary diagnosis of HF and postdischarge readmissions. Unique primary HF hospitalizations were grouped by number of visits for the same patient in a given year.ResultsThere were 8 273 270 primary HF hospitalizations with a single primary HF admission present in 5 092 626 unique patients, and 1 269 109 had 2 or more HF hospitalizations. The mean age was 72.1 (95% CI, 72.0-72.3) years, and 48.9% (95% CI, 48.7-49.0) were women. The primary HF hospitalization rates per 1000 US adults declined from 4.4 in 2010 to 4.1 in 2013 and then increased from 4.2 in 2014 to 4.9 in 2017. The rates per 1000 US adults for postdischarge HF readmissions (1.0 in 2010 to 0.9 in 2014 to 1.1 in 2017) and all-cause 30-day readmissions (0.8 in 2010 to 0.7 in 2014 to 0.9 in 2017) had similar trends.Conclusions and relevanceIn this analysis of a nationally representative administrative data set, for primary HF admissions, crude rates of overall and unique patient hospitalizations declined from 2010 to 2014 followed by an increase from 2014 to 2017. Additionally, readmission visits after index HF hospitalizations followed a similar trend. Future studies are needed to verify these findings to improve policies for HF management.

Background The U.S. lacks a stroke surveillance system. This study develops a method to transform an existing registry into a nationally representative database to evaluate acute ischemic stroke care quality. Methods Two statistical approaches are used to develop post-stratification weights for the Get With The Guidelines-Stroke registry by anchoring population estimates to the National Inpatient Sample. Post-stratification survey weights are estimated using a raking procedure and Bayesian interpolation methods. Weighting methods are adjusted to limit the dispersion of weights and make reasonable epidemiologic estimates of patient characteristics, quality of hospital care, and clinical outcomes. Standardized differences in national estimates are reported between the two post-stratification methods for anchored and non-anchored patient characteristics to evaluate estimation quality. Primary measures evaluated are patient and hospital characteristics, stroke severity, vital and laboratory measures, disposition, and clinical outcomes at discharge. Results A total of 1,388,296 acute ischemic strokes occurred between 2012 and 2014. Raking and Bayesian estimates of clinical data not available in administrative data are estimated within 5 to 10% of margin for expected values. Median weight for the raking method is 1.386 and the weights at the 99th percentile is 6.881 with a maximum weight of 30.775. Median Bayesian weight is 1.329 and the 99th percentile weights is 11.201 with a maximum weight of 515.689. Conclusions Leveraging existing databases with patient registries to develop post-stratification weights is a reliable approach to estimate acute ischemic stroke epidemiology and monitoring for stroke quality of care nationally. These methods may be applied to other diseases or settings to better monitor population health.

Background Telemedicine and telemonitoring have become invaluable tools in managing chronic diseases, such as heart failure (HF). With the recent pandemic, telemedicine has become the preferred method of providing consultative care. Local problem This rapid paradigm shift from face-to-face (F2F) consultations to telemedicine required a collaborative approach for successful implementation while maintaining quality of care. The processes for conducting a telemedicine visit for HF patient are not well defined or outlined. Method Using a collaborative practice model and nurse practitioner led program, technology was leveraged to manage the high-risk HF population using virtual care (consultation via phone or video-to-home) with two aims: first to provide ongoing HF care using available telemedicine technologies or F2F care when necessary and, second, to evaluate and direct those needing urgent/emergent level of care to emergency department (ED). Intervention The process was converted into an intuitive algorithm that describes essential elements and team roles necessary for execution of a successful HF consultation. Results Following the algorithm, nurse practitioners conducted 132 visits, yielding 100% success in the conversion of F2F appointments to telemedicine, with 3 patients referred to ED for care. The information obtained through telemedicine consultation accurately informed decision for ED evaluation with resultant admission. Conclusion Collaborative team-based approach delineated in the algorithm facilitated successful virtual consultations for HF patients and accurately informed decisions for higher level of care.