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BACKGROUND: Fatigue is a common and distressing symptom of heart failure and has important implications for patient-reported and clinical outcomes. Despite being a common and bothersome symptom, fatigue has been understudied in heart failure. OBJECTIVE: To synthesize existing literature on fatigue in heart failure through a systematic literature review guided by the biopsychosocial model of health. METHODS: A systematic search of the literature was performed on March 18(th), 2020, using Pubmed, Embase, and CINAHL. Full-text, primary research articles, written in English, in which fatigue was a primary symptom of interest in adults with a diagnosis of heart failure were included. RESULTS: The search yielded 1138 articles; 33 articles that met inclusion criteria were selected for extraction and synthesis. Biological and psychological factors associated with fatigue were New York Heart Association functional class, hemoglobin level, history of stroke, and depression. However, there are limited HF specific factors linked to fatigue. Social factors related to fatigue included social roles, relationship strain, and loneliness/isolation. Few non-pharmacologic interventions have been tested by show some promise for alleviating fatigue in HF. Studies show conflicting evidence related to the prognostic implications of fatigue. CONCLUSIONS: Important biological correlates of fatigue were identified; however, psychological and social variables were limited to qualitative description. There is need for expanded models to better understand the complex physiologic nature of fatigue in HF. Additionally, more research is needed to 1) define the relationships between fatigue and both psychological and social factors, 2) better describe the prognostic implications of fatigue, and 3) develop more therapeutic approaches to alleviate fatigue with the goal of improving overall quality of life.

Background Perceived health is one of the strongest determinants of subjective well-being, but it has received little attention among survivors of ARDS. Research question How well do self-reported measures of physical, emotional, and social functioning predict perceived overall health (measured using the EQ-5D visual analog scale [EQ-5D-VAS]) among adult survivors of ARDS? Are demographic features, comorbidity, or severity of illness correlated with perceived health after controlling for self-reported functioning? Study Design and Methods We analyzed the ARDSNet Long Term Outcomes Study (ALTOS) and Improving Care of Acute Lung Injury Patients (ICAP) Study, two longitudinal cohorts with a total of 823 survivors from 44 US hospitals, which prospectively assessed survivors at 6 and 12 months after ARDS. Perceived health, evaluated using the EQ-5D-VAS, was predicted using ridge regression and self-reported measures of physical, emotional, and social functioning. The difference between observed and predicted perceived health was termed perspective deviation (PD). Correlations between PD and demographics, comorbidities, and severity of illness were explored. Results The correlation between observed and predicted EQ-5D-VAS scores ranged from 0.68 to 0.73 across the two cohorts and time points. PD ranged from –80 to +34 and was more than the minimum clinically important difference for 52% to 55% of survivors. Neither demographic features, comorbidity, nor severity of illness were correlated strongly with PD, with |r| Interpretation About half of survivors of ARDS showed clinically important differences in actual perceived health vs predicted perceived health based on self-reported measures of functioning. Survivors of ARDS demographic features, comorbidities, and severity of illness were correlated only weakly with perceived health after controlling for measures of perceived functioning, highlighting the challenge of predicting how individual patients will respond psychologically to new impairments after critical illness.

(1) Background: people who migrate from low-to high-income countries are at an increased risk of weight gain, and excess weight is a risk factor for cardiovascular disease. Few studies have quantified the changes in body mass index (BMI) pre- and post-migration among African immigrants. We assessed changes in BMI pre- and post-migration from Africa to the United States (US) and its associated risk factors. (2) Methods: we performed a cross-sectional analysis of the African Immigrant Health Study, which included African immigrants in the Baltimore-Washington District of the Columbia metropolitan area. BMI category change was the outcome of interest, categorized as healthy BMI change or maintenance, unhealthy BMI maintenance, and unhealthy BMI change. We explored the following potential factors of BMI change: sex, age at migration, percentage of life in the US, perceived stress, and reasons for migration. We performed multinomial logistic regression adjusting for employment, education, income, and marital status. (3) Results: we included 300 participants with a mean (±SD) current age of 47 (±11.4) years, and 56% were female. Overall, 14% of the participants had a healthy BMI change or maintenance, 22% had an unhealthy BMI maintenance, and 64% had an unhealthy BMI change. Each year of age at immigration was associated with a 7% higher relative risk of maintaining an unhealthy BMI (relative risk ratio [RRR]: 1.07; 95% CI 1.01, 1.14), and compared to men, females had two times the relative risk of unhealthy BMI maintenance (RRR: 2.67; 95% CI 1.02, 7.02). Spending 25% or more of life in the US was associated with a 3-fold higher risk of unhealthy BMI change (RRR: 2.78; 95% CI 1.1, 6.97). (4) Conclusions: the age at immigration, the reason for migration, and length of residence in the US could inform health promotion interventions that are targeted at preventing unhealthy weight gain among African immigrants.

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Uncontrolled hypertension is a major risk factor for cardiovascular disease. Evidence-based interventions to improve hypertension control in high-income countries have not been translated equally in sub-Saharan Africa (SSA). The objective of the Addressing Hypertension Care in Africa (ADHINCRA) Study was to test the feasibility and signal of efficacy of a multilevel, nurse-led, mobile health enhanced intervention in improving hypertension control in Ghana.Using a cluster randomized controlled pilot trial design, four hospitals in Kumasi, Ghana, were randomized to the intervention arm (2 hospitals) and enhanced usual care arm (2 hospitals). A total of 240 patients with uncontrolled hypertension defined as systolic blood pressure (BP) ≥140 mmHg on their most recent visit were included (60 patients per hospital). Patients in the intervention arm received an intervention that consisted of nurse-led task-shifting and a mobile health application (Medtronic® Labs' Empower Health), and home BP monitoring. The enhanced usual care arm received usual care as determined by their providers, plus short text messages on health. The intervention was administered for six months, after which it was withdrawn, and patients were followed for six more months to assess outcomes. Feasibility measures included recruitment and dropout rates of study participants, protocol adherence in both arms. Clinical outcomes included changes in BP control status and systolic BP levels from baseline. Secondary outcomes included change in glycemic control, rates of hypertensive urgencies/emergencies, cardiovascular disease events, and medication adherence.Findings from this study will provide critical pilot data to inform the conduct of a larger scale trial and the development of scalable health system and policy interventions to improve hypertension control in low-resource settings. Trial registration NCT04010344. Registered on July 8, 2019 at ClinicalTrials.govhttps://clinicaltrials.gov/ct2/show/NCT04010344.

ObjectiveTo examine the association between social determinants of health, hypertension, and diabetes among African immigrants.MethodsThe African Immigrant Health Study was a cross-sectional study of the health of African immigrants in the Baltimore-Washington Metropolitan Area. The outcomes of interest were self-reported diagnoses of hypertension and diabetes. Logistic regression was used to examine the relationship between educational status, employment, income, social support, health insurance, and self-reported diagnoses of hypertension and diabetes, adjusting for age, sex, and length of stay in the U.S.ResultsA total of 465 participants with mean (±SD) age 47 (±11.5) years were included. Sixty percent were women, 64% had a college degree or higher, 83% were employed, 67% had health insurance, and 70% were married/cohabitating. Over half (60%) of the participants had lived in the United States for ≥ 10 years, and 84% were overweight/obese. The overall prevalence of hypertension and diabetes was 32% and 13%, respectively. The odds of diabetes was higher (aOR: 5.00, 95% CI: 2.13, 11.11) among those who were unemployed than among those who were employed, and the odds of hypertension was higher among those who had health insurance (aOR:1.73, 95% CI: 1.00, 3.00) than among those who did not.ConclusionsAmong African immigrants, those who were unemployed had a higher likelihood of a self-reported diagnosis of diabetes than those who were employed. Also, people who had health insurance were more likely to self-report a diagnosis of hypertension. Additional studies are needed to further understand the influence of social determinants of health on hypertension and diabetes to develop health policies and interventions to improve the cardiovascular health of African immigrants.

Background: Social determinants of health (SDOH) are associated with a variety of health outcomes, yet their relation to emer­gency department (ED) visits among individu­als with coronary heart disease (CHD) or stroke is unclear. Objective: We examined whether SDOH were associated with ≥1 ED visit among persons diagnosed with CHD or stroke. Methods: We performed a cross-sectional analysis of the 2010-2018 National Health Interview Survey, examining ED visits among individuals who self-reported CHD or stroke diagnosis. The outcome was defined as re­porting ≥1 ED visit in the previous 12 months vs none. The SDOH examined were race, employment status, poverty, insurance status, marital status, and educational status. Results: We included N=14,925 partici­pants with a diagnosis of CHD or stroke. The mean (±SD) age was 68 (±.14) years. After adjusting for age and sex, non-Hispanic Blacks were more likely (adjusted odds ratio [AOR]: 1.29; 95%CI: 1.15-1.44) to report having ≥1 ED visits than Whites. Compared with Whites, Asians had lower odds of having ≥1 ED visit in the previous 12 months (AOR: .63, 95%CI: .49-.82). Those who were unmarried (AOR: 1.21, 95%CI: 1.12 – 1.31), unemployed (AOR: 1.53, 95%CI: 1.36- 1.72) and had a poverty income ratio of

Background Social determinants influence the development and control of hypertension. METHODS National Health and Nutrition Examination Survey (2011–2018) data for adults aged ≥18 included education, income, employment, race/ethnicity, healthcare access, marital status, and nativity status. Outcomes were hypertension (blood pressure [BP] ≥130/80 mm Hg or self-reported hypertension medication use), stage 2 hypertension (BP ≥140/90 mm Hg), and controlled BP (BP RESULTS The analysis included 21,664 adults (mean age 47.1 years), of whom 51% were women. After adjustment, hypertension and stage 2 hypertension prevalence remained higher among Black and Asian than White adults, regardless of sex. Blacks had lower prevalence of controlled BP than Whites. Compared with college graduates, men and women with less education had a higher prevalence of hypertension and stage 2 hypertension. Men (prevalence ratio [PR]: 0.28, 95% confidence interval: 0.16–0.49) and women (PR: 0.44, 0.24–0.78) with no routine place for healthcare had lower prevalence of controlled BP than those who had a routine place for healthcare. Uninsured men (PR: 0.66, 0.44–0.99) and women (PR: 0.67, 0.51–0.88) had lower prevalence of controlled BP than those insured. Unemployed or unmarried women were more likely to have controlled BP than employed or married women. Conclusions Social determinants were independently associated with hypertension outcomes in US adults. Policy interventions are urgently needed to address healthcare access and education, and eliminate racial disparities.

Dennison Himmelfarb and Baptiste discuss the implications of coronavirus disease (COVID-19) for cardiovascular and socially at-risk populations COVID-19 is an infectious respiratory disease caused by the newly discovered pathogen, SARS-CoV-2, a novel RNA-dependent RNA polymerase betacoronavirus that is thought to derive from bats At this time, there are no specific vaccines or treatments for COVID-19 The best way to prevent and slow transmission is to be well informed about the COVID-19 virus, the disease it causes, and how it spreads

Objective: Anemia is common during critical illness and often persists after hospital discharge; however, its potential association with physical outcomes after critical illness is unclear. Our objective was to assess the associations between hemoglobin at intensive care unit (ICU) and hospital discharge with physical status at 3-month follow-up in acute respiratory distress syndrome (ARDS) survivors. Methods: This is a secondary analysis of a multisite prospective cohort study of 195 mechanically ventilated ARDS survivors from 13 ICUs at 4 teaching hospitals in Baltimore, Maryland. Multivariable regression was utilized to assess the relationships between ICU and hospital discharge hemoglobin concentrations with measures of physical status at 3 months, including muscle strength (Medical Research Council sumscore), exercise capacity (6-minute walk distance [6MWD]), and self-reported physical functioning (36-Item Short-Form Health Survey [SF-36v2] Physical Function score and Activities of Daily Living [ADL] dependencies). Results: Median (interquartile range) hemoglobin concentrations at ICU and hospital discharge were 9.5 (8.5-10.7) and 10.0 (9.0-11.2) g/dL, respectively. In multivariable regression analyses, higher ICU discharge hemoglobin concentrations (per 1 g/dL) were associated with greater 3-month 6MWD mean percent of predicted (3.7% [95% confidence interval 0.8%-6.5%]; P = .01) and fewer ADL dependencies (−0.2 [−0.4 to −0.1]; P = .02), but not with percentage of maximal muscle strength (0.7% [−0.9 to 2.3]; P = .37) or SF-36v2 normalized Physical Function scores (0.8 [−0.3 to 1.9]; P = .15). The associations of physical outcomes and hospital discharge hemoglobin concentrations were qualitatively similar, but none were statistically significant. Conclusions: In ARDS survivors, higher hemoglobin concentrations at ICU discharge, but not hospital discharge, were significantly associated with improved exercise capacity and fewer ADL dependencies. Future studies are warranted to further assess these relationships.

Introduction: People who migrate from low to high-income countries are at an increased risk of weight gain and excess weight is a risk factor for cardiovascular diseases. Little is known about changes in BMI categories pre-and post-migration. We assessed changes in BMI pre-and post-migration and associated risk factors. Methods: We performed a cross-sectional analysis of data from the African Immigrant Health Study which included African immigrants in the Baltimore, Washington D.C. metropolitan area. BMI category change was the outcome and was categorized as healthy BMI change, unhealthy BMI maintenance, and unhealthy BMI change. We explored the following potential factors: age at migration, percentage of life in the US, physical activity, diet, depression, country of origin, and reasons for migration. We used multinomial logistic regression adjusting for age, sex, employment, education, income, and marital status. Results: Among 300 participants, the mean (SD) age was 47.6 (11.7) years, and 167 (55.6%) were females. Also, 14.0% had healthy BMI change, 25.7% had unhealthy BMI maintenance, and 60.3% had unhealthy BMI change. Individuals who migrated at age 40-49 years were six times likely to maintain unhealthy BMI than immigrants at age 20-29 years (OR = 6.55, 95% CI: 1.53, 28.04). Immigrants from Sierra Leone had the lowest odds of unhealthy BMI change compared to Ghanaians (OR: 0.05, 95% CI: 0.01, 0.33). Migrating for employment or economy (OR: 0.11, 95% CI: 0.03, 0.46), and family (OR: 0.10, 95% CI: 0.02, 0.43) was associated with lower odds of unhealthy BMI change than migrating for educational reasons. Spending 25% or more of life in the US was associated with a 3-fold higher odds of unhealthy BMI change (OR: 3.03, 95% CI: 1.30, 8.38) (Table). Conclusion: Majority of African immigrants had unhealthy BMI change upon migrating to the US. Tailored interventions that consider acculturation, country of origin and reasons for migration are needed to prevent obesity in this population.

Introduction: Infection with the SARS-CoV-2 virus can lead to myocardial injury, with cardiac biomarker elevations. Objective: To quantify the association between biomarkers of myocardial injury, coagulation, and severe COVID-19 and death in hospitalized patients. Methods: Studies were identified from PubMed, Embase, CINAHL, Cochrane, Web of Science, and Scopus, published between December 2019 to August 2021. Effect estimates for association between markers of myocardial injury (Troponin), myocardial stretch (N-terminal-pro hormone BNP, NT-proBNP), and coagulopathy (D-Dimer) and death or severe/critical COVID-19 were pooled using random-effects models. Odds Ratios (OR), Hazard Ratios (HR), and 95% Confidence Intervals (CI) were pooled separately and reported by outcomes of critical/severe COVID-19 and death. A meta-analysis of proportions summarized pooled prevalence of co-morbidities. Results: We included 62 articles, with 41,013 patients. Pooled proportion of patients with hypertension history was 39% (95% CI: 34-44%); diabetes, 21% (95% CI: 18%-24%); coronary artery disease, 13% (95% CI: 10-16%); chronic obstructive pulmonary disease, 7% (95% CI: 5-8%), and cancer, 5% (95% CI: 4-7%). Elevated troponin was associated with higher pooled odds of critical/severe COVID-19 and death [Odds Ratio (OR: 1.77, 95% CI: 1.42-2.18)] ( Figure ); also, separately for death (OR: 1.72, 95% CI: 1.32-2.25), and critical/severe COVID-19 (OR: 1.93, 95% CI: 1.45-2.40). Elevated NT-proBNP were associated with higher odds for severe COVID-19/death (OR: 3.00, 95% CI: 1.58-5.70). Elevated D-dimer levels was significantly associated with critical/severe COVID-19 and death (OR: 1.38, 95% CI: 1.07-1.79). Conclusions: This meta-analysis synthesizes evidence showing that myocardial injury, and coagulopathy are complications of COVID-19. Patients who have recovered from COVID-19 may benefit from minimally invasive assessment for markers of myocardial injury, stretch and coagulopathy for early risk stratification.

Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as

BackgroundHeart failure is a troublesome condition with high healthcare utilization and cost. Most individuals with heart failure experience multiple symptoms including breathlessness, pain, depression, and anxiety.PurposeThe aim of this study was to review the literature describing the use of the Edmonton Symptom Assessment Scale to assess the burden of symptoms and the impact of symptoms on heart failure outcomes including quality of life and functional outcomes.MethodsThe search engines PubMed, Scopus, CINAHL, and Web of Science were searched from January 2001 to March 2020. A review of literature was undertaken using key terms "heart failure," "CHF," "cardiac failure," "heart decompensation," "myocardial failure," "Edmonton Symptom Assessment Scale". Hand searching of articles was also undertaken.ResultsThe search resulted in 33 relevant articles, which were imported into Rayyan, a Web-based systematic review software program. We present synthesis of results of studies (1) using the Edmonton Symptom Assessment Scale as an assessment of symptom burden and (2) evaluating the impact of symptom burden on quality of life and functional status.ConclusionThis review highlighted the Edmonton Symptom Assessment Scale as a predictive instrument to identify symptom burden, symptom clusters, and symptom changes for patients living with heart failure. The clinical use of the Edmonton Symptom Assessment Scale may identify treatment priorities, promote self-management, inform the treatment plan, and advance effective therapeutic adjustments. The symptom burden in heart failure is high, and improving the symptom experience is an important focus of future healthcare interventions. The Edmonton Symptom Assessment Scale has utility in heart failure management due to psychometric properties and ease of administration.Clinical implicationsThe Edmonton Symptom Assessment Scale may be useful in measuring patient-reported symptom burden in patients with heart failure in the clinical setting because it correlates well with other heart failure measures on quality of life and functional outcomes and provides useful information on symptom burden.

Storytelling is increasingly recognized as a culturally relevant, human-centered strategy and has been linked to improvements in health knowledge, behavior, and outcomes. The Community Engagement Program of the Johns Hopkins Institute for Clinical and Translational Research designed and implemented a storytelling training program as a potentially versatile approach to promote stakeholder engagement. Data collected from multiple sources, including participant ratings, responses to open-ended questions, and field notes, consistently pointed to high-level satisfaction and acceptability of the program. As a next step, the storytelling training process and its impact need to be further investigated.

Background Heart failure is the final common pathway of many cardiovascular diseases, and yet many individuals with heart failure die hospitalised, suffering needlessly and experiencing what could be termed a ‘bad death'. While it is essential to address the wishes of individuals and their families in improving the quality of end-of-life care for patients with heart failure, their unmet needs remain poorly understood. Aim To systematically review the literature describing a good death or end-of-life care in heart failure and to synthesise identified studies to describe how elements of heart failure care may contribute to a good death. Methods PubMed and Scopus were searched from January 2001 to April 2018. The method of Whittemore and Knafl guided this review to identify emergent themes. Findings Of the 436 studies identified, 43 met the inclusion criteria. Five themes associated with end-of-life care in heart failure and a good death were generated: (1) location of death, (2) preferred care, (3) palliative care utilisation, (4) interventions to improve the likelihood of a good death, (5) the intersection of individual, family, healthcare providers, and community-level factors. Discussion This integrative review highlights a number of factors that prevent patients with heart failure from receiving palliative care, such as difficulty predicting mortality, late referral misconception of the role of palliative care and low availability of resources. Conclusion This review has identified modifiable barriers and facilitator of a good death and emphasised the importance of considering the intersection of patient, provider and healthcare system issues in facilitating a good death for patients with heart failure.

Background/aim:Cost-efficient methods are essential for successful participant recruitment in clinical trials. Patient portal messages are an emerging means of recruiting potentially eligible patients into trials. We assessed the response rate and complaint rate from direct-to-patient, targeted recruitment through patient portals of an electronic medical record for a clinical trial, and compared response rates by differences in message content.Methods:The Study to Understand Fall Reduction and Vitamin D in You (STURDY) trial is a National Institutes of Health–sponsored, community-based study of vitamin D supplementation for fall prevention in older adults conducted at Johns Hopkins. Potential participants were identified using the Epic electronic medical record at the Johns Hopkins Health System based on age (≥70 years), ZIP code (30-mile radius of study site), and prior activation of a patient portal account. We prepared a shorter message and a longer message. Both had basic information about study participation, but the longer message also contained information about the significance of the study and a personal invitation from the STURDY principal investigator. The Hopkins Institutional Review Board did not require prior consent from the patient or their providers. We calculated the response rate and tracked the number of complaints and requests for removal from future messages. We also determined response rate according to message content.Results:Of the 5.5 million individuals receiving care at the Johns Hopkins Health System, a sample of 6896 met our inclusion criteria and were sent one patient portal recruitment message between 6 April 2017 and 3 August 2017. Assessment of enrollment by this method ended on 1 December 2017. There were 116 patients who expressed interest in the study (response rate: 1.7%). Twelve (0.2%) recipients were randomized. There were two complaints (0.03%) and one request to unsubscribe from future recruitment messages (0.01%). Response rate was higher with the longer message than the shorter message (2.1% vs 1.2%; p = 0.005).Conclusion:Patient portal messages inviting seniors to participate in a randomized controlled trial resulted in a response rate similar to commercial email marketing and resulted in very few complaints or opt-out requests. Furthermore, a longer message with more content enhanced response rate. Recruitment through patient portals might be an effective strategy to enroll trial participants.

Objective The study sought to characterize institution-wide participation in secure messaging (SM) at a large academic health network, describe our experience with electronic medical record (EMR)–based cohort selection, and discuss the potential roles of SM for research recruitment. Materials and Methods Study teams defined eligibility criteria to create a computable phenotype, structured EMR data, to identify and recruit participants. Patients with SM accounts matching this phenotype received recruitment messages. We compared demographic characteristics across SM users and the overall health system. We also tabulated SM activation and use, characteristics of individual studies, and efficacy of the recruitment methods. Results Of the 1 308 820 patients in the health network, 40% had active SM accounts. SM users had a greater proportion of white and non-Hispanic patients than nonactive SM users id. Among the studies included (n = 13), 77% recruited participants with a specific disease or condition. All studies used demographic criteria for their phenotype, while 46% (n = 6) used demographic, disease, and healthcare utilization criteria. The average SM response rate was 2.9%, with higher rates among condition-specific (3.4%) vs general health (1.4%) studies. Those studies with a more inclusive comprehensive phenotype had a higher response rate. Discussion Target population and EMR queries (computable phenotypes) affect recruitment efficacy and should be considered when designing an EMR-based recruitment strategy. Conclusions SM guided by EMR-based cohort selection is a promising approach to identify and enroll research participants. Efforts to increase the number of active SM users and response rate should be implemented to enhance the effectiveness of this recruitment strategy.

ObjectivesWomen report higher atrial fibrillation (AF) symptom severity and receive less AF therapies than their male counterparts. It is understudied if differences in AF therapies received explains sex differences in AF symptom severity. We investigate the impact of sex and AF therapies on patient-reported outcomes.MethodsParticipants were recruited (n=953) across four academic medical centres with an AF diagnosis and age ≥18 years. Patient-reported outcomes (AF symptom severity, AF-related quality of life, functional status and emotional status) were determined by biannual surveys. We performed multiple linear regressions on propensity-matched cohorts to determine the association of AF therapies and sex on patient-reported outcomes.ResultsOur study population (n=953) was 65% male (n=616), 93% white (n=890) and 72 (±10) years old. Individuals receiving rate control therapy reported comparatively lower AF-related quality of life (−7.22, 95% CI −11.51 to –2.92) and poorer functional status (−3.69, 95% CI −5.27 to –2.12). Individuals receiving rhythm control strategies did not report significantly different patient-reported outcomes. Women were more likely to report poorer functional status (−2.63, 95% CI −3.86 to –1.40) and poorer AF-related quality of life, higher anxiety (2.33, 95% CI 1.07 to 3.59), higher symptoms of depression (1.48, 95% CI 0.31 to 2.65) and AF symptom severity (0.29, 95% CI 0.07 to 0.52).ConclusionsFemale sex was associated with comparatively poorer AF symptom severity and quality of life, and this association remained after accounting for AF therapies received. Receiving rate control medication alone was associated with comparatively poorer AF-related quality of life and functional status.

Background The Fuld Fellows Program provides selected pre-licensure nursing students with a foundation in the science of patient safety, quality improvement and leadership through coursework and a mentored experience working on a quality improvement project. We evaluated this program’s impact on Fellows’ patient safety competence and systems thinking. Methods Cohorts I-VI (n = 116) completed pre-post program evaluation that included measurement of patient safety competence through the Health Professional Education in Patient Safety Survey (H-PEPSS) and systems thinking using the Systems Thinking Scale. Pre- and post-program H-PEPSS and Systems Thinking Scale scores were compared using the Wilcoxon Signed-Rank Test. The Fellows were compared to non-Fellows on patient safety competence and systems thinking using t-tests. Results Patient safety competence on all H-PEPSS scales improved from baseline to end of program: teamwork (2.6 to 3.1), communication (2.1 to 3.2), managing risk (2.2 to 3.3), human environment (2.8 to 3.7), recognize and respond to risk (2.7 to 3.6), and culture (2.9 to 3.8) (p

Background In atrial fibrillation (AF), there are known sex and sociodemographic disparities in clinical outcomes such as stroke. We investigate whether disparities also exist with respect to patient-reported outcomes. We explored the association of sex, age, and education level with patient-reported outcomes (AF-related quality of life, symptom severity, and emotional and functional status). Methods The PaTH AF cohort study recruited participants (N = 953) with an AF diagnosis and age ≥ 18 years across 4 academic medical centers. We performed longitudinal multiple regression with random effects to determine if individual characteristics were associated with patient-reported outcomes. Results Women reported poorer functional status (β − 2.23, 95% CI: -3.52, − 0.94) and AF-related quality of life (β − 4.12, 95% CI: -8.10, − 0.14), and higher symptoms of anxiety (β 2.08, 95% CI: 0.76, 3.40), depression (β 1.44, 95% CI: 0.25, 2.63), and AF (β 0.29, 95% CI: 0.08, 0.50). Individuals

Background The Asian population is the fastest‐growing immigrant population in the United States. Prior studies have examined the Asian immigrant population as a homogenous group. We hypothesized that there will be heterogeneity in cardiovascular disease risk factors among Asian immigrant subgroups (Indian subcontinent, Southeast Asia, Asia) compared with the non‐Hispanic White population. Methods and Results A cross‐sectional analysis of the 2010 to 2018 National Health Interview Survey was conducted among 508 941 adults who were born in Asian regions or were non‐Hispanic White and born in the United States. Generalized linear models with Poisson distribution were fitted to compare the prevalence of self‐reported hypertension, overweight/obesity, diabetes mellitus, high cholesterol, physical inactivity, and current smoking among Asian immigrants compared with White adults, adjusting for known confounders. We included 33 973 Asian immigrants from Southeast Asia (45%), Asia (29%), the Indian subcontinent (26%), and 474 968 White adults. Compared with non‐Hispanic White adults, Indian subcontinent immigrants had the highest prevalence of overweight/obesity (prevalence ratio, 1.22; 95% CI, 1.19–1.25); Southeast Asian immigrants had the highest prevalence of high cholesterol (prevalence ratio, 1.16; 95% CI, 1.10–1.23); Indian subcontinent (prevalence ratio, 1.69; 95% CI, 1.49–1.93) and Southeast Asian (prevalence ratio, 1.38; 95% CI, 1.26–1.52) immigrants had a higher prevalence of diabetes. All Asian immigrant subgroups were more likely to be physically inactive and less likely to smoke than White adults. Conclusions We observed significant heterogeneity in cardiovascular disease risk factors among Asian immigrants and a varied prevalence of risk factors compared with non‐Hispanic White adults. Providers caring for Asian immigrants should provide tailored and culturally informed care to improve the cardiovascular health of this diverse group.

BACKGROUND: Education about patient safety has historically been limited in health professionals curricula and largely inaccessible to the general public. We developed a massive open online course (MOOC), The Science of Safety in Healthcare, to present the foundational patient safety principles to a broad global audience of health professionals, learners, and patients interested in patient safety. OBJECTIVES: To describe the Science of Safety in Healthcare MOOC, its effects on patient safety competence, and the satisfaction of course participants. METHODS: The five-week video-based course was delivered in 2013 and 2014, and was organized in five modules: 1) overview of science of safety and safety culture, 2) enabling and contextual factors that influence patient safety and quality, 3) methods to improve safety and quality, 4) translating evidence intro practice and leading change, and 5) summary and opportunities for capacity building. Each module had three or four segments. Participants were introduced to key concepts, and tools and skills to promote patient safety. Participants completed the Health Professional Education in Patient Safety Survey (H-PEPSS), which measures patient safety competence, and a course satisfaction survey. Pre- and post- course H-PEPSS scores were compared using paired t-tests. Course satisfaction surveys were administered at the completion of the course and six months later. RESULTS: A total of 20,957, and 9,679 participants enrolled in the course in 2013 and 2014, respectively. About half of participants were 25–44 years old (57%), and female (54%). Participants joined from over 100 countries. The majority were health professionals (61%) or health professionals in training (7%). Mean H-PEPSS scores improved after course completion, with significant increases on all survey domains in both years (p

Introduction: The COVID-19 pandemic has required urgent scientific response to investigate the disease, its prevention and treatment and interactions with cardiovascular conditions. Consequently, a centralized workflow was needed to effectively recruit, screen and connect volunteers to COVID-19 research opportunities. Objective: To create a centralized registry to match eligible and interested volunteers ≥18 years with COVID-19 outpatient research studies at an academic health system. Methods: Key stakeholders, including researchers and participant advocates, collaborated to build the Hopkins Opportunity for Participant Engagement (HOPE) Registry in English and Spanish. REDCap, a secure web-based application, served as the Registry platform. Study teams recruiting for outpatient studies were invited to present their studies through the Registry. Study volunteers were recruited using multiple methods, including patient portal messages, email, social media, and online advertisement. The Registry included COVID testing results and participant survey of demographic and COVID-19 related questions. Branching logic was used to pre-screen and present participating studies for which the person was eligible. The individual then selected which studies, if any, they were interested in. Study teams received an automatic notification and reached out directly to individuals expressing interest in their study ( Figure ). Results: The HOPE Registry includes 7 studies and has enrolled 4186 people. Over half (55%) were >55 years and the majority were female (64%). Racial/ethnic groups represented were Whites (80%), Black s (9%), Asians (4.7%), Hispanics (5%), and American Indian (0.3%). Participants were interested in: 29%, treatment study; 37%, vaccine study; and 66%, donating plasma. Within 10 weeks, 585 persons were matched with an actively recruiting study. Conclusions: The ongoing HOPE registry has shown promise in engaging individuals with COVID-19 research and improving research recruitment workflow.

Standard triplicate blood pressure (BP) measurements pose time barriers to hypertension screening, especially in resource‐limited settings. We assessed the implications of simplified approaches using fewer measurements with adults (≥18 years old) not using anti‐hypertensive medications from the US National Health and Nutrition Examination Survey 1999‐2016 (n = 30 614), and two datasets from May Measurement Month 2017‐2018 (n = 14 795 for Nepal and n = 6 771 for India). We evaluated the proportion of misclassification of hypertension when employing the following simplified approaches: using only 1st BP, only 2nd BP, 2nd if 1st BP in a given range (otherwise using 1st), and average of 1st and 2nd BP. Hypertension was defined as average of 2nd and 3rd systolic BP ≥140 and/or diastolic BP ≥90 mm Hg. Using only the 1st BP, the proportion of missed hypertension ranged from 8.2%–12.1% and overidentified hypertension from 4.3%–9.1%. Using only 2nd BP reduced the misclassification considerably (corresponding estimates, 4.9%–6.4% for missed hypertension and 2.0%–4.4% for overidentified hypertension) but needed 2nd BP in all participants. Using 2nd BP if 1st BP ≥130/80 demonstrated similar estimates of missed hypertension (3.8%–8.1%) and overidentified hypertension (2.0%–3.9%), but only required a 2nd BP in 33.8%–59.8% of participants. In conclusion, a simplified approach utilizing 1st BP supplemented by 2nd BP in some individuals has low misclassification rates and requires approximately half of the total number of measurements compared to the standard approach, and thus can facilitate screening in resource‐constrained settings.

Background Community engagement may make research more relevant, translatable, and sustainable, hence improving the possibility of reducing health disparities. The purpose of this study was to explore strategies for community engagement adopted by research teams and identify areas for enhancing engagement in future community engaged research. Methods The Community Engagement Program of the Johns Hopkins Institute for Clinical and Translational Research hosted a forum to engage researchers and community partners in group discussion to reflect on their diverse past and current experiences in planning, implementing, and evaluating community engagement in health research. A total of 50 researchers, research staff, and community partners participated in five concurrent semi-structured group interviews and a whole group wrap-up session. Group interviews were audiotaped, transcribed verbatim, and analyzed using content analysis. Results Four themes with eight subthemes were identified. Main themes included: Community engagement is an ongoing and iterative process; Community partner roles must be well-defined and clearly communicated; Mutual trust and transparency are central to community engagement; and Measuring community outcomes is an evolving area. Relevant subthemes were: engaging community partners in various stages of research; mission-driven vs. “checking the box”; breadth and depth of engagement; roles of community partner; recruitment and selection of community partners; building trust; clear communication for transparency; and conflict in community engaged research. Conclusion The findings highlight the benefits and challenges of community engaged research. Enhanced capacity building for community engagement, including training and communication tools for both community and researcher partners, are needed.

BACKGROUND: The prevalence of heart failure (HF) is increasing in many low-income and middle-income countries, but the limited availability of data on patient profiles and clinical outcomes, particularly at a community level, challenges health service planning. METHODS: The Thai HF Snapshot Study was a multi-site, observational study conducted in Thailand between June 2017 to June 2019. It aimed to document demographic, clinical and sociodemographic characteristics, and to compare clinical outcomes by the level of the hospital. RESULTS: A total of 512 participants were recruited across Thailand: mean age was 64.9±15.3 years and 286 were female (55.9%). The most frequently identified admitting diagnosis was ischaemic heart disease (45.1%). Most patients (70.3%) were classified as New York Heart Association class II at discharge. Patients in university hospitals were frailer (3.2 vs 2.9; p=0.015), had more depressive symptoms (8.1 vs 5.7; p

Purpose The burden of cardiovascular diseases (CVD) is high in low- and middle-income countries (LMICs). Medications are integral to the management and control of CVD; however, suboptimal adherence impacts health outcomes. This systematic review aims to critically examine interventions targeted at improving medication adherence among persons with CVD in LMICs. Methods In this systematic review, we searched online databases PubMed, Embase, and CINAHL for studies that evaluated a medication adherence intervention for CVD, reported adherence as an outcome measure, were conducted in LMICs and reported the strategy or tool used to measure adherence. We included articles published in English, available in full text, peer-reviewed, and published between 2010 and 2020. Results We included 45 articles in this review. The majority of the studies implemented counseling and educational interventions led by nurses, pharmacists, or community health workers. Many of the studies delivered medication-taking reminders in the form of phone calls, text messages, short message services (SMS), and in-phone calendars. Multi-component interventions were more effective than unifocal interventions. Interventions involving technology, such as mobile phone calls, electronic pillboxes, and interactive phone SMS reminders, were more effective than generic reminders. The outcomes reported in the studies varied based on the complexity and combination of strategies. When interventions were implemented at both the patient level, such as reminders, and at the provider level, such as team-based care, the effect on medication adherence was larger. Conclusion In LMICs, medication adherence interventions among persons with CVD included a combination of patient education, reminders, fixed-dose combination therapy and team-based care approach were generally more effective than singular interventions. Among patients who had CVD, the medication adherence interventions were found to be moderately effective. Future studies focusing on improving medication adherence in LMICs should consider non-physician-led interventions and appropriately adapt the interventions to the local context.

Introduction: Cardiovascular disease (CVD) is the leading cause of death in the US. Asians are the fastest-growing immigrant group in the US and are disproportionately affected by CVD risk factors, compared to Whites. Studies on CVD risk aggregate Asians into a homogenous group. It is unclear how Asian immigrants (Indian subcontinent, Southeast Asia, Asia) differ with respect to CVD risks and in comparison, to Whites. Hypothesis: We hypothesize that there will be significant heterogeneity in CVD risk factors among Asian immigrant subgroups as compared to Non-Hispanics Whites. Methods: A cross-sectional comparative analysis of the 2010 to 2018 National Health Interview Survey was conducted among 508,941 participants. A generalized linear model using Poisson distribution was fitted to compare the prevalence of self-reported hypertension, overweight/obesity, diabetes, high cholesterol, physical inactivity, and smoking among Asian immigrants to Whites, adjusting for known confounders. Results: In this sample, 33,973 were Asian immigrants (26% Indian subcontinent; 45% Southeast Asia; 29% Asia) and 474,968 Whites; Indian subcontinent were the youngest (39 years; SE: 0.36). Compared to Whites, the Indian subcontinent had the highest prevalence of overweight/obesity (PR:1.22; 95% CI:1.19-1.25) and Southeast Asian had highest in high cholesterol (PR:1.16; 95% CI:1.10-1.23). Both, the Indian subcontinent (PR:1.69; 95% CI:1.49 - 1.93) and Southeast Asian (PR:1.38; 95%:1.26-1.52), reported a higher prevalence of diabetes. All Asian subgroups were more likely to be physically inactive and less likely to smoke than Whites (Table). Conclusion: Significant heterogeneity in CVD risk factors among Asian immigrants was observed compared to Whites. Providers caring for Asians should consider health behaviors and cultural beliefs influencing health outcomes and provide tailored and culturally informed care to improve the cardiovascular health of diverse populations.

Objectives The National Academy of Medicine identified diagnostic error as a pressing public health concern and defined failure to effectively communicate the diagnosis to patients as a diagnostic error. Leveraging Patient’s Experience to improve Diagnosis (LEAPED) is a new program for measuring patient-reported diagnostic error. As a first step, we sought to assess the feasibility of using LEAPED after emergency department (ED) discharge. Methods We deployed LEAPED using a cohort design at three EDs within one academic health system. We enrolled 59 patients after ED discharge and queried them about their health status and understanding of the explanation for their health problems at 2-weeks, 1-month, and 3-months. We measured response rates and demographic/clinical predictors of patient uptake of LEAPED. Results Of those enrolled (n=59), 90% (n=53) responded to the 2-week post-ED discharge questionnaire (1 and 3-month ongoing). Of the six non-responders, one died and three were hospitalized at two weeks. The average age was 50 years (SD 16) and 64% were female; 53% were white and 41% were black. Over a fifth (23%) reported they were not given an explanation of their health problem on leaving the ED, and of those, a fourth (25%) did not have an understanding of what next steps to take after leaving the ED. Conclusions Patient uptake of LEAPED was high, suggesting that patient-report may be a feasible method of evaluating the effectiveness of diagnostic communication to patients though further testing in a broader patient population is essential. Future research should determine if LEAPED yields important insights into the quality and safety of diagnostic care.

Background/aims:Electronic-based recruitment methods are increasingly utilized in clinical trials to recruit and enroll research participants. The cost-effectiveness of electronic-based methods and impact on sample generalizability is unknown. We compared recruitment yields, cost-effectiveness, and demographic characteristics across several electronic and traditional recruitment methods.Methods:We analyzed data from the diet gout trial recruitment campaign. The diet gout trial was a randomized, controlled, cross-over trial that examined the effects of a dietary approaches to stop hypertension (DASH)–like diet on uric acid levels in adults with gout. We used four electronic medical record and four non-electronic medical record–based recruitment methods to identify and recruit potentially eligible participants. We calculated the response rate, screening visit completion rate, and randomization rate for each method. We also determined cost per response, the screening, and randomization for each method. Finally, we compared the demographic characteristics among individuals who completed the screening visit by recruitment method.Results:Of the 294 adults who responded to the recruitment campaign, 51% were identified from electronic medical record–based methods. Patient portal messaging, an electronic medical record–based method, resulted in the highest response rate (4%), screening visit completion rate (37%), and randomization rate (21%) among these eight methods. Electronic medical record–based methods ($60) were more cost-effective per response than non-electronic medical record–based methods ($107). Electronic-based methods, including patient portal messaging and Facebook, had the highest proportion of White individuals screened (52% and 60%). Direct mail to non-active patient portal increased enrollment of traditionally under-represented groups, including both women and African Americans.Conclusion:An electronic medical record–based recruitment strategy that utilized the electronic medical record for participant identification and postal mailing for participant outreach was cost-effective and increased participation of under-represented groups. This hybrid strategy represents a promising approach to improve the timely execution and broad generalizability of future clinical trials.

OBJECTIVES/GOALS: The extent that Clinical and Translational Science Award (CTSA) programs offer resources accessible online for training in community-engaged research (CEnR) core competencies is unknown. This study cataloged CEnR resources accessible online from CTSAs and mapped resources to CEnR core competencies. METHODS/STUDY POPULATION: Eight domains of CEnR core competencies were identified: knowledge/perceptions of CEnR; personal traits necessary for CEnR; knowledge of/relationships with communities; training for performing CEnR; CEnR methods; program evaluation; resource sharing and communication; and dissemination and advocacy. A systematic review of CEnR resources accessible online from CTSAs was conducted between July 2018 and May 2019. Resource content was independently reviewed by two reviewers and scored for inclusion of each domain of CEnR core competencies. Domain scores across all resources and inter-rater reliability in scoring domains were assessed using descriptive statistics and Cohen’s kappa coefficients. RESULTS/ANTICIPATED RESULTS: Overall, 214 resources available from 24 CTSAs were eligible for full review. Scoring discrepancies for at least one domain within a resource initially occurred in 51% of resources. “CEnR methods” (50.5%; 108 of 214) and “Knowledge of/relationships with the community” (40.2%; 86 of 214) were most frequently addressed and “Program evaluation” (12.1%; 26 of 214) and “Dissemination and advocacy” (11.2%; 24 of 214) were least frequently addressed domains. Additionally, challenges were noted in navigating CTSA websites to access CEnR resources, and CEnR competency nomenclature was not standardized. DISCUSSION/SIGNIFICANCE OF IMPACT: Our findings guide CEnR stakeholders to identify CEnR resources accessible online and gaps to address in CEnR resource development. Standardized nomenclature for CEnR competencies is needed for effective CEnR resource classification. Uniform organization of CTSA websites may maximize navigability. CONFLICT OF INTEREST DESCRIPTION: In addition to the funding information listed previously (see above), within the last three years, R.J. Piasecki has been employed as: Project Coordinator, CEnR Online Learning Project, Johns Hopkins University School of Nursing (Current) Temporary Employee (Doctoral Student Intern), Michigan State University Institute for Health Policy (Current) Clinical RN, Intrastaff at the Johns Hopkins Health System (Past) Research Data Analysis Assistant, Maryland Institute for Emergency Medical Services (Past - contracted)