Post Discharge Research Articles

Impact of opioid law on prescriptions and satisfaction of pediatric burn and orthopedic patients: An epidemiologic study.

The objective of this study was to determine the reduction in prescribed opioid pain dosage units to pediatric patients experiencing acute pain and to assess patient satisfaction with pain control 90-day post discharge following the 2017 Ohio opioid prescribing cap law. The retrospective chart review included 960 pediatric (age 0-18 years) burn injury and knee arthroscopy patients treated between August 1, 2015-August 31, 2019. Prospectively, legal guardians completed a survey for a convenience sample of 50 patients. Opioid medications (days and morphine milligram equivalents (MMEs)/kg) prescribed at discharge before and after the Ohio law implementation were collected. Guardians reported experience and satisfaction with their child's opioid prescription at 90-days post discharge. From pre-law to post-law, there was a significant decrease (p<0.001) within the burn and knee cohorts in the median days (1.7 to 1.0 and 5.0 to 3.8, respectively) and median total MMEs prescribed (15.0 to 2.5 and 150.0 to 90.0, respectively). An interrupted time series analysis revealed a statistically significant decrease in MMEs/kg and days prescribed at discharge when the 2017 Ohio opioid prescription law went into effect, with an abrupt level change. Prospectively, more than half of participants were satisfied (72% burn and 68% knee) with their pain control and felt they received the right amount of medication (84% burn and 56% knee). Inpatient opioid use was not changed pre- and post-law. Discharge opioids prescribed for pediatric burn and knee arthroscopy procedures has decreased from 2015-2019. Caregivers varied greatly in their satisfaction with pain control and the amount of opioid prescribed.

Child development education in the Neonatal Unit: Understanding parent developmental literacy needs, priorities and preferences

ObjectiveTo describe child development knowledge needs, priorities, and preferences for education to enhance developmental literacy among parents with children admitted to the neonatal unit (NNU). MethodsTwo separate cohorts completed a survey; 1) Parents with children graduated from Australian NNUs (n = 316); 2) Parents with infants’ inpatient at two South Australian NNUs (n = 209). ResultsParents considered it extremely important to understand child development (Graduates: 80%; Inpatients: 71%). Inpatient parents reported lower child development knowledge. Almost half (42%) of graduate parents described the child development education provided by neonatal staff as poor or inadequate. There was consistency in preferences for developmental literacy education provision. Parents desired education to commence during NNU and continue post discharge. Priorities included content specific to preterm birth and how to support child development over the first two years of life. Individualised education by a Neonatal Nurse/Midwife was most preferred. ConclusionMothers and fathers value guidance to support their child’s development during NNU admission and early childhood. Our study highlights the importance of improved early developmental literacy education for parents with children admitted to the neonatal unit. Practice implicationsOur findings can be used to inform the creation of future educational resources targeting improved parent developmental literacy.

Prognostic impact of lung ultrasound detected B-Line on hospitalized ischemic HFmrEF patients

Abstract Background The prognostic impact of lung ultrasound derived B-Line (LU-BL) in heart failure patients with mildly reduced left ventricular ejection fraction (HFmrEF) remains elusive. We evaluated the correlation between LU-BL and prognosis in HFmrEF patients. Methods This study screened consecutive hospitalized HFmrEF patients in our hospital between January 2015 and August 2020 with LU-BL results at admission. LU-BL results at admission were available in 610 HFmrEF patients, and majority patients were diagnosed as ischemic HFmrEF (574, 94.1%). We thus observed the prognostic impact of LU-BL on ischemic HFmrEF patients. Patients completed at least one year of clinical follow-up through telephone, clinical or community visits after discharge. The primary endpoint was defined as the composite endpoint of cardiovascular (CV) death or heart failure hospitalization (CV event) at 90 days and 1-year post discharge. Results CV event at 90 days were significantly higher with higher LU-BL number (0; 1-2; 3-9; ≥10: 12.8%, 11.9%, 14.3% and 28.9%, P&amp;lt;0.001). Kaplan-Meier curves showed LU-BL &amp;gt;6 was associated with increased CV event at 90 days (Log rank P&amp;lt;0.001) and at 1 year (Log rank P = 0.029). After adjusted for clinical and echocardiographic covariates, multivariable Cox regression analysis showed that LU-BL&amp;gt;6 (HR 1.036, 95% CI 1.011-1.062, P = 0.005) and LU-BL &amp;gt;11 (HR 1.882, 95% CI 1.225-2.891, P = 0.004) were independently associated with increased CV event rate at 90 days. The lowest CV event rate at 90 days post discharge was identified in patients with LU-BL&amp;lt;11 and free of diabetes (10.4%). Presence of diabetes was associated with 2-fold higher CV event rate at 90 days post discharge in ischemic HFmrEF patients with LU-BL ≤11 (20.3%). Conclusions LU-BL&amp;gt;6 and 11 is independently related worse cardiovascular outcome at 90 days post discharge in ischemic HFmrEF patients. Diabetes is a fundamental risk factor of worse cardiovascular outcome within 90 days post discharge in ischemic HFmrEF patients with LU-BL&amp;lt;11.LU-BL and outcome of ischemic HFmrEF

Early discharge after low-risk ST-eletavation myocardial infarction and risk of adverse clinical ouctomes. validity and applicability of the zwolle risk score in a resource-restricted health system

Abstract Background/Introduction A Low Zwolle Risk Score (ZRS) identifies patients suitable for early hospital discharge after primary percutaneous coronary intervention (PPCI) without subsequent increase in post-discharge major adverse events (MAE).1 Data supporting this approach in resource-limited health care systems is sparse. This is particularly relevant in locales where the primary health care infrastructure is not efficiently geared towards managing patients with cardiovascular diseases and where the risk of MAE approaches 4% in the first-year post discharge.2. Purpose We aim to validate the ZRS in our population and correlate it with MAE. We intend to examine the rates of the individual adverse events at 1-month and 6-months post discharge and identify any potential gaps in management during the short hospital stay. Methods This was a retrospective analysis from the local PCI Registry at our Hospital. It included patients from 2014-2020 who were &amp;gt; 18 years of age who underwent PPCI for ST-elevation myocardial infarction. The rates of MAE were examined at 1-month and 6-months post-discharge. These were compared against patients with high ZRS (&amp;gt;4) from the same registry. Results A total of 570 patients were included in the analysis; 406 (71.2%) had a low ZRS of &amp;lt;4 and the remaining 164 (28.8%) were high risk (ZRS &amp;gt;4). The low ZRS group were younger (52.8 + 11.7 yrs. vs. 64.7 + 12.4 yrs., p&amp;lt;0.001), less likely to have CKD (6.4% vs. 17.7%, p&amp;lt;0.001) and previous CABG (0.5% vs. 2.4%, p=0.03). The median total length of hospital stay was 2 days (IQR 1-3) and significantly shorter than that in the high ZRS group of up to 7 days (p&amp;lt;0.001). The low-risk group were less likely to have an infarct culprit lesion in the LM (0.5% vs. 4.9%, p&amp;lt;0.001) or the LAD (42.6% vs. 68.3%. p&amp;lt;0.001). They were also less likely to have multivessel disease (32.8% vs. 47.6%, p=0.001). When comparing outcomes between the Low ZRS and high ZRS groups, the overall event rate at 1-month was 11.8% vs.37.1% (p&amp;lt;0.001), respectively and 14.0% vs. 45.7% (p&amp;lt;0.001) at 6-months, respectively. Interestingly, 1 in 20 patients at 1-month and 1 in 15 patients at 6-months post-discharge were re-hospitalized for decompensated heart failure. A ZRS of &amp;lt;4 was associated with lower procedural (0.4% vs. 3%, p=0.01), in-hospital (2.4% vs. 14.0%, p&amp;lt;0.001), and 6-month mortality (0.24% vs. 1.8%, p&amp;lt;0.001). A ZRS of &amp;gt;4 was an independent predictor of increased mortality at 6 months (OR 1.37, 95% CI 1.275-1.500, p&amp;lt;0.001] Conclusion(s) Even within a resource-restricted health system, the ZRS can identify patients safe for early discharge with a low event rate at 1- and 6-months post-discharge. Additionally, a low ZRS was associated with low mortality. Our study captured more MAE than previous reports. There is a potential for optimization of medical therapy during the short hospital stay to minimize risk of adverse events, especially re-hospitalizations for heart failure.Baseline CharacteristicsMain Study Outcomes

A national heart failure initiative is associated with improved use of quadruple guideline-directed medical therapy

Abstract Background Heart Failure (HF) is projected to impact over 8 million people in the US by 2030. The 2022 AHA/ACC/HFSA Guideline for the Management of HF recommend four foundational medication classes for treating HFrEF patients: RAAS inhibitors, preferably angiotensin receptor/neprilysin inhibitor (ARNi), evidence-based beta-blockers (EBBB), sodium-glucose cotransporter-2 inhibitor (SGLT2i) and mineralocorticoid receptor antagonist (MRA) referred to as Quadruple Guideline-Directed Medical Therapy (Q-GDMT). Q-GDMT has shown an estimated 73% relative and 26% absolute reduction in all-cause mortality over 2 years. Yet, despite remarkable clinical potential, these therapies are patently underutilized in clinical practice. It is unknown whether an implementation science strategy may enhance adherence to Q-GDMT for HF. Methods IMPLEMENT-HF (IHF) is a national HF quality improvement initiative composed of a multidisciplinary learning collaborative and resource repository across seven U.S regions. IHF promotes adherence to Q-GDMT by focusing on early adoption and rapid adherence to prescribing at hospital discharge and within 30 days post discharge. Multi-disciplinary participation in the learning collaborative includes pharmacy, provider groups, nursing, quality, social services, outpatient clinics and others. Shared interventions to promote Q-GDMT include formulary changes (e.g., adding SGLT2i), optimizing electronic health record tools (disease-specific order sets, dot phrases), clinician education, and user-friendly patient resources to address medication access. IHF sites receive educational materials, including webinars, learning modules, pocket guideline booklets, and reminder cards to reinforce Q-GDMT. IHF participating hospitals collect Q-GDMT data at discharge and at 30 days post discharge in Get With The Guidelines®-Heart Failure (GWTG-HF). These data were analyzed from baseline (Q1 Q2 2021 aggregate) through Q3 2022. Results Data from 71 IHF participating sites of 13,858 HFrEF patient hospitalization episodes (median age 69, 34% females, median LVEF 24%), demonstrated Q-GDMT prescription at discharge increased from 14% at baseline to 47% in Q3 2022 (p value &amp;lt;0.001). 30-day post discharge data from 52 IHF sites demonstrated an increase in Q-GDMT from 9% at baseline to 58% in Q3 2022 (p value &amp;lt;0.001) as seen in Figure 1. Conclusions Among sites participating in IHF, the use of an implementation science strategy suggest a rapid increase in prescribing Q-GDMT for eligible HFrEF patients at discharge and 30-days post discharge. This multi-region quality improvement initiative demonstrates the potential for this learning collaborative model to drive improvement in adherence to Q-GDMT prescribing, using shared implementation strategies to overcome barriers. Ongoing study will assess continued compliance and clinical outcomes with Q-GDMT beyond the timeframe of this analysis.Quadruple Medication Therapy baseline-Q3

Validation of the impact of post discharge change in hemoglobin on the prognosis of HFpEF patients after acute decompensated heart failure from PURSUIT-HFpEF registry

Abstract Background Anemia has been reported as poor prognostic factor on heart failure with preserved ejection fraction (HFpEF) in past reports. However, it is not clear at which level hemoglobin (Hb) should be managed to prevent worsening the prognosis of HFpEF. Aim The aim of this study is to evaluate the impact of the change in Hb from discharge of congestive heart failure to one year after discharge on the prognosis of HFpEF and verify at which level hemoglobin (Hb) should be managed to prevent worsening the prognosis of HFpEF. Method First, 809 HFpEF cases enrolled from June 2016 to June 2021 in PURSUIT-HFpEF registry were divided into three groups according to Hb at discharge, group with Hb &amp;lt; 11 g/dl (n = 327), group with 11 g/dl ≤ Hb &amp;lt; 13 g/dl (n = 300), and group with Hb ≥ 13 g/dl (n = 182). Secondly, the group with Hb &amp;lt; 11 g/dl (n = 327) was divided into two groups according to Hb one year later, group with Hb &amp;lt; 11 g/dl (G1, n = 179) and group with Hb ≥ 11 g/dl (G2, n = 148). Thirdly, the group with 11 g/dl ≤ Hb &amp;lt; 13 g/dl (n = 300) at discharge was divided into three groups according to Hb one year later, group with Hb &amp;lt; 11 g/dl (G3, n = 94), group with 11 g/dl ≤ Hb &amp;lt; 13 g/dl (G4, n = 129), and group with Hb ≥ 13 g/dl (G5, n = 77). Fourthly, the group with Hb ≥ 13 g/dl (n = 182) at discharge was divided into two groups, group with Hb &amp;lt; 13 g/dl (G6, n = 65) and group with Hb ≥ 13 g/dl (G7, n = 117). Major Adverse Cardiovascular Events (MACE) were defined as composite of all-cause death and heart failure readmission. We examined adjusted Hazard ratio (aHR) and incidence rate for MACE between each two groups by Cox regression model and log-rank test. Result MACE and all-cause death were significantly lower in G2 than in G1 (MACE；aHR : 0.71, 95%Confidence Interval (CI) : 0.48 - 1.04, log-rank p = 0.012), all-cause death；aHR : 0.47, 95%CI : 0.27 - 0.82, log-rank p = 0.010). MACE, all-cause death and heart failure readmission were significantly higher in G3 than in G4 (MACE；aHR : 1.69, 95%CI : 1.11 - 2.57, log-rank p = 0.005, all-cause death；aHR : 2.71, 95%CI : 1.37 - 5.40, log-rank p = 0.026, heart failure readmission ; aHR : 1.59, 95% CI : 1.01 - 2.52, log-rank p = 0.006). All-cause death was significantly lower in G5 than in G4 (aHR : 0.20, 95%CI : 0.05 - 0.84, log-rank p = 0.045). All-cause death was significantly higher in G6 than in G7 (aHR : 10.2, 95%CI : 1.13 - 92.5, log-rank p &amp;lt; 0.001). In multivariate Cox regression model, worsening anemia to Hb &amp;lt; 11 g/dl one year later in patients with 11 g/dl ≤ Hb &amp;lt; 13 g/dl at discharge was independent predictor for MACE (HR : 2.02, 95%CI : 1.17 – 3.49, log-rank p = 0.011). Conclusion The impact of post discharge change in hemoglobin seemed to be associated more strongly with all-cause death than heart failure readmission. Hemoglobin levels of at least 11 g/dl might be maintained to prevent the prognosis of HFpEF patients worse after discharge of acute decompensated heart failure.Study flowchart and Forrest plotKaplan-Meier curves and log-rank test

Surviving critical COVID-19 requiring mechanical ventilation is associated with a high risk of cardiovascular events post discharge

Abstract Background The long-term risk for cardiovascular adverse events after severe COVID-19 requiring intensive care are largely unknown. Purpose The primary aim of this study was to investigate the composite risk of incident atherosclerotic cardiovascular disease (ASCVD) during six months after discharge from an intensive care unit (ICU) for severe COVID-19 requiring mechanical ventilation. Secondary aims were to assess the risk for individual cardiovascular and thrombotic events. Methods We performed a nationwide case-control study on all patients with severe COVID-19 treated with mechanical ventilation and discharged alive from an intensive care unit in Sweden between March 2020 and June 2021. Each case was matched (age, sex, district of residence) with up to 10 population-based controls. The study database was merged with multiple national registries. Patients with pre-existing diagnosis for MI longer than one month ago, CVL or Heart failure were excluded. Also COVID-19 patients receiving the same diagnosis during their ICU-stay as in the follow up period were excluded, making sure all post-covid events were new. The primary outcome was a composite of ASCVD defined as a fatal or non-fatal myocardial infarction, unstable angina pectoris requiring urgent revascularization, fatal and non-fatal ischemic stroke and cardiovascular death. Secondary outcomes were pre-specified as, fatal or nonfatal MI, fatal or nonfatal stroke, myocarditis, pericarditis, PE and DVT. To compare groups, Hazard ratios (HR) with (95% CI) were calculated with adjustments for age, sex, comorbidities (hypertension, hyperlipedemia, diabetes 1&amp;2, obesity, chronic kidney failure, atrial fibrillation, COPD, asthma, malignancy), level of education, marital status, and income quintile. Results In total, included 3 023 patients with severe Covid-19 that were treated with mechanical ventilation at a Swedish ICU and were subsequently discharged alive and compared with 28,463 control subjects. All results in Table 1. The incidence rate for ASCVD was 22.2 (14.9-33.2) per 1,000 person years in patients discharged after severe COVID-19 compared to 2.9 (2.3-3.8) in control subjects. When adjusted for confounders, the risk for ASCVD during the follow-up period was increased compared to control subjects (HR 4.0, 95% CI 2.4-6.7). The incidence rate for pulmonary embolism was 97.4 (80.6-120.0) per 1,000 person years after severe COVID-19 compared to 1.0 (0.6-1.7) in control subjects with a markedly increased risk HR 89.8 (95% CI 48.6-166.1) in patients discharged after severe Covid-19 compared to controls. Conclusions Among patients treated at the intensive care due to severe Covid-19, we found a significant and substantial increased risks for ASCVD and thrombotic events within 6 months from discharge. This finding implies that these patients should be closely monitored after discharge with a low threshold to initiate preventive treatment for ASCVD and thrombotic events during this period.

Therapeutic gaps in low-density lipoprotein cholesterol management have narrowed over time but remain wide: a wide study of 40,141 acute coronary syndrome patients from 2016 to 2021

Abstract Background There are significant therapeutic gaps in ‘real-word’ low-density lipoprotein cholesterol (LDL-C) management in very-high risk patients. Understanding these gaps is important for developing strategies to bridge these gaps. Purpose We aimed to evaluate trends and identify therapeutic gaps in LDL-C management in very-high risk patients. Methods We retrospectively analyzed consecutive patients admitted with a diagnosis of acute coronary syndrome (ACS) to 16 public hospitals in between 2016 and 2021. Baseline and 12-month lipid-lowering therapy (LLT) including statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor and LDL-C levels were recorded. We evaluated trends-over-time in percentage achievement of guideline Class I recommendations including (i) in-hospital initiation of high-intensity LLT; (ii) lipid-profile at follow-up post discharge; (iii) achieve at least 50% reduction in LDL-C from baseline with a goal of (iv) LDL-C &amp;lt;1.4 mmol/L. Results Of 40,141 ACS patients (mean age 71, male 66.5%), 61.2% were statin-naïve on admission. Baseline average LDL-C was 2.35 mmol/L (IQR 1.74 to 3.13 mmol/L). LLT prescription on discharge increased over time from 63.8% in 2016 to 96.2% in 2021. The use of high-intensity statins on discharge also increased over time from 24.7% to 53.7% but still suboptimal. The use of high-intensity statins increased significantly at 12-months (29.4% in 2016 and 59% in 2021) compared to on discharge (44.1% vs. 40.9% overall, p&amp;lt;0.001). The use of combination LLT was very low (1.3%-3.8%). Up to 22% of patients did not have repeated lipid profile after discharge. Of patients who had follow-up lipid profile, the median LDL-C was 1.74 mmol/L with a median LDL-C reduction of 29%. Only 27.5% reached the LDL-C goal of &amp;lt;1.4 mmol/L and 22.5% achieved at least 50% of LDL-C reduction. LDL-C reduction improved over time from 25.8% in 2016 to 31% in 2021, proportion of patients who reached LDL-C goal of &amp;lt;1.4 mmol/L improved over time from 20.8% in 2016 to 28.7% in 2021, and proportion of patients who achieved at least 50% of LDL-C reduction improved over time from 18.5% in 2016 to 24.6% in 2021, respectively. Conclusion Despite an increasing trend in the use of high-intensity statins and combination LLT over time, most patients did not reach guideline-recommended LDL-C target. Early up-titration of statin and addition of non-statin LLT may be required in the majority of patients.

Fagerstrom score predicts smoking status six months after hospitalization for acute myocardial infraction:a prospective study

Abstract Backround Cardiovascular patients who quit smoking reduce their risk for future disease and mortality by 1/3 after 2 years. Despite this, more than half of all cardiac patients continue to smoke after being discharged from the hospital. Fagerstrom score is a validated marker of nicotine addiction in smokers. Purpose The aim of this study is to investigate the predictive value of the Fargestrom score (F.Sc) as a smoking cessation tool in patients with acute myocardial infarction (AMI) at 3 and 6 months after discharge. Methods We investigated a) the predictive value of F.Sc for the smoking status in patients early after AMI and b) the effectiveness of medically assisted smoking cessation programs in the prevention of relapsing to smoking post discharge. In 103 smokers (58±12 years,79.6% males) we assessed F.Sc during hospitalization for AMI. Patients filled a questionnaire during a face-to-face interview were followed-up at 3 and 6 months. The questionnaire was divided into the following sections: demographics, habits related to smoking, knowledge of smoking risks to health and methods to quit smoking. We recorded the type of MI, number and type of diseased coronary vessels, peak cardiac enzymes levels, left ventricular ejection fraction by echocardiography, intervention during hospitalization, previous medical history. The hospital anxiety and depression scale (HADS) were used to assess the patient’s mental health condition. For the evaluation of nicotine addiction, we use F.Sc. Results 59 people were hospitalized for STEMI and 44 for NSTEMI. The peak levels of high-sensitivity (hs)-troponin T during hospitalization were 3843.2 [991.3–9338.8] ng/mL. 100 AMI patients underwent PCI and 3 received thrombolysis. All patients were smoking conventional cigarettes before admission for AMI. 29 (28.2%) οf participants had a previous diagnosis of CAD, 55 (53.4%) had hypertension, 49 (47.6%) had hyperlipidemia. The mean HADS-D value was 7.4 ± 1.6, and only 20/103 (19.41%) participants had HADS-D score equal or greater than 10. 28 patients (27.2%) did not quit smoking throughout the 6 months of follow-up (F.Sc: 8.1±1.6), 39 patients (37.8%) ceased smoking at 3 months but relapsed to smoking at 6 months (score:6.8±2.1) and only 34 (33%) had ceased smoking for 6 consecutive months (F.Sc:5.2±2 P&amp;lt;0.05 for all comparisons between subgroups). Out of 73 patients that abstained from smoking the first 3 months post-AMI, those who participated in a smoking cessation program displayed lower rate of relapsing to smoking compared with those who opted to cease smoking without any support(33.3% vs 61.8% p=0.012). Conclusion Fagerstrom score was found to be a valid quantitative predictor of smoking cessation in the period of 6-months follow-up AMI. Patients who participated in a smoking cessation program displayed lower relapse rates suggesting the effectiveness of these programs for smoking cessation in AMI patients.F.Sc and different smoking behaviorsAssociation of F.Sc with smoking status

Validation of the impact of post discharge change in hemoglobin by renal function on the prognosis of HFpEF patients after acute decompensated heart failure from the PURSUIT-HFpEF registry

Abstract Background Anemia has been reported as poor prognostic factor on heart failure with preserved ejection fraction (HFpEF). However, it is not clear at what minimum level hemoglobin (Hb) by renal function should be managed to prevent worsening the prognosis of HFpEF. Aim The aim of this study is to evaluate the impact of the change in Hb by renal function from discharge of congestive heart failure to one year after discharge on the prognosis of HFpEF and verify at what minimum level hemoglobin (Hb) should be managed to prevent worsening the prognosis of HFpEF. Method 809 HFpEF cases enrolled from 2016 to 2021 in PURSUIT-HFpEF registry were divided into two groups according to estimated glomerular filtration rate (eGFR) at discharge, group with eGFR &amp;lt; 45 (n = 438) and group with eGFR ≥ 45 (n = 371). Two groups were further divided according to whether Hb was above or below 11 &amp;lt; g/dl at discharge: the group with Hb &amp;lt; 11 g/dl was divided into two groups, one with progression anemia (G1) and preserved anemia (G2) after one year, and the group with Hb ≥ 11 g/dl was divided into three groups, Hb &amp;lt; 11 g/dl (G3), 11 g/dl ≤ Hb &amp;lt; 13 g/dl (G4a), Hb ≥ 13 g/dl (G4b). We examined Hazard ratio (HR) and incidence rate of Major Adverse Cardiovascular Events (MACE), all-cause death and heart failure readmission between each two groups, G1 and G2, G3 and G4a, G4a and G4b, and examined predictor for MACE in each two groups with Hb &amp;lt; 11g/dl and ≥ 11 g/dl at discharge by Cox regression model, in two groups with eGFR &amp;lt;45 and ≥ 45 at discharge. Result All-cause death was significantly lower in G2 than in G1 (HR : 0.33, [95%Confidence Interval (CI), 0.14 - 0.80], p = 0.011) in the group with eGFR ≥ 45. MACE was significantly higher in G3 than in G4a by log-rank test (HR : 1.61, [95%CI, 1.02 - 3.45], p = 0.038) in the group with eGFR &amp;lt; 45, however, MACE, all-cause death and heart failure readmission were significantly higher in G3 than in G4a in the group with eGFR ≥ 45 (MACE ; HR : 1.99, [95%CI, 1.15 - 3.45], p = 0.013, All-cause death ; HR : 2.09, [95%CI, 1.02 - 4.29], p = 0.042, heart failure readmissio ; HR : 2.43, [95%CI, 1.22 - 4.82], p = 0.009). Only all-cause death was significantly lower in G4b than in G4a by log-rank test regardless of renal function (eGFR &amp;lt; 45 ; HR : 0.08, [95%CI, 0.01 - 0.60], p = 0.002, eGFR ≥ 45 ; HR : 0.38, [95%CI, 0.18 - 0.83], p = 0.012). In multivariate Cox regression model, worsening anemia to Hb &amp;lt; 11 g/dl one year later was independent predictor for MACE in patients with eGFR ≥ 45 and Hb ≥ 11 g/dl at discharge (HR : 2.45, [95%CI, 1.22 – 4.91], p = 0.012). Conclusion Hb levels of at least 11 g/dl should be maintained to prevent the prognosis of HFpEF worse after discharge of acute decompensated heart failure regardless of renal function, however it might be necessary to maintain higher hemoglobin level in HFpEF patients with moderate to severe renal dysfunction than those with mild renal dysfunction.study flow by eGFR and outcomekaplan-meier curves of outcomes

Abstract 17229: Atrioventricular Conduction System Changes During Transcatheter Aortic Valve Replacement (TAVR)

Introduction: Transcatheter aortic valve replacement (TAVR) is complicated by atrioventricular (AV) conduction disturbance in 8-15% of cases. Prior studies have not utilized complete electrophysiology studies (EPS) with continuous recording during TAVR. We sought to better understand the potential utility of intraprocedural electrophysiologic study to identify patients at risk for developing high-grade AV conduction disturbances after TAVR. Hypothesis: Intraprocedural EPS has the potential to identify patients at risk of developing AV conduction block after TAVR. Methods: We conducted a prospective study of TAVR patients at BIDMC between 5/2021-3/2023, excluding those with pre-existing pacemakers/defibrillators. We performed EPS in the cath lab prior to and after valve replacement: atrial pacing to AV block, recording His bundle electrogram (HBE) and RV pacing to assess VA conduction. When possible we recorded the HBE continuously during valve implant. Results: We studied 400 consecutive patients. Forty-three patients (10.8%) received permanent pacemakers (PPMs). Patients receiving PPM had significantly longer post-HV intervals, greater change in HV interval as well as longer AV Wenckebach cycle length after valve replacement. There were no differences in pre-TAVR AV Wenckebach cycle length or VA conduction. Twenty patients (46.5% of all PPMs) were implanted for AV block post discharge, and after adjustment for age, gender, and baseline HV interval, the only predictor of need for post-discharge PPM was peri-TAVR change in HV interval with an adjusted OR of 1.19 per each 10 ms increase. Conclusions: In contrast to prior studies, we have found that EPS at the time of TAVR may have utility in predicting AV conduction disturbances. Larger increases in HV interval and AV block CL were associated with need for PPM. Measuring the peri-TAVR change in HV interval may be useful in predicting late AV block.

Abstract 18392: Sedentary Behavior and Risk of 1-Year Cardiac Events and Mortality After Suspected Acute Coronary Syndrome

Background: Patients hospitalized with acute coronary syndrome (ACS) remain at high risk for recurrent cardiac events in the first year after discharge, necessitating a need to identify modifiable targets to improve outcomes. While moderate-vigorous physical activity (MVPA) is a hallmark of secondary prevention in this population, sedentary behavior (SB) has emerged as a potentially unique aspect of the physical activity profile that may also have prognostic relevance. Yet little is known regarding whether SB confers risk independent from MVPA and what types of activity should be substituted for SB to impart health benefit among ACS patients in the first year after discharge. Aim: Examine the association between SB and risk of 1-year cardiac events and mortality among patients evaluated for ACS. Methods: Patients (n=609, 52% male, 62 ± 13 y) evaluated in the emergency room for ACS were fitted with a GENEActiv wrist accelerometer in-hospital and wore the device for 30 days post discharge to measure SB, light intensity physical activity (LIPA), MVPA, and sleep. Major adverse cardiovascular events 1-year post discharge were defined as the composite of unstable angina, myocardial infarction, or death. Results: Over follow up, 50 patients (8%) had a major adverse cardiovascular event. SB was associated with an increased risk of 1-year major adverse cardiovascular events after adjusting for demographic and disease severity indicators (HR per 1 h/d increase: 1.33, 95% CI: 1.12, 1.58). The association remained significant after adjusting for MVPA (HR per 1 h/d increase: 1.30, 95% CI: 1.06, 1.59). In isotemporal substitution analyses there were beneficial associations for replacing SB with sleep (per 30 min HR: 0.89, 95% CI: 0.81, 0.97), LIPA (per 30 min HR: 0.51, 95% CI: 0.34, 0.76), and MVPA (per 30 min HR: 0.32, 95% CI: 0.12, 0.85) on 1-year major adverse cardiovascular event risk. Conclusion: SB was associated with increased risk of 1-year cardiac events and mortality among patients evaluated for ACS, independent of MVPA. Replacing SB with sleep, LIPA, or MVPA was associated with lower risk. These findings suggest reducing SB may improve outcomes in ACS survivors and support the public health message that ACS patients should sit less and move or sleep more to mitigate risk.

Abstract 19079: Assessment of Heart Sounds, Physiologic Changes, and Sleep Performance Using Non-Invasive Monitoring in a Volume Depleted Heart Failure Patient

Case: A 46-year-old male with EF 15% who was co-enrolled in two non-invasive remote monitoring clinical trials, using the WHOOP strap and Nanowear vest to track heart failure (HF) progression at Hershey Medical Center was readmitted for volume depletion. Our patient presented to his PCP’s office complaining of daytime fatigue. Review of systems was negative including no dizziness or light headedness. Blood pressures during this visit was 85/50 and 79/49. He was sent to the emergency department where he had persistent hypotension with a creatinine elevation from 2.4 to 3.71. He was admitted for IV fluid resuscitation and diuretic optimization. Methods: We report cumulative metrics pre- and post-hospitalization showing significant changes in sleep performance and S3 heart sound magnitude. Other measured variables with WHOOP included heart rate (HR), respiratory rate (RR), rapid eye movement (REM) sleep, and heart rate variability (HRV). Results: Following adequate hydration, return to euvolemia, and diuretic adjustment, the patient had statistically significant improvement in sleep metrics (Figure 1, Graph C). Patient’s daily strain, a surrogate of HR elevation over time, was also significantly decreased post discharge (5.19 to 0.73, p &lt;0.01). Patient’s S3 heart sounds were measured during both hospitalizations and showed a decrease in amplitude consistent with volume depletion (Figure 1, Graphs A/B). Conclusion: We report physiologic trends that correlate with clinical status as measured using two novel non-invasive monitoring strategies. Poor sleep secondary to orthopnea and paroxysmal nocturnal dyspnea are considered signs that indicate volume overload. This case, indicates that volume depletion in patients with severely reduced EFs could also contribute to poor sleep performance, indicating a narrow therapeutic window. Further studies may validate these devices as remote monitoring tools for HF management.

Peer support for discharge from inpatient to community mental health care: the ENRICH research programme

Peer support for discharge from inpatient to community mental health care: the ENRICH research programme

Latin-American Registry of Cardiovascular Disease and COVID-19: Final Results.

Socioeconomic factors contribute to a more severe impact of COVID-19 in Latin American and Caribbean (LA&C) countries than in developed countries. Patients with a severe or critical illness can develop respiratory and cardiovascular complications. To describe a LA&C population with COVID-19 to provide information related to this disease, in-hospital cardiovascular complications, and in-hospital mortality. The CARDIO COVID-19-20 Registry is an observational, multicenter, prospective, and hospital-based registry of patients with confirmed COVID-19 infection that required in-hospital treatment in LA&C. Enrollment of patients started on May 01, 2020, and ended on June 30, 2021. The CARDIO COVID-19-20 Registry included 3260 patients from 44 institutions of 14 LA&C countries. 63.2% patients were male and median age was 61.0 years old. Most common comorbidities were overweight/obesity (49.7%), hypertension (49.0%), and diabetes mellitus (26.7%). Most frequent cardiovascular complications during hospitalization or reported at discharge were cardiac arrhythmia (9.1%), decompensated heart failure (8.5%), and pulmonary embolism (3.9%). The number of patients admitted to the Intensive Care Unit (ICU) was 1745 (53.5%), and median length of their stay at the ICU was 10.0 days. Support required in ICU included invasive mechanical ventilation (34.2%), vasopressors (27.6%), inotropics (10.3%), and vasodilators (3.7%). Rehospitalization after 30-day post discharge was 7.3%. In-hospital mortality and 30-day post discharge were 25.5% and 2.6%, respectively. According to our findings, more than half of the LA&C population with COVID-19 assessed required management in ICU, with higher requirement of invasive mechanical ventilation and vasoactive support, resulting in a high in-hospital mortality and a considerable high 30-day post discharge rehospitalization and mortality.

Inpatient Rehabilitation Facility Ownership Type Yields Mixed Performances on Quality Measures

ObjectiveTo evaluate the effects of inpatient rehabilitation facility (IRF) ownership type on IRF-Quality Reporting Program (IRF-QRP) measures. DesignCross-sectional, observational design. SettingWe used 2 Centers for Medicare and Medicare publicly-available, facility-level data sources: (1) IRF compare files and (2) IRF rate setting files – final rule. Data from 2021 were included. ParticipantsThe study sample included 1092 IRFs (N=1092). InterventionsNot applicable. Main Outcome MeasuresWe estimated the effects of IRF ownership type, defined as for-profit and nonprofit, on 15 IRF-QRP measures using general linear models. Models were adjusted for the following facility-level characteristics: (1) Centers for Medicare and Medicaid census divisions; (2) number of discharges; (3) teaching status; (4) freestanding vs hospital unit; and (5) estimated average weight per discharge. ResultsOwnership type was significantly associated with 9 out of the fifteen IRF-QRP measures. Nonprofit IRFs performed better with having lower readmissions rates within stay and 30-day post discharge. For-profit IRFs performed better for all the functional measures and with higher rates of returning to home and the community. Lastly, for-profit IRFs spent more per Medicare beneficiary. ConclusionsIdeally, IRF performance would not vary based on ownership type. However, we found that ownership type is associated with IRF-QRP performance scores. We suggest that future studies investigate how ownership type affects patient-level outcomes and the longitudinal effect of ownership type on IRF-QRP measures.

Measuring the impact of therapy on medication use: data-linkage study.

The psychological therapies service (PTS) in the Northern Health and Social Care Trust, in Northern Ireland, provides therapies to adults with moderate or severe mental health difficulties. Psychometric outcomes data are routinely collected to assess if a patient demonstrates significant improvement in their main presenting problem area following therapy. The wider impact of therapy is not fully measured in the outcomes database as this would be disproportionately burdensome for both patient and therapist. The present study, to our knowledge, is the first to use data linkage to link patient therapy outcomes data with prescriptions data. To widen our understanding of patient medication use before and after therapy. Using Health and Care Number as a unique identifier, the Psychological Therapies Service - Routine Outcome Measurement Database (n = 3625) and data from 72 500 controls were linked with data from the Enhanced Prescribing Database (EPD). The EPD data were sourced from the Honest Broker Service. Key findings from the study were: (a) the odds of PTS clients using antipsychotics in the year before therapy were 25 times greater compared with controls (odds ratio (OR) = 24.53, 95% CI 20.16-29.84); (b) in the 1st year post discharge, PTS clients who clinically improved post therapy discharge were more likely than 'non-engagers' and 'non-improvers' to come off antianxiety medication (OR = 0.61, 95%, CI 0.38-0.98); and (c) therapy did not have an impact on antidepressant use. The results highlight the need for discussion between therapy services, GPs and psychiatry about whether more engagement and collaboration is needed to plan phased reduction in medication.

Exploring rehabilitation options and resources of support for stroke survivors in Eldoret, Kenya: qualitative study

BackgroundStroke is a major cause of death and disability in adults globally. Most post-stroke survivors experience various impairments which requires rehabilitation. Likewise, returning home after a stroke represents challenging moments full of struggle. This study, therefore, explores options of rehabilitation and resources of support for stroke survivors in Eldoret, Kenya.MethodA qualitative descriptive approach was used to conduct the study. The study utilised semi-structured interviews. Fifteen dyads of stroke survivors (10 men and 5 women; aged 40–75 years) were enrolled from a rehabilitation outpatient clinic (Medical Park Physical Therapy) in Eldoret, Kenya. Interviews were conducted at the patients’ house, and an inductive approach was used to enable thematic content analysis.ResultsTwo dominant themes and several categories emerged from the participants; these included the following: (1) rehabilitation services available for stroke survivors and (2) resources of support.ConclusionsThe study found that stroke units are only available at the national hospitals and not accessible to many. Patients receive physiotherapy and occupational therapy services during hospital stay but has poor access post discharge. Transport, distance, and lack of finances have been highlighted as the main challenges. There is scarcity of speech therapist as well as advanced orthotics for stroke rehabilitation. From a clinical perspective, healthcare system should be better structured to accommodate continuity of care post discharge for stroke survivors.

The Temporal Relationship Between Moderate to Vigorous Physical Activity and Secondary Conditions During the First Year After Moderate to Severe Traumatic Brain Injury

ObjectiveTo determine the cross-sectional and temporal relationships between minutes per week of moderate to vigorous physical activity (MVPA) as measured by a wrist-worn accelerometer and secondary conditions in the first year after moderate to severe traumatic brain injury (TBI). DesignProspective longitudinal cohort study. SettingFour inpatient rehabilitation centers. ParticipantsIndividuals (N = 180) with moderate-severe TBI enrolled in the TBI Model Systems Study. InterventionsParticipants wore a wrist accelerometer for 7 days immediately post discharge, and for 7 consecutive days at 6- and 12-months post injury. Main Outcome MeasuresMinutes per week of MVPA from daily averages based on wrist worn accelerometer. Secondary conditions included depression (Patient Health Questionnaire-9), fatigue (PROMIS Fatigue), Pain (Numeric Rating Scale), Sleep (Pittsburgh Sleep Quality Index), and cognition (Brief Test of Adult Cognition by Telephone). ResultsAt baseline, 6 and 12 months, 61%, 70% and 79% of the sample achieved at least 150 minutes per week of MVPA. The correlations between minutes of MVPA between baseline, 6 and 12 months were significant (r = 0.53-0.73), as were secondary conditions over these time points. However, no significant correlations were observed between minutes of MVPA and any secondary outcomes cross-sectionally or longitudinally at any time point. ConclusionsGiven the robust relationships physical activity has with outcomes in the general population, further research is needed to understand the effect of physical activity in individuals with moderate-severe TBI.

Traumatic Brain Injury Rehabilitation Outcome Prediction Using Machine Learning Methods

ObjectiveTo investigate the performance of machine learning (ML) methods for predicting outcomes from inpatient rehabilitation for subjects with TBI using a dataset with a large number of predictor variables. Our second objective was to identify top predictive features selected by the ML models for each outcome and to validate the interpretability of the models. DesignSecondary analysis using computational modeling of relationships between patients, injury and treatment activities and 6 outcomes, applied to the large multi-site, prospective, longitudinal observational dataset collected during the traumatic brain injury inpatient rehabilitation study. SettingAcute inpatient rehabilitation. Participants1946 patients aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, and were admitted to 1 of 9 US inpatient rehabilitation sites between 2008 and 2011 (N=1946). Main Outcome MeasuresRehabilitation length of stay, discharge to home, FIM cognitive and FIM motor at discharge and at 9-months post discharge. ResultsAdvanced ML models, specifically gradient boosting tree model, performed consistently better than all other models, including classical linear regression models. Top ranked predictive features were identified for each of the 6 outcome variables. Level of effort, days to rehabilitation admission, age at rehabilitation admission, and advanced mobility activities were the most frequently top ranked predictive features. The highest-ranking predictive feature differed across the specific outcome variable. ConclusionsIdentifying patient, injury, and rehabilitation treatment variables that are predictive of better outcomes will contribute to cost-effective care delivery and guide evidence-based clinical practice. ML methods can contribute to these efforts.