Unplanned Hospital Research Articles

Risk Factors for Emergency Room Visit by Head and Neck Cancer Patients: A Longitudinal Cohort Study in the Korean Healthcare System.

Due to the application of multiple treatment modalities, a substantial proportion of patients with head and neck cancer (HNC) experience one or more emergency room (ER) visits or unplanned hospitalizations during or after treatment. We investigated HNC cases that visited ERs after cancer treatment to identify potential risk factors in the context of the Korean healthcare system. This was a single-center cohort study of HNC patients who underwent cancer treatments at OOOO in 2019 (N = 566). The patients were treated with surgery alone (N = 184), surgery plus adjuvant therapy (N = 138), curative non-surgical treatment (radiation or chemo-radiation) (N = 209), or palliative treatments (N = 35). We followed up cases for up to 3 years, who visited the ER after (or during) cancer treatments and analyzed the main reasons and risk factors for ER visits. The rate of ER visits was 8.0% (N = 45) of patients with HNC (no. of ER visits, N = 70, 12.4%, mean = 1.56, range = 1-4), among which treatment-related ER visits made up 4.6%. Common reasons for ER visits were surgical site or wound problems (31.1% per patient, 22.9% per ER visits), and oral intake or feeding problems (22.2% per patient, 31.4% per ER visit). Tumor subsite (17.9% of treatment-related ER visits in hypopharynx cancer), tumor burden (8.6-12.2% in T2-4 and 6.7% in N+ status), and treatment modalities (surgery with adjuvant chemo-radiation, 19.4%) were identified as significant risk factors for ER visits, while patient age and comorbidities were not. The most common causes for ER visits were wound and feeding problems in HNC patients, and tumor factors and treatment modalities were independent risk factors for ER visits. Adequate planning and management to address these problems could help reduce ER visits and costs and improve patient care.

Myosteatosis Is Associated With Frailty and Poor Physical Function in Patients Undergoing Liver Transplant Evaluation: A Cohort Study.

Myosteatosis is fat infiltration within skeletal muscle. The impact of myosteatosis on physical function and clinical outcomes in patients referred for liver transplantation (LT) is unclear. We explored associations between myosteatosis and sarcopenia, frailty, physical function, and pre- and early post-LT outcomes. Myosteatosis was assessed by computed tomography (CT) in 237 patients referred for LT (March 2018 to September 2022). Chi-square/Fishers exact tests and multivariable regression compared myosteatosis and sarcopenia, frailty (liver frailty index), physical function (short physical performance battery, SPPB); and associations with pre-LT unplanned hospitalizations, post-LT surgical complications (Clavien-Dindo grade≥3), and LT admission length of stay (LOS). Kaplan-Meier and Cox-proportional hazards models explored myosteatosis and time to LT and unplanned admission. Fine-Gray model evaluated the competing risks of receiving an LT. Myosteatosis was present in 74 (31%) patients. Patients with myosteatosis were 2.5 times (95% confidence interval [CI] 1.1-5.7, p=0.03) more likely to be frail, and 3.0 times (95% CI 1.6-5.6, p<0.001) more likely to have a poor physical function (SPPB≤9/12) than those without myosteatosis. Patients with myosteatosis versus those without were more likely to have a pre-LT unplanned hospitalization (51% vs. 36%, p=0.03), but significance was lost after adjusting for age, sex, Model for End-stage Liver Disease (MELD), and the presence of hepatocellular carcinoma. Myosteatosis did not impact the likelihood of receiving an LT (p=0.39), post-LT complications (p=0.93), or LOS in intensive care unit (ICU) (p=0.66) or hospital (p=0.34). Myosteatosis is prevalent in patients referred for LT and is associated with impaired physical function. Using existing CTs to assess myosteatosis in practice may help identify physically compromised patients.

Utilization of Neurology and Allied Health Services by People With Parkinson's Disease in Israel: A Retrospective Observational Study.

Sustainable utilization of neurology and allied health professions' services is pivotal for effective management of Parkinson disease (PD) and is correlated with positive health-related outcomes. (1) To describe the utilization of neurology and allied health services by people with PD (PwP); (2) to explore the associations between demographic and structural variables and utilization; and (3) to test associations between utilization and unplanned hospitalizations. A retrospective observational cohort study of 1761 PwP in the years 2014-2019 was conducted. Utilization of neurology and allied health services was mapped. Regression models were examined to test associations between demographic and structural variables, utilization of neurology and physical therapy (PT), and unplanned hospitalizations. Approximately 50% of the study population utilized neurology services. Utilization rate of allied health services ranged between 0% and 19%. The likelihood of utilizing neurology services increased for people with extended health insurance and people with more years since diagnosis and decreased for women and for people living at a great distance from a neurology service. The likelihood of utilizing PT increased for Jews and people with extended health insurance and decreased for people with more years since diagnosis and for people living at a great distance from a PT service. Among patients with fewer years since diagnosis (<5years), those who utilized PT had a higher likelihood of unplanned hospitalization. Neurology and allied health services are underutilized by PwP, particularly by minorities and women. Policymakers should take proactive steps to increase utilization. for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A496).

Recent Advancements and Techniques Regarding the Roles of Pharmacists, Nutritionists, Nurses, Laboratory Technicians, and Other Healthcare Professionals in the Care of Cancer Patients: A Comprehensive Review

Background: The paradigm of cancer care has evolved significantly, from a physician-centric model to a comprehensive multidisciplinary approach. Aim: This review analyzes the changing roles of healthcare personnel and technological advancements in modern cancer care. Results: Implementing advanced multidisciplinary care models resulted in notable enhancements in patient outcomes, namely, a 48% decrease in emergency department visits and a 43% decline in unplanned hospitalizations. Interventions by clinical pharmacists decreased medication errors by 42% and enhanced protocol adherence by 95%. Incorporating digital health technology boosted care coordination by 45% and improved infection control methods reduced healthcare-associated infections by 45%. Laboratory diagnostics have attained 99.8% accuracy in mutation detection with next-generation sequencing, transforming precision medicine methodologies in cancer. Conclusions: This study presents significant data demonstrating the beneficial effects of advanced healthcare professional roles and technological integration on cancer treatment. The results indicated superior patient outcomes, greater care coordination, and increased treatment efficacy using interdisciplinary strategies. Future research should standardize these improved methods across various healthcare environments and address implementation obstacles to provide fair access to enhancements in cancer care delivery.

Nurse and doctor turnover and patient outcomes in NHS acute trusts in England: retrospective longitudinal study

ObjectiveTo investigate the association between monthly turnover rates of hospital nurses and senior doctors and patient health outcomes (mortality and unplanned hospital readmissions).DesignRetrospective longitudinal study.SettingAll 148 NHS acute trusts in...

Association of Observation Stays with Clinical Outcomes and Costs in Medicare: An Instrumental Variable Analysis.

Observation stays in Medicare have grown over the last 15years, yet limited research exists on how observation may impact outcomes for older adults. To examine the relationship of an observation stay with 30-day hospital returns, total acute care days post-discharge, mortality, and out-of-pocket costs, compared to an inpatient admission. Retrospective cohort study using instrumental variable analysis. A 20% sample of US Medicare beneficiaries admitted to acute care with a length of stay < 5days between 2009 and 2019. Observation stay vs inpatient admission. Unplanned hospital return within 30days, total 30-day post-discharge acute care days, 30-day mortality, and 30-day acute care out-of-pocket spending. A total of 3,958,377 hospitalizations met study criteria, of which 1,656,631 (42%) were observation stays and 2,301,746 (58%) were inpatient admissions. Compared to inpatient admissions, observation stays were associated with a 4.39 percentage point (95% confidence interval [CI] 3.56%, 5.22%) higher rate of 30-day unplanned hospital returns, but no difference in total 30-day post-discharge acute care days (difference - 0.02days; 95% CI - 0.08, 0.03), no difference in 30-day mortality (difference 0.20 percentage points; 95% CI 0.00, 0.40), and lower 30-day out-of-pocket costs (difference - $552; 95% CI - $561, - $542). Among Medicare beneficiaries hospitalized for fewer than 5days, observation stay was associated with higher rates of 30-day unplanned hospital returns compared to inpatient admission. However, we simultaneously observed lower out-of-pocket costs among those hospitalized under an observation stay. The mixed results suggest that additional research and engagement with relevant parties is needed to optimize observation stay policy.

Patient Reported Outcome Measures in cancer care: a hybrid effectiveness-Implementation trial to optimise Symptom control and health service Experience (PROMISE)–protocol for a randomised controlled trial of electronic self-reporting of symptoms versus usual care during and following treatment in patients with cancer

IntroductionRoutine collection of patient-reported outcome measures (PROMs) has the potential to inform and improve cancer care. It is now feasible for patients to complete PROMs electronically (ePROMs) providing information about...

Clinical Relevance of Intensive Laboratory Monitoring With Standard Venetoclax Ramp-Up for Chronic Lymphocytic Leukemia: A Real-World Experience

PURPOSE Venetoclax is the standard of care for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) but requires intensive monitoring for optimal safety. Clinical relevance of intensive monitoring in practice is unknown, especially for patients with low or intermediate risk for tumor lysis syndrome (TLS). PATIENTS AND METHODS A retrospective review was conducted to determine clinical significance of monitoring for TLS during standard ramp-up for patients with CLL/SLL. Patients receiving abbreviated ramp-up, clinical trials, or concurrent Bruton tyrosine kinase inhibitors were excluded. The primary end point was TLS incidence, with secondary end points describing associated clinical interventions. RESULTS Fifty-five patients met study criteria. The majority of patients received venetoclax as first-line therapy (58%), with anti-CD20 antibody therapy (82%), and were at low risk of TLS (75%). No clinical TLS events occurred, whereas laboratory TLS occurred in only 1.8% of patients. No patients required antihyperuricemic therapy, and few interventions for hyperphosphatemia or hypocalcemia (3.6% of patients) were required. Additional intravenous fluids were uncommonly required (1.8% of patients), and no unplanned hospitalizations were required. CONCLUSION These findings support efforts to reduce intensive monitoring requirements during venetoclax ramp-up for patients with CLL, potentially increasing accessibility of venetoclax.

A Pharmacist Medication Titration Program for Patients with Cardiac Sarcoidosis and Systolic Heart Failure: A Retrospective Cohort Study

Background A multidisciplinary approach improves guideline‐directed medical therapy (GDMT) in systolic heart failure (HF), but its efficacy in patients with HF due to cardiac sarcoidosis (CS) is unreported. Methods and Results In a retrospective cohort study, we reviewed 848 patients from our institutional CS clinics, identifying those with a CS diagnosis, HF (LVEF &lt; 50%) at index evaluation, and echocardiograms within 90 days and 11‐36 months. Patients were stratified by participation in a pharmacist‐led medication therapy management (MTM) program for GDMT optimization (MTM vs non‐MTM [NMTM]) without randomization. Demographics, LVEF, GDMT (quantified by Kansas City Medical Optimization [KCMO] score), and immunosuppressive therapy were assessed. Primary outcomes included changes in KCMO score, LVEF, and cardiovascular event‐free survival (unplanned HF hospitalization, LVAD/heart transplant, or death). The final cohort included 111 patients (median age 57 years, 34% female, 64% NYHA Class I‐II); 43 (39%) were MTM and 68 (61%) were NMTM. Mean KCMO score was similar at index evaluation (MTM: 23.2; NMTM: 29.6, p=0.83). At follow‐up (median 16 months), the KCMO score increased significantly in both groups (MTM: 23.2 to 74.8, p&lt;0.001; NMTM: 29.6 to 58.7, p&lt;0.001), but was higher in MTM (p=0.001). Mean LVEF trended towards higher values in MTM (44.4% vs 40.0%, p=0.05). The primary clinical outcome occurred in 1 MTM (2.3%) and 16 NMTM (23.5%) patients, with higher risk in NMTM (HR 11.97 [95%CI 1.58 ‐ 90.54], p=0.002). Conclusions In this retrospective cohort study, a pharmacist‐led MTM program was associated with favorable GDMT optimization and lower risk of adverse cardiovascular outcomes in CS patients with HF.

Finerenone in Women and Men With Heart Failure With Mildly Reduced or Preserved Ejection Fraction

Sex is associated with the clinical presentation, outcomes, and response to treatment in patients with heart failure (HF). However, little is known about the safety and efficacy of treatment with finerenone according to sex. To estimate the efficacy and safety of finerenone compared with placebo in both women and men. Prespecified analyses were conducted in the phase 3 randomized clinical trial Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients with Heart Failure (FINEARTS-HF). The trial was conducted across 653 sites in 37 countries. Participants were adults aged 40 years and older with symptomatic HF and left ventricular ejection fraction (LVEF) of 40% or greater randomized between September 2020 and January 2023. Finerenone (titrated to 20 mg or 40 mg) or placebo. The primary outcome was a composite of cardiovascular death and total (first and recurrent) HF events (unplanned HF hospitalizations or urgent HF visits). A total of 6001 patients were randomized in FINEARTS-HF, of whom 2732 were women (45.5%), with a mean (SD) age of 73.6 (9.1) years. Women had higher rates of any obesity, higher LVEF (54.6 [7.6%] vs 50.9 [7.6] for men), lower mean (SD) estimated glomerular filtration rate than men (59.7 [19.1] vs 64.1 [20.0] for men; P<.001) , worse New York Heart Association functional class, and lower Kansas City Cardiomyopathy Questionnaire-Total Symptom Scores (KCCQ-TSS) (mean [SD] 62.3 [24.0] vs 71.0 [23.1]). The incident rate of the primary outcome was slightly lower in women (15.7; 95% CI, 14.3-17.3) than in men (16.8; 95% CI, 15.4-18.3) per 100 person-years. Compared with placebo, finerenone reduced the risk of the primary end point similarly in women and men: rate ratio 0.78 (95% CI, 0.65-0.95) in women and 0.88 (95% CI, 0.74-1.04) in men (P = .41 for interaction). Consistent effects were observed for the components of the primary outcome and all-cause mortality. The mean increase (improvement) in KCCQ-TSS from baseline to 12 months was greater with finerenone, regardless of sex (P = .73 for interaction). Finerenone had similar tolerability in women and men. In FINEARTS-HF, finerenone reduced the risk of the primary end point similarly in women and men with heart failure with mildly reduced or preserved ejection fraction. Finerenone had similar tolerability in women and men. ClinicalTrials.gov Identifier: NCT04435626.

Synergistic use of Unplanned Reoperation and Hospital Readmission rates for quality monitoring in pediatric surgical care.

Unplanned reoperation (URO) and unplanned hospital readmission (UHR) are key quality indicators used to assess healthcare quality improvement. The aim of this study was to describe, quantify, analyze and compare both indicators in a Pediatric Surgery Department. An observational study was conducted reviewing the medical records of pediatric patients who underwent unplanned reoperation and unplanned hospital readmission over a six-year period in a pediatric surgical unit. The incidence, indications, and causes of reoperations and readmissions were analyzed. A total of 6,376 surgeries were performed over a six-year period. During this time, there were 37 (0.58%) URO and 20 (0.31%) UHR. There were 23/2,437(0.94%) URO and 14/2,437(0.57%) UHR among emergency surgeries. In contrast, there were 14/3,939(0.35%) URO and 6/3,939(0.15%) UHR among elective surgeries (p < 0.05). Outpatient surgeries had 3/1,639 (0.18%) URO and 1/1,639 (0.06%) UHR compared to inpatient surgeries that had 11/2,300(0.47%) URO and 5/2,300 (0.21%) UHR respectively (p = ns). A total of 1,570 appendectomies were performed during the study period, with 8/1,570(0.5%) patients requiring either a URO or a UHR. The most frequent indication for both URO and UHR were intra-abdominal infections. The main cause of URO was a technical error during surgery (70%), while the main cause of UHR was an error in the medical treatment (35%). In our practice, URO are more frequent than UHR. Emergency surgeries have a higher risk of undergoing an URO or a UHR. Acute appendicitis is the most common diagnosis associated with the need for an URO or a UHR. The majority of unplanned reoperation cases are due to technical errors during surgery.

Patient use of pulse oximetry to support management of COVID-19 in Greater Manchester: A non-randomised evaluation using a target trial approach.

The pandemic saw widespread use of home pulse oximeters to patients diagnosed with COVID-19 to support early detection of low oxygen saturation levels and appropriate care. Rapid implementation made conventional evaluation challenging, highlighting the need for rigorous non-randomised methods to support decision-making about future use of these technologies. We used routine data to explore the benefits of pulse oximetry in Greater Manchester, under the 'COVID-19 oximetry at home' (CO@h) programme. We used data from the Greater Manchester Secure Data Environment and defined study parameters using a 'target trial' model to compare patients receiving pulse oximetry under the CO@h programme, with matched controls using various comparator groups. Primary outcomes were unplanned hospitalisation and all-cause mortality. This study is based on data from the Greater Manchester Care Record (GMCR), using anonymised, routinely collected data provided in a de-identified format for research. Informed written consent is needed for primary care patient data to be collected for service improvement and research, before data extraction to the GMCR. The study was approved under protocol GMCR RQ-048, on 12/05/2022. As indicated by the University of Manchester ethics decision tool, formal ethical approval was not required for this study. The adjusted odds ratios for an unplanned hospitalisation were higher among patients receiving pulse oximetry: OR 1.86 (95% CI 1.54-2.25) at 28 days, 1.5 (95% CI 1.3-1.74) at 90 days and 1.63 (95% CI 1.44-1.83) at 1 year. Overall odds of mortality were lower among patients receiving pulse oximetry: adjusted ORs of 0.5 (95% CI 0.25-0.98) at 28 days, 0.5 (95% CI 0.32-0.78) at 90 days and 0.58 (95% CI 0.44-0.76) at 1 year. The results were robust to different comparison groups. Use of pulse oximetry at home under the CO@h programme, through the resulting prioritisation for appropriate care, was associated with a higher frequency of unplanned admissions and a reduction in the risk of mortality up to 1 year later. Therefore, it is likely effective for early detection of clinical deterioration and timely intervention among patients with COVID-19. Further research is needed to understand whether this is a cost-effective use of healthcare resources.

Impact of hospital readmissions following hospitalisation with delirium on 12-month mortality: a quaternary Australian hospital experience.

Inpatient delirium and unplanned hospital readmissions are associated with increased mortality. This study aimed to determine the effect of 28-day unplanned hospital readmissions on 12-month mortality post-discharge in patients with delirium during index hospitalisation. Retrospective longitudinal cohort study of adults aged 65 or above with delirium during hospitalisation at a Victorian quaternary hospital was performed. Delirium was identified by the inclusion of ICD-10 (International Classification of Diseases, 10th revision) codes in the hospital medical discharge summary. Descriptive statistics was obtained for baseline characteristics. Cox proportional hazards model was developed to identify independent predictors of 12-month post-discharge mortality. One thousand six hundred thirty-four patients with delirium during in-patient admission were included. The overall 12-month mortality rate was 35% (572 patients). Of the 1,425 patients who survived their index admission, 11.2% had an unplanned 28-day readmission. In Cox regression analysis, unplanned readmission (hazard ratio (HR) 2.3, 95% confidence internal (CI) 1.7-2.9), older age (HR 1.38, CI 1.11-1.72), Charlson Comorbidity Index (HR 1.21, CI 1.17-1.27), and discharge to nursing home (HR 1.58, CI 1.23-2.02) were independent predictors of 12-month mortality. Readmitted patients with 12-month mortality were older, with higher rates of dementia, polypharmacy, and nursing home residence compared to readmitted patients who did not reach this endpoint. Unplanned hospital readmission within 28days of discharge is an independent predictor of 12-month mortality post in-hospital delirium admission. Admissions complicated by delirium and readmission episodes should instigate discussions regarding prognostication and goals of care. Greater research is required to minimise hospital readmission rates following discharge in this cohort.

Per-Patient Illness Trajectory Analyses.

Background: Summary statistics often hide individual patients' suffering, thereby impeding quality improvement efforts. Objectives: We aimed to show the experience of a population with health care toward the end of life while preserving the experience of the individual. Design: We developed a data display method called per-patient illness trajectory analysis. We tested it using a demonstration cohort of 192 patients with cancer referred to a regional Swedish specialized home-based palliative care practice. Chart review provided detailed information about illness trajectory events with a focus on unplanned hospitalization. Results: We created per-patient timelines spanning from cancer diagnosis until death and using a logarithmic scale: Compared with a conventional, linear timescale, this scale expands the time resolution toward the end of life. The method fosters the assessment of unmet palliative care need and care quality for individuals, small high-need groups, and populations. Conclusion: In populations of up to 200 people, per-patient illness trajectory analysis is feasible and promising. Using random sampling, it could be extended to larger populations.

Abstract 4130072: Prognostic Impact of Renal Microcirculatory Dysfunction in Heart Failure Assessed by the Advanced Doppler technique, Superb Microvascular Imaging

Aims: The significance of cardio-renal interactions in heart failure (HF) prognosis has become increasingly evident, yet there are no established methods to assess them. To address this issue, we propose a novel approach using Superb Microvascular Imaging (SMI), an ultrasound method that that enables detailed visualization of microvascular flow, to assess renal microcirculation. Methods: We retrospectively analyzed 78 patients who underwent renal ultrasonography using SMI from October 2020 to May 2023. We measured changes over time of Vascular Index (VI), which quantifies the blood flow signal area in the region of interest on the SMI image (Figure 1). Key measurements included Maximum VI (Max.VI), Minimum VI (Min.VI), and the cyclic variation of VI, calculated as the intrarenal perfusion index (IRPI) = (Max.VI - Min.VI) / Max.VI within one cardiac cycle. The primary endpoint of this study was a composite event (CE), defined as a composite of all-cause death and unplanned hospitalization for worsening HF. Results: During a mean follow-up period of 1.6±0.8 years, 13 of 78 patients (17%) experienced a CE. Compared with patients without CE, those with CE had significantly lower Max.VI (0.28±0.15 vs 0.46±0.18, p=0.002) and Min.VI (0.10±0.12 vs 0.22±0.14, p=0.007), and IRPI was significantly higher in the event group (0.68±0.19 vs 0.55±0.17, p=0.018). In univariable Cox regression analyses, Max.VI (HR 0.35, 95%CI 0.17-0.71, p=0.004), Min.VI (HR 0.28, 95%CI 0.10-0.75, p=0.012), IRPI (HR 1.97, 95%CI 1.11-3.51, p=0.021), creatinine (Cr) (HR 1.67, 95%CI 1.26-2.21, p&lt;0.001) and estimated right atrial pressure by echocardiography (eRAP) (HR 4.22, 95%CI 1.42-12.5, p&lt;0.001) were significantly associated with CE. In multivariable Cox regression analyses, Min.VI remained significantly associated with CE in the model adjusted for Cr (HR 0.35, 95%CI: 0.13-0.92, p=0.033), and in the model adjusted for eRAP (HR 0.11, 95%CI: 0.11-0.82, p=0.019). ROC curve analysis showed that, although not statistically significant, the predictive power of Min.VI was superior to that of Cr and eRAP (Figure 2). Stratifying patients by a Min.VI cut-off value of 0.08, determined through ROC analysis, showed that those with Min.VI &lt; 0.08 had a significantly poorer prognosis (log-rank p&lt;0.001) (Figure 3). Conclusion: The use of Superb Microvascular Imaging to assess renal circulation provides new insights into the prognosis of HF and allows risk stratification beyond conventional markers.

Identifying and Predicting Risk for Hospital Admission among Patients with Parkinsonism.

Patients with parkinsonism are more likely than age-matched controls to be admitted to hospital. It may be possible to reduce the cost and negative impact by identifying patients at highest risk and intervening to reduce hospital-related costs. Predictive models have been developed in nonparkinsonism populations. The aims were to (1) describe the reasons for admission, (2) describe the rates of hospital admission/emergency department attendance over time, and (3) use routine data to risk stratify unplanned hospital attendance in people with parkinsonism. This retrospective cohort study used Clinical Practice Research Datalink GOLD, a large UK primary care database, linked to hospital admission and emergency department attendance data. The primary diagnoses for nonelective admissions were categorized, and the frequencies were compared between parkinsonism cases and matched controls. Multilevel logistic and negative binomial regression models were used to estimate the risk of any and multiple admissions, respectively, for patients with parkinsonism. There were 9189 patients with parkinsonism and 45,390 controls. The odds of emergency admission more than doubled from 2010 to 2019 (odds ratio [OR] 2.33; 95% confidence interval [CI] 1.96, 2.76; P-value for trend <0.001). Pneumonia was the most common reason for admission among cases, followed by urinary tract infection. Increasing age, multimorbidity, parkinsonism duration, deprivation, and care home residence increased the odds of admission. Rural location was associated with reduced OR for admission (OR 0.79; 95% CI 0.70, 0.89). Our risk stratification tool may enable empirical targeting of interventions to reduce admission risk for parkinsonism patients.

Early Intervention in Patients With Asymptomatic Severe Aortic Stenosis and Myocardial Fibrosis

Development of myocardial fibrosis in patients with aortic stenosis precedes left ventricular decompensation and is associated with an adverse long-term prognosis. To investigate whether early valve intervention reduced the incidence of all-cause death or unplanned aortic stenosis-related hospitalization in asymptomatic patients with severe aortic stenosis and myocardial fibrosis. This prospective, randomized, open-label, masked end point trial was conducted between August 2017 and October 2022 at 24 cardiac centers across the UK and Australia. Asymptomatic patients with severe aortic stenosis and myocardial fibrosis were included. The final date of follow-up was July 26, 2024. Early valve intervention with transcatheter or surgical aortic valve replacement or guideline-directed conservative management. The primary outcome was a composite of all-cause death or unplanned aortic stenosis-related hospitalization in a time-to-first-event intention-to-treat analysis. There were 9 secondary outcomes, including the components of the primary outcome and symptom status at 12 months. The trial enrolled 224 eligible patients (mean [SD] age, 73 [9] years; 63 women [28%]; mean [SD] aortic valve peak velocity of 4.3 [0.5] m/s) of the originally planned sample size of 356 patients. The primary end point occurred in 20 of 113 patients (18%) in the early intervention group and 25 of 111 patients (23%) in the guideline-directed conservative management group (hazard ratio, 0.79 [95% CI, 0.44-1.43]; P = .44; between-group difference, -4.82% [95% CI, -15.31% to 5.66%]). Of 9 prespecified secondary end points, 7 showed no significant difference. All-cause death occurred in 16 of 113 patients (14%) in the early intervention group and 14 of 111 (13%) in the guideline-directed group (hazard ratio, 1.22 [95% CI, 0.59-2.51]) and unplanned aortic stenosis hospitalization occurred in 7 of 113 patients (6%) and 19 of 111 patients (17%), respectively (hazard ratio, 0.37 [95% CI, 0.16-0.88]). Early intervention was associated with a lower 12-month rate of New York Heart Association class II-IV symptoms than guideline-directed conservative management (21 [19.7%] vs 39 [37.9%]; odds ratio, 0.37 [95% CI, 0.20-0.70]). In asymptomatic patients with severe aortic stenosis and myocardial fibrosis, early aortic valve intervention had no demonstrable effect on all-cause death or unplanned aortic stenosis-related hospitalization. The trial had a wide 95% CI around the primary end point, with further research needed to confirm these findings. ClinicalTrials.gov Identifier: NCT03094143.

Remote monitoring and prioritisation for patients awaiting transcatheter aortic valve implantation safely mitigates longer waiting times

Abstract Background • The UK National Health Service (NHS) faces an unprecedented backlog of over 400,000 patients awaiting critical cardiac procedures, incurring thousands of excess deaths (1). • Longer waiting times to transcatheter aortic valve implantation (TAVI) can increase rates of unplanned hospitalisation and death (2). • Remote patient monitoring (RPM) can improve cardiovascular clinical outcomes (3), but its effectiveness in detecting and managing TAVI waiting list deterioration is untested. Purpose 1. Measure the systemic increase in waiting time to TAVI 2. Determine if RPM and prioritisation: · Is acceptable to patients · Detects clinical deterioration · Mitigates the expected increase in adverse events associated with longer waiting times · Does not unfairly disadvantage patients who are not prioritised Methods • We performed an observational cohort study including all patients awaiting TAVI at one UK regional centre between 24th April and 15th November 2023. • Patients were supported to complete an online or telephone-based weekly symptom questionnaire. • Responses were monitored by non-specialist nurses staffing a 'hub', with rule-based escalation to the TAVI team, who could prioritise treatment (Figure 1). • A historical control cohort who did not receive RPM was identified, as sequential unselected patients on the TAVI waiting list in reverse order, from 24th April 2023 to 1st January 2023. This cohort was propensity score-matched to adjust for age, sex, ethnicity and comorbidities. • Waiting time was defined as the date difference between a patient being placed on the waiting list and TAVI completion. • We defined patient acceptability as &amp;gt;80% engagement with at least one symptom questionnaire. • Sensitivity was calculated as the percentage of escalations to the TAVI Consultant resulting in prioritisation. • Kaplan-Meier survival analysis was performed for the primary endpoint of adverse events, defined as emergency department presentation, unplanned hospitalisation or death. Results • The median waiting time to TAVI increased by one month (104 days versus 75 days, p&amp;lt;0.001). • There was 99% (200/202) engagement with RPM • Despite the increased waiting time, there was no significant difference in rate of adverse events between the propensity score-matched RPM and historical control groups (12.5% versus 13.7%, p=0.86) (Figure 2) • 87% (27/31) of escalations to the TAVI Consultant resulted in treatment prioritisation • There was a non-significant difference in median waiting time between prioritised and non-prioritised patients during the study period, but with no clinical consequence to the delay (97 versus 120 days, p=0.16). Conclusions • An RPM pathway can detect patient deterioration on TAVI waiting lists with high sensitivity • RPM-based prioritisation for patients awaiting TAVI can mitigate the increased risk of adverse events associated with longer waiting times, without unfairly disadvantaging non-prioritised patients.Figure 1.RPM pathwayFigure 2

Diagnostic performance of computed tomography-derived fractional flow reserve in patients with severe aortic stenosis

Abstract Background Computed tomography-derived fractional flow reserve (FFR-CT) is a clinical modality for assessing coronary artery disease; however, its use has not been validated in patients with severe aortic stenosis (AS). Purpose This study assessed the diagnostic performance of FFR-CT in patients with severe AS. Methods Retrospectively recruited patients with severe AS underwent standard-protocol invasive fractional flow reserve (FFR) and coronary CT angiography. The FFR-CT values were compared with the invasive FFR values (ischemia defined as invasive FFR ≦0.80). Results Among 46 patients (105 vessels), the mean age was 82.8 ± 5.9 years (37% male). Mean invasive FFR and FFR-CT values were 0.86 ± 0.11 and 0.83 ± 0.10, respectively. In a per-vessel analysis, there was a positive correlation between invasive FFR and FFR-CT values (Pearson correlation coefficient, R= 0.64; P&amp;lt;0.0001). In addition, the sensitivity, specificity, positive predictive, and negative predictive values were 100%, 86%, 43%, and 100% with 88% diagnostic accuracy, respectively. The Bland-Altman plot showed that the mean bias between invasive FFR and FFR-CT values was 0.031 (-0.146 to 0.209). The per vessels area under the receiver-operating characteristic curve analysis was 0.97 (95 % CI: 0.94-1.00, P&amp;lt;0.0001). Importantly, among another 58 patients who deferred invasive coronary angiography (ICA) because the FFR-CT value was negative (&amp;gt; 0.80), none experienced deterioration of condition during transcatheter aortic valve replacement (TAVR) or major adverse cardiac events (all-cause death, myocardial infarction, and unplanned hospitalization with urgent revascularization) within 30 days after TAVR. Conclusions FFR-CT values were significantly correlated with invasive FFR values and had a high negative predictive value in patients with severe AS. Patients with a negative FFR-CT value and deferred ICA had an excellent short-term prognosis after TAVR. FFR-CT is expected to serve as a gatekeeper for unnecessary ICA prior to TAVR.

An elevated mPAP over CO slope by exercise echocardiography predicts outcome in unexplained dyspnea

Abstract Background Exercise pulmonary hypertension, defined by a slope of mean pulmonary artery pressure (mPAP) over cardiac output (CO) &amp;gt;3 mmHg/L/min, measured by invasive exercise hemodynamics, is associated with worse event-free survival in patients with unexplained dyspnea. Whether non-invasive techniques yield similar results has yet to be tested. Purpose To investigate the prognostic value of an mPAP/CO slope &amp;gt; 3 mmHg/L/min determined by exercise echocardiography in suspected heart failure with preserved ejection fraction (HFpEF). Methods This prospective cohort study included patients with unexplained dyspnea defined as dyspnea with an ejection fraction ≥50%. Patients with more than mild valvular heart disease, more than mild pulmonary disease, a history of heart failure, and myocardial or pericardial disease were excluded. A positive HFpEF score was defined as either an HFA-PEFF score of ≥5, including the diastolic stress test and exercise tricuspid regurgitation velocity, or a H2FPEF score of ≥6. The mPAP and CO were obtained by Doppler echocardiography. The primary outcome was the composite endpoint of unplanned cardiovascular hospitalisation (CVH) or all-cause mortality. Results Among the 1922 patients studied (median age 66 [56 to 74] years, 48% women), 39% (n=721) had exercise pulmonary hypertension. After a median follow-up of 14 (10-34) months; 57(3%) patients died and 235 (12%) had at least 1 unplanned CVH. A mPAP/CO slope &amp;gt;3 mmHg/L/min predicted death or unplanned CVH with an odds ratio of 1.51(1.11-2.07) when adjusted for age, sex and pulmonary pressures at rest (Figure 1). The mPAP/CO slope had incremental prognostic value irrespective of whether patients had a positive HFpEF score or not (increase in χ² from 19 to 29; p =0.002) (Figure 2). Conclusion Exercise pulmonary hypertension determined by exercise echocardiography is prognostically relevant as it predicts death and unplanned CVH in patients with unexplained dyspnea. These findings were independent of age, sex, pulmonary hypertension at rest and both the HFpEF scores with the diastolic stress test included.KM exPHTKM exPHT and HFpEF score