Utilization Of Evidence-based Therapies Research Articles

Sex-Related Temporal Trends in Donor and Recipient Profile and Outcome after Heart Transplantation: Analysis of the ISHLT Registry

<h3>Purpose</h3> The complex interactions between recipient and donor risk factors play a critical role in heart transplantation (HT) outcomes, particularly in light of the changing clinical phenotypes of candidates and donors and the continuing improvements and utilization of evidence-based therapies in women. The aim of this study was to explore temporal sex-related changes in recipient and donor features and effect of sex on HT outcomes. <h3>Methods</h3> We performed an analysis of the ISHLT Registry including primary adult HT performed in 1996-2018. We built a multivariable regression model which explored the likelihood of a set of high-risk clinical characteristics (Figure 1A) to be prevalent in earlier vs later years. We treated transplant year as a continuous variable and the analysis was stratified by sex. Interaction terms of recipient sex and each variable were used to identify differences between male and female recipient sex. <h3>Results</h3> Among 86,307 recipients, there were 19,983 women and 66,324 men. The proportion of transplanted women increased from 19% in 1996 to 27% in 2018 (p<0.001). Recipient and donor characteristics changed significantly over time. This change has been similar for both male and female recipients, with the exception of women with diabetes and history of dialysis having lower likelihood of transplant and women with recent infection having higher likelihood of transplant (Figure 1A). A significant reduction in 5-year mortality and 5-year malignancy rate after transplant was seen over the years. There were no significant sex-related differences in the degree of mortality and malignancy improvement (p=NS for interaction with sex, Figure 1B). <h3>Conclusion</h3> The proportion of women receiving HT has increased. Among those transplanted, there does not appear to be significant sex disparities, as evidenced by similar recipient and donor profiles and a similar improvement of survival and post-transplant malignancy rates in both male and female recipients.

The aging burden of hospitalization for heart failure in Chinese populations: evidence from the Macao Heart Failure Study.

ObjectiveTo assess the aging burden of hospitalization for heart failure in Chinese populations in Macao.MethodsThe Macao Heart Failure Study consists of patients hospitalized with a diagnosis of acute heart failure (AHF) at Centro Hospitalar Conde de São Januário (the only public hospital that provides medical care for the approximately 600, 000 residents of Macao) from January 2014 to December 2016. First, we investigated the relationship between socioeconomic development and epidemiological characteristics of HF in Macao. Then we assessed the patientso clinical features and outcomes according to the age groups.ResultsA total of 967 patients were included in the final analysis. The median age at admission was 82 years old. The advanced age at the admission of HF in Macao was significantly associated with a high-income level and the aging population structure. Marked heterogeneity existed in the epidemiological characteristics, clinical features, utilization of evidence-based therapies, short- and long-term outcomes, and prognostic utility of clinical variables among the different age groups.ConclusionRapid economic development and significantly aging populations have produced a profound impact on the epidemiological characteristics of HF in Chinese populations. Acute decompensated heart failure (ADHF) is predominantly a disease of the elderly in Macao, and a significant heterogeneity exists in the clinical features, managements, and outcomes among different age groups. Age-based risk stratification models and multidisciplinary HF teams are urgently needed to improve the management and outcomes of hospitalized heart failure (HHF) patients.

Patient-Provider Communication and Health Outcomes Among Individuals With Atherosclerotic Cardiovascular Disease in the United States: Medical Expenditure Panel Survey 2010 to 2013.

Consumer-reported patient-provider communication (PPC) assessed by Consumer Assessment of Health Plans Survey in ambulatory settings is incorporated as a complementary value metric for patient-centered care of chronic conditions in pay-for-performance programs. In this study, we examine the relationship of PPC with select indicators of patient-centered care in a nationally representative US adult population with established atherosclerotic cardiovascular disease. The study population consisted of a nationally representative sample of 6810 individuals (aged ≥18 years), representing 18.3 million adults with established atherosclerotic cardiovascular disease (self-reported or International Classification of Diseases, Ninth Edition diagnosis) reporting a usual source of care in the 2010 to 2013 pooled Medical Expenditure Panel Survey cohort. Participants responded to questions from Consumer Assessment of Health Plans Survey that assessed PPC, and we developed a weighted PPC composite score using their responses, categorized as 1 (poor), 2 (average), and 3 (optimal). Outcomes of interest were (1) patient-reported outcomes: 12-item Short Form physical/mental health status, (2) quality of care measures: statin and ASA use, (3) healthcare resource utilization: emergency room visits and hospital stays, and (4) total annual and out-of-pocket healthcare expenditures. Atherosclerotic cardiovascular disease patients reporting poor versus optimal were over 2-fold more likely to report poor outcomes; 52% and 26% more likely to report that they are not on statin and aspirin, respectively, had a significantly greater utilization of health resources (odds ratio≥2 emergency room visit, 1.41 [95% confidence interval, 1.09-1.81]; odds ratio≥2 hospitalization, 1.36 [95% confidence interval, 1.04-1.79]), as well as an estimated $1243 ($127-$2359) higher annual healthcare expenditure. This study reveals a strong relationship between PPC and patient-reported outcomes, utilization of evidence-based therapies, healthcare resource utilization, and expenditures among those with established atherosclerotic cardiovascular disease.

Abstract 157: Gender Differences in the Ambulatory Treatment of Hypertension in Patients with Heart Failure

Background: We investigated gender-specific differences in treatment of hypertension (HTN), and how they may affect outcomes in congestive heart failure (CHF) patients. Methods: Records of 194 (100 male, 94 female) unselected consecutive patients with HTN enrolled in the CHF clinic were reviewed. Left ventricular ejection fraction (LVEF) was compared to LVEF at time of enrollment in the clinic. The average interval between the two echocardiograms was 30 months. Results: ANOVA, chi-square, and logistic regression analyses demonstrated that men were more likely than women to have baseline LVEF ≤35%, (50% vs. 36%, p=0.108), coronary artery disease (63% vs. 43%, p=0.004), diabetes mellitus (p=0.095), and be ever smokers (66% vs. 40%, p&lt;0.0001). Factors such as age, peripheral vascular disease, hyperlipidemia, serum K+, creatinine clearance, body mass index, and heart rate were similar in both genders. Optimal BP control noted during the most recent visit was more often achieved in men (59% vs. 46%, p=0.002). Remarkably, during follow up, more men experienced decline in LV dysfunction (29% vs. 18%, p=0.081), women were more likely to have no change in LVEF (51% vs 34%, p=0.081), and men were only slightly more likely to show improvement (37% vs. 31%, p=0.081). There was no gender difference in utilization of angiotensin converting enzyme inhibitors (ACE), beta blockers (BB), or aldosterone receptor antagonists (ARA). Women were more likely to be treated with angiotensin receptor blockers (ARBs, p=0.054) and men were more likely to be on diuretics (57% vs. 43%, p=0.069). Conclusions: In patients with HTN enrolled in the HF clinic, male gender was associated with increased cardiovascular comorbidities and lower LVEF at baseline. Despite improved blood pressure control and similar utilization of evidence-based therapy, men experienced more decline in LVEF, had LV systolic function that was less likely to remain unchanged, and were only slightly more likely to demonstrate improvement of LVEF compared to women. This study suggests a potential gender-related pharmacodynamic difference in response to guideline therapy, or perhaps the manifestation of an already described gender difference of adaptation to chronic elevated after load.

Use of evidence-based therapy and survival in heart failure in Sweden 2003-2012.

In heart failure with reduced ejection fraction, drug and device therapy improve survival. We studied contemporary trends in utilization of evidence-based therapy and associated survival. We studied 5908 patients with NYHA class II-IV heart failure, EF <30%, and duration of heart failure ≥6 months registered in the Swedish Heart Failure Registry between 2003 and 2012. Regression using generalized estimation equations was used to examine temporal trends in crude and risk-adjusted rates of utilization of evidence-based heart failure therapy and 30-day, 1-year, and 3-year survival. In 2003 vs. 2012, the risk-adjusted use of therapy and P-values for trends were as follows: renin-angiotensin system antagonists, 88% vs. 86% (P = 0.091); beta-blockers, 85% vs. 93% (P = 0.008); mineralocorticoid receptor antagonists, 53% vs. 42% (P < 0.001); CRT, 2.4% vs. 8.2% (P = 0.074); and implantable cardioverter-defibrillators, 4.0% vs. 10.7% (P = 0.004). During the same period, the risk-adjusted 30-day, 1-year, and 3-year survival was 92% vs. 94% (P = 0.532), 81% vs. 77% (P = 0.260), and 58% vs. 54% (P = 0.425), respectively. In this large nationwide registry, over the last decade the use of evidence-based drug therapy was high and remained stable over time, but, despite an increased use of device therapy, the absolute use was poor. This was associated with an absence of improvement in survival. The improvements in therapy and prognosis over the last generation may be levelling off, and efforts should be directed at improving implementation of evidence-based therapy.

Utilization of Evidence-Based Therapy for Acute Coronary Syndrome in High Income and Middle/Low Income Countries

Utilization of Evidence-Based Therapy for Acute Coronary Syndrome in High Income and Middle/Low Income Countries

Pre-Hospital Cardiac Arrest in Acute Coronary Syndromes: Insights from the Global Registry of Acute Coronary Events and the Canadian Registry of Acute Coronary Events

Objectives: Cardiac arrest in acute coronary syndromes (ACS) is associated with high morbidity and mortality. We examined the clinical characteristics, contemporary management patterns and outcomes of ACS patients with pre-hospital cardiac arrest. Methods: The Global Registry of Acute Coronary Events and the Canadian Registry of Acute Coronary Events enrolled 14,010 ACS patients in 1999-2008. We compared the clinical characteristics, in-hospital treatment and outcomes between patients with and without pre-hospital cardiac arrest. Results: Overall, 206 (1.4%) patients had cardiac arrest prior to hospital presentation. ACS patients with pre-hospital cardiac arrest were less frequently treated with aspirin, β-blocker, angiotensin-converting enzyme inhibitors, and statins within the first 24 h of presentation, but the use of cardiac procedures was similar compared to the group without cardiac arrest. Patients with pre-hospital cardiac arrest had significantly higher rates of in-hospital adverse events. Factors independently associated with pre-hospital cardiac arrest included male gender, current smoker status, tachycardia, higher Killip class and ST-segment deviation. Conclusion: ACS patients with pre-hospital cardiac arrest continue to have more in-hospital complications and higher mortality. Their use of evidence-based medical therapies was lower but the use of cardiac procedures was similar compared to the group without cardiac arrest. Better utilization of evidence-based therapies in these patients may translate into improved outcomes.

Abstract 184: Patterns of Outpatient Follow-up after Acute Myocardial Infarction: Follow-up Frequency is Associated with Utilization of Evidence-based Therapies

Background: ACC/AHA guidelines recommend that patients with acute myocardial infarction (AMI) follow-up within several weeks of hospital discharge. Recommendations regarding intensity of following-up in the year following AMI are not provided. The relationship between frequency of follow-up and use of evidence-based therapies following AMI is unknown. Methods: 6,838 patients from 2 multicenter prospective AMI registries, PREMIER and TRIUMPH registries were studied. We divided the number of patient self-reported outpatient follow-up visits with cardiologists, primary care providers, or both into tertiles: low, medium, and high. The primary outcome was use of statins, beta blockers, aspirin, ACE/ARBs, and a composite of all four medications at 12 months among eligible patients. The association between tertiles of visits following AMI among patients who had at least one visit and primary outcome was evaluated using hierarchical multivariable modified Poisson models. Results: Mean number of follow-up visits in the year following AMI was 6 (IQR 3 - 8) and 189 (4%) of patients had no visits. In lowest tertile, patients had 1 to &lt; 4 visits, in the medium tertile, 4 to &lt; 7 visits, and in highest tertile, 7 to 59 visits. Patients in medium and high intensity tertiles were older, more likely to have insurance, and had higher GRACE 6-month mortality risk scores compared to the lowest tertile. In multivariable analyses, patients in the medium tertile were more likely to use statins and ASA than those in the lowest tertile (Figure). There were no differences in use of individual medications when comparing the highest and medium tertiles although individuals in the highest tertile were less likely to use all four medications. Conclusions: Significant variability exists in follow-up frequency following AMI and 4% of the cohort had no follow-up. Patients who had medium intensity visits were more likely to use some evidence-based medications than those with low intensity. Higher intensity visits was not associated with greater medication use. It is possible that the observed differences may be attributed to unmeasured differences among patients rather than the actual follow-up visits. Prospective studies are needed to assess key elements of outpatient visits that may lead to better utilization of evidence-based therapies.

427 Providing a Platform for Organized Care in ST Elevation Myocardial Infarction: The LHIN-4 SMART-AMI Project in Southern Ontario Experience

427 Providing a Platform for Organized Care in ST Elevation Myocardial Infarction: The LHIN-4 SMART-AMI Project in Southern Ontario Experience

RANDOMIZATION TO DIGOXIN IS ASSOCIATED WITH IMPROVEMENT IN RENAL FUNCTION AND REDUCTION IN DEATH OR HOSPITALIZATION IN PATIENTS WITH CHRONIC HEART FAILURE: INSIGHTS FROM THE DIGITALIS INTERVENTION GROUP TRIAL LIMITED DATASET

Renal dysfunction is one of the most powerful prognostic factors for clinical outcomes in heart failure and often impedes adequate decongestion and utilization of evidence-based therapies. To date, no successful therapeutic strategies to improve renal function or outcomes in these patients have been

Acute coronary syndromes: clinical characteristics, management, and outcomes at the American University of Beirut Medical Center, 2002-2005.

Data on acute coronary syndromes (ACS) in developing countries is scarce. In this report, we analyze the temporal trends in the management and outcomes of a large series of ACS patients hospitalized at the American University of Beirut Medical Center (AUBMC), a tertiary referral university hospital located in a middle income Middle Eastern developing country. A total of 1025 consecutive patients hospitalized and discharged with the diagnosis of ACS were enrolled between 2002 and 2005. The utilization of evidence-based therapies and in-hospital outcomes were determined. The study enrolled 228 patients (22%) with ST-elevation myocardial infarction (STEMI), 275 patients (27%) with non-ST-elevation myocardial infarction (NSTEMI), and 522 patients (51%) with unstable angina. The STEMI group was younger and had a higher percentage of men. The utilization rates of coronary angiography and percutaneous coronary intervention (PCI) were highest in the STEMI group. Comparison to earlier ACS data (1997-1998) from the same hospital, showed an increase in the utilization of reperfusion therapy, coronary angioplasty, bypass surgery, aspirin, beta-blockers, angiotensin-converting enzymes (ACE), angiotensin receptor blockers (ARB), and statins over the past decade (P < .05). This was associated with a significant decrease in hospital mortality (13%-7.7%, P < .01). This study analyzes one of the largest series of ACS patients reported from a single center in a developing country. The utilization of evidence-based therapies in the management of ACS at AUBMC has improved significantly over the past decade with an associated decrease in hospital mortality.

Underutilization of Evidence‐Based Therapies in Heart Failure: The Pharmacist's Role

Utilization of evidence-based therapy in the heart failure population includes implementation of heart failure treatment guidelines, interventions to improve prescribing, and inclusion of pharmacists on the multidisciplinary team. Use of treatment guidelines eases the challenge of selecting the appropriate drug and dosage; quality interventions by pharmacists can ensure optimal prescribing of therapy; and provision of care by a multidisciplinary team can improve outcomes in patients with heart failure. Evidence-based therapy, however, remains underutilized in the heart failure population. Barriers to utilization include misperceptions that various heart failure subpopulations do not need certain medical therapies, a fear of polypharmacy, inappropriate assumptions about adverse effects and contraindications, and cost. In fact, optimal prescribing of evidence-based therapy can actually reduce costs. Clearly documented processes and systems are needed to ensure that evidence-based therapy and education are available to every patient.