Publications by authors named "Erica S Spatz"

138 Publications

Patient Awareness and Clinical Inertia: Obstacles to Hypertension Control in Rural Communities in the Dominican Republic.

Am J Hypertens 2021 Apr 5. Epub 2021 Apr 5.

Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.

Background: Many obstacles exist for adequate hypertension control, including low individual awareness and clinical inertia (CI). In this study, we aimed to determine hypertension prevalence, awareness, treatment and control among community residents of rural areas of Peravia in Dominican Republic, followed by an assessment of CI in their primary care clinics (PCC).

Methods: We interviewed 827 adults from 8 rural communities of Peravia. Demographics, medical history, health care information and blood pressure (BP) were obtained. We reviewed the community PCC visits of patients with known hypertension or a BP ≥ 140/90, abstracting medical history and the physician's action towards uncontrolled BP.

Results: Of those interviewed, 57% (95% CI: 53%-60%) had hypertension, with 63% (95% CI: 59%-68%) of those aware of their diagnosis. Among individuals with hypertension, 60% (95% CI: 56%-65%) were receiving pharmacological treatment, and only 35% (95% CI: 31%-40%) were controlled. Characteristics associated with awareness were female sex, age >55 years, diabetes, private insurance, and having at least one health care visit within the past year. Of the 507 PCC patients reviewed, 340 (67%) had uncontrolled BP. Of these, 220 had no clinical action to address the uncontrolled BP, corresponding to a CI rate of 65%.

Conclusion: Among rural communities in the Dominican Republic, undiagnosed hypertension remains common, especially in individuals who are younger, uninsured, or with limited access to health care. For those seen in PCCs, therapeutic intensification to achieve controlled BP is infrequently done. Strategies to address population awareness and CI are needed to improve hypertension control.
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http://dx.doi.org/10.1093/ajh/hpab054DOI Listing
April 2021

Treatment decisions for patients with peripheral artery disease and symptoms of claudication: Development process and alpha testing of the SHOW-ME PAD decision aid.

Vasc Med 2021 Feb 25:1358863X20988780. Epub 2021 Feb 25.

Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.

Patients with peripheral artery disease (PAD) face a range of treatment options to improve survival and quality of life. An evidence-based shared decision-making tool (brochure, website, and recorded patient vignettes) for patients with new or worsening claudication symptoms was created using mixed methods and following the International Patient Decision Aids Standards (IPDAS) criteria. We reviewed literature and collected qualitative input from patients ( = 28) and clinicians ( = 34) to identify decisional needs, barriers, outcomes, knowledge, and preferences related to claudication treatment, along with input on implementation logistics from 59 patients and 27 clinicians. A prototype decision aid was developed and tested through a survey administered to 20 patients with PAD and 23 clinicians. Patients identified invasive treatment options (endovascular or surgical revascularization), non-invasive treatments (supervised exercise therapy, claudication medications), and combinations of these as key decisions. A total of 65% of clinicians thought the brochure would be useful for medical decision-making, an additional 30% with suggested improvements. For patients, those percentages were 75% and 25%, respectively. For the website, 76.5% of clinicians and 85.7% of patients thought it would be useful; an additional 17.6% of clinicians and 14.3% of patients thought it would be useful, with improvements. Suggestions were incorporated in the final version. The first prototype was well-received among patients and clinicians. The next step is to implement the tool in a PAD specialty care setting to evaluate its impact on patient knowledge, engagement, and decisional quality. .
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http://dx.doi.org/10.1177/1358863X20988780DOI Listing
February 2021

Association of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers with the Risk of Hospitalization and Death in Hypertensive Patients with Coronavirus Disease-19.

J Am Heart Assoc 2021 Feb 24:e018086. Epub 2021 Feb 24.

Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.

Background Despite its clinical significance, the risk of severe infection requiring hospitalization among outpatients with SARS-CoV-2 infection who receive angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) remains uncertain. Methods and Results In a propensity score-matched outpatient cohort (January - May 2020) of 2,263 Medicare Advantage and commercially insured individuals with hypertension and a positive outpatient SARS-CoV-2 test, we determined the association of ACE inhibitors and ARBs with COVID-19 hospitalization. In a concurrent inpatient cohort of 7,933 hospitalized with COVID-19, we tested their association with in-hospital mortality. The robustness of the observations was assessed in a contemporary cohort (May - August). In the outpatient study, neither ACE inhibitors (HR, 0.77, 0.53-1.13, P=0.18), nor ARBs (HR, 0.88, 0.61-1.26, P=0.48), were associated with hospitalization risk. ACE inhibitors were associated with lower hospitalization risk in the older Medicare group (HR, 0.61, 0.41-0.93, P=0.02), but not the younger commercially insured group (HR, 2.14, 0.82-5.60, P=0.12; P-interaction 0.09). Neither ACE inhibitors nor ARBs were associated with lower hospitalization risk in either population in the validation cohort. In the primary inpatient study cohort, neither ACE inhibitors (0.97, 0.81-1.16; P=0.74) nor ARBs (1.15, 0.95-1.38, P=0.15) were associated with in-hospital mortality. These observations were consistent in the validation cohort. Conclusions ACE inhibitors and ARBs were not associated with COVID-19 hospitalization or mortality. Despite early evidence for a potential association between ACE inhibitors and severe COVID-19 prevention in older individuals, the inconsistency of this observation in recent data argues against a role for prophylaxis.
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http://dx.doi.org/10.1161/JAHA.120.018086DOI Listing
February 2021

The Groundwater of Racial and Ethnic Disparities Research: A Statement From .

Circ Cardiovasc Qual Outcomes 2021 Feb 11;14(2):e007868. Epub 2021 Feb 11.

Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.).

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http://dx.doi.org/10.1161/CIRCOUTCOMES.121.007868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958971PMC
February 2021

Effect of institutional transcatheter aortic valve replacement volume on mortality: A systematic review and meta-analysis.

Catheter Cardiovasc Interv 2021 Feb 10. Epub 2021 Feb 10.

Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.

Objective: We sought to conduct a systematic review and network meta-analysis to examine the association between institutional transcatheter aortic valve replacement (TAVR) volume and all-cause mortality.

Background: Since inception in 2011, there has been an exponential increase in the number of TAVR centers across the world. Multiple studies have questioned if a relationship exists between institutional TAVR volume and patient outcomes.

Methods: We performed a systematic literature search for relevant articles using a combination of free text terms in the title/abstract related to volume, TAVR, and patient outcomes. Two reviewers independently screened all titles/abstracts for eligibility based on pre-specified criteria. All-cause mortality data was pooled from eligible studies and centers were categorized as low-(30-50 cases), intermediate-, or high-volume (75-130 cases) based on their annual TAVR volumes.

Results: Our search yielded an initial list of 11,153 citations, 120 full text studies were reviewed and 7 studies met all inclusion and exclusion criteria, yielding a total of 1,93,498 TAVRs. Categorized according to center's annual volume; 25,062 TAVRs were performed in low-, 77,093 in intermediate- and 91,343 in high-volume centers. Network meta-analysis showed a relative reduction in mortality rates of 37%, 23% and 19%, for high volume versus low volume centers, high volume versus intermediate volume centers and intermediate versus low volume centers, respectively.

Conclusions: Existing research clearly shows an inverse relationship between annual TAVR procedural volume and all-cause mortality. We need to focus on development of strong referral networks and consolidation rather than expansion of existing TAVR centers to improve patient outcomes, while ensuring adequate access-to-care.
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http://dx.doi.org/10.1002/ccd.29502DOI Listing
February 2021

Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association.

Circulation 2021 Mar 25;143(10):e763-e783. Epub 2021 Jan 25.

As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD.
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http://dx.doi.org/10.1161/CIR.0000000000000947DOI Listing
March 2021

Assessment of Prevalence, Awareness, and Characteristics of Isolated Systolic Hypertension Among Younger and Middle-Aged Adults in China.

JAMA Netw Open 2020 12 1;3(12):e209743. Epub 2020 Dec 1.

National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases.

Importance: Isolated systolic hypertension (ISH) is increasing in prevalence among young and middle-aged adults. However, most studies of ISH are limited to older individuals, and a substantial knowledge gap exists regarding younger adults with ISH.

Objective: To assess the prevalence, awareness, and characteristics of ISH among younger and middle-aged adults in China.

Design, Setting, And Participants: This cross-sectional study was performed as part of the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project, which enrolled 3.1 million community residents aged 35 to 75 years from all of the 31 provinces in China between December 15, 2014, and May 15, 2019. The present analysis included only participants younger than 50 years. Data were analyzed from May to November 2019.

Main Outcomes And Measures: Prevalence and awareness of ISH (defined as systolic blood pressure of 140 mm Hg or higher and diastolic blood pressure of less than 90 mm Hg) and individual characteristics of participants with ISH.

Results: Among 898 929 participants aged 35 to 49 years, the mean (SD) age was 43.8 (3.9) years; 548 657 participants (61.0%) were women, and 235 138 participants (26.2%) had hypertension. Of those with hypertension, 62 819 participants (26.7%; 95% CI, 26.5%-26.9%) had ISH (mean [SD] age, 45.0 [3.5] years; 41 417 women [65.9%]), and 54 463 of those with ISH (86.7%; 95% CI, 86.4%-87.0%) had not received treatment. The prevalence of ISH was higher among individuals who were older, were female, were farmers, resided in the eastern region of China, and had an educational level of primary school or lower. Women and older individuals were more likely to have ISH than to be normotensive or to have other hypertension subtypes. Participants who were obese, currently used alcohol, had diabetes, and experienced previous cardiovascular events were more likely to have other types of hypertension and less likely to have normotension than to have ISH. Among the 54 463 participants with ISH who had not received treatment, only 3682 individuals (6.8%; 95% CI, 6.6%-7.0%) were aware of having hypertension, and awareness rates remained low even among those with systolic blood pressure of 160 mm Hg or higher (7135 individuals [13.1%; 95% CI, 12.4%-13.9%]).

Conclusions And Relevance: In this study, ISH was identified in 1 of 4 young and middle-aged adults with hypertension in China, most of whom remained unaware of having hypertension. These results highlight the increasing need for better guidance regarding the management of ISH in this population.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.9743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724558PMC
December 2020

Association Between Industry Payments to Physicians and Device Selection in ICD Implantation.

JAMA 2020 11;324(17):1755-1764

Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.

Importance: Little is known about the association between industry payments and medical device selection.

Objective: To examine the association between payments from device manufacturers to physicians and device selection for patients undergoing first-time implantation of a cardioverter-defibrillator (ICD) or cardiac resynchronization therapy-defibrillator (CRT-D).

Design, Setting, And Participants: In this cross-sectional study, patients who received a first-time ICD or CRT-D device from any of the 4 major manufacturers (January 1, 2016-December 31, 2018) were identified. The data from the National Cardiovascular Data Registry ICD Registry was linked with the Open Payments Program's payment data. Patients were categorized into 4 groups (A, B, C, and D) corresponding to the manufacturer from which the physician who performed the implantation received the largest payment. For each patient group, the proportion of patients who received a device from the manufacturer that provided the largest payment to the physician who performed implantation was determined. Within each group, the absolute difference in proportional use of devices between the manufacturer that made the highest payment and the proportion of devices from the same manufacturer in the entire study cohort (expected prevalence) was calculated.

Exposures: Manufacturers' payments to physicians who performed an ICD or CRT-D implantation.

Main Outcomes And Measures: The primary outcome of the study was the manufacturer of the device used for the implantation.

Results: Over a 3-year period, 145 900 patients (median age, 65 years; 29.6% women) received ICD or CRT-D devices from the 4 manufacturers implanted by 4435 physicians at 1763 facilities. Among these physicians, 4152 (94%) received payments from device manufacturers ranging from $2 to $323 559 with a median payment of $1211 (interquartile range, $390-$3702). Between 38.5% and 54.7% of patients received devices from the manufacturers that had provided physicians with the largest payments. Patients were substantially more likely to receive devices made by the manufacturer that provided the largest payment to the physician who performed implantation than they were from each other individual manufacturer. The absolute differences in proportional use from the expected prevalence were 22.4% (95% CI, 21.9%-22.9%) for manufacturer A; 14.5% (95% CI, 14.0%-15.0%) for manufacturer B; 18.8% (95% CI, 18.2%-19.4%) for manufacturer C; and 30.6% (95% CI, 30.0%-31.2%) for manufacturer D.

Conclusions And Relevance: In this cross-sectional study, a large proportion of ICD or CRT-D implantations were performed by physicians who received payments from device manufacturers. Patients were more likely to receive ICD or CRT-D devices from the manufacturer that provided the highest total payment to the physician who performed an ICD or CRT-D implantation than each other manufacturer individually.
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http://dx.doi.org/10.1001/jama.2020.17436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7610190PMC
November 2020

Community factors and hospital wide readmission rates: Does context matter?

PLoS One 2020 23;15(10):e0240222. Epub 2020 Oct 23.

Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America.

Background: The environment in which a patient lives influences their health outcomes. However, the degree to which community factors are associated with readmissions is uncertain.

Objective: To estimate the influence of community factors on the Centers for Medicare & Medicaid Services risk-standardized hospital-wide readmission measure (HWR)-a quality performance measure in the U.S.

Research Design: We assessed 71 community variables in 6 domains related to health outcomes: clinical care; health behaviors; social and economic factors; the physical environment; demographics; and social capital.

Subjects: Medicare fee-for-service patients eligible for the HWR measure between July 2014-June 2015 (n = 6,790,723). Patients were linked to community variables using their 5-digit zip code of residence.

Methods: We used a random forest algorithm to rank variables for their importance in predicting HWR scores. Variables were entered into 6 domain-specific multivariable regression models in order of decreasing importance. Variables with P-values <0.10 were retained for a final model, after eliminating any that were collinear.

Results: Among 71 community variables, 19 were retained in the 6 domain models and in the final model. Domains which explained the most to least variance in HWR were: physical environment (R2 = 15%); clinical care (R2 = 12%); demographics (R2 = 11%); social and economic environment (R2 = 7%); health behaviors (R2 = 9%); and social capital (R2 = 8%). In the final model, the 19 variables explained more than a quarter of the variance in readmission rates (R2 = 27%).

Conclusions: Readmissions for a wide range of clinical conditions are influenced by factors relating to the communities in which patients reside. These findings can be used to target efforts to keep patients out of the hospital.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240222PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7584172PMC
December 2020

Newly diagnosed diabetes and outcomes after acute myocardial infarction in young adults.

Heart 2021 Apr 20;107(8):657-666. Epub 2020 Oct 20.

Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA

Objective: To examine prevalence and characteristics of newly diagnosed diabetes (NDD) in younger adults hospitalised with acute myocardial infarction (AMI) and investigate whether NDD is associated with health status and clinical outcomes over 12-month post-AMI.

Methods: In individuals (18-55 years) admitted with AMI, without established diabetes, we defined NDD as (1) baseline or 1-month HbA1c≥6.5%; (2) discharge diabetes diagnosis or (3) diabetes medication initiation within 1 month. We compared baseline characteristics of NDD, established diabetes and no diabetes, and their associations with baseline, 1-month and 12-month health status (angina-specific and non-disease specific), mortality and in-hospital complications.

Results: Among 3501 patients in Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients study, 14.5% met NDD criteria. Among 508 patients with NDD, 35 (6.9%) received discharge diagnosis, 91 (17.9%) received discharge diabetes education and 14 (2.8%) initiated pharmacological treatment within 1 month. NDD was more common in non-White (OR 1.58, 95% CI 1.23 to 2.03), obese (OR 1.72, 95% CI 1.39 to 2.12), financially stressed patients (OR 1.27, 95% CI 1.02 to 1.58). Compared with established diabetes, NDD was independently associated with better disease-specific health status and quality of life (p≤0.04). No significant differences were found in unadjusted in-hospital mortality and complications between NDD and established or no diabetes.

Conclusions: NDD was common among adults≤55 years admitted with AMI and was more frequent in non-White, obese, financially stressed individuals. Under 20% of patients with NDD received discharge diagnosis or initiated discharge diabetes education or pharmacological treatment within 1 month post-AMI. NDD was not associated with increased risk of worse short-term health status compared with risk noted for established diabetes.

Trial Registration Number: NCT00597922.
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http://dx.doi.org/10.1136/heartjnl-2020-317101DOI Listing
April 2021

Dying to know: prognosis communication in heart failure.

ESC Heart Fail 2020 Sep 24. Epub 2020 Sep 24.

Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.

Prognosis communication in heart failure is often narrowly defined as a discussion of life expectancy, but as clinical guidelines and research suggest, these discussions should provide a broader understanding of the disease, including information about disease trajectory, the experiences of living with heart failure, potential burden on patients and families, and mortality. Furthermore, despite clinical guidelines recommending early discussions, evidence suggests that these discussions occur infrequently or late in the disease trajectory. We review the literature concerning patient, caregiver, and clinician perspectives on discussions of this type, including the frequency, timing, desire for, effects of, and barriers to their occurrence. We propose an alternate view of prognosis communication, in which the patient and family/caregiver are educated about the nature of the disease at the time of diagnosis, and a process of engagement is undertaken so that the patient's full participation in their care is marshalled, and the care team engages the patient in the informed decision making that will guide care throughout the disease trajectory. We also identify and discuss evidence gaps concerning (i) patient preferences and readiness for prognosis information along the trajectory; (ii) best practices for communicating prognosis information; and (iii) effects of prognosis communication on patient's quality of life, mental health, engagement in critical self-care, and clinical outcomes. Research is needed to determine best practices for engaging patients in prognosis communication and for evaluating the effects of this communication on patient engagement and clinical outcomes.
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http://dx.doi.org/10.1002/ehf2.12941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754721PMC
September 2020

Identifying characteristics of high-poverty counties in the United States with high well-being: an observational cross-sectional study.

BMJ Open 2020 09 17;10(9):e035645. Epub 2020 Sep 17.

Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.

Objective: To identify county characteristics associated with high versus low well-being among high-poverty counties.

Design: Observational cross-sectional study at the county level to investigate the associations of 29 county characteristics with the odds of a high-poverty county reporting population well-being in the top quintile versus the bottom quintile of well-being in the USA. County characteristics representing key determinants of health were drawn from the Robert Wood Johnson Foundation County Health Rankings and Roadmaps population health model.

Setting: Counties in the USA that are in the highest quartile of poverty rate.

Main Outcome Measure: Gallup-Sharecare Well-being Index, a comprehensive population-level measure of physical, mental and social health. Counties were classified as having a well-being index score in the top or bottom 20% of all counties in the USA.

Results: Among 770 high-poverty counties, 72 were categorised as having high well-being and 311 as having low well-being. The high-well-being counties had a mean well-being score of 71.8 with a SD of 2.3, while the low-well-being counties had a mean well-being score of 60.2 with a SD of 2.8. Among the six domains of well-being, basic access, which includes access to housing and healthcare, and life evaluation, which includes life satisfaction and optimism, differed the most between high-being and low-well-being counties. Among 29 county characteristics tested, six were independently and significantly associated with high well-being (p<0.05). These were lower rates of preventable hospital stays, higher supply of primary care physicians, lower prevalence of smoking, lower physical inactivity, higher percentage of some college education and higher percentage of heavy drinkers.

Conclusions: Among 770 high-poverty counties, approximately 9% outperformed expectations, reporting a collective well-being score in the top 20% of all counties in the USA. High-poverty counties reporting high well-being differed from high-poverty counties reporting low well-being in several characteristics.
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http://dx.doi.org/10.1136/bmjopen-2019-035645DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500307PMC
September 2020

Use of Mobile Health Applications in Low-Income Populations: A Prospective Study of Facilitators and Barriers.

Circ Cardiovasc Qual Outcomes 2020 09 4;13(9):e007031. Epub 2020 Sep 4.

Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (E.S.S.).

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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.007031DOI Listing
September 2020

Comparison of Mortality and Readmission in Non-Ischemic Versus Ischemic Cardiomyopathy After Implantable Cardioverter-Defibrillator Implantation.

Am J Cardiol 2020 10 24;133:116-125. Epub 2020 Jul 24.

Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut. Electronic address:

Data is lacking on the contemporary risk of death and readmission following implantable cardioverter-defibrillator (ICD) implantation in patients with non-ischemic cardiomyopathies (NICM) compared with ischemic cardiomyopathies (ICM) in a large nationally representative cohort. We performed a retrospective cohort study using the National Cardiovascular Data Registry ICD Registry linked with Medicare claims from April 1, 2010 to December 31, 2013. We established a cohort of NICM and ICM patients with a left ventricular ejection fraction ≤35% who received a de novo, primary prevention ICD. We compared mortality and readmission using Kaplan-Meier curves and Cox proportional hazard regressions models. We also evaluated temporal trends in mortality. In 31,044 NICM and 68,458 ICM patients with a median follow up of 2.4 years, 1-year mortality was significantly higher in ICM patients (12.3%) compared with NICM (7.9%, p < 0.001). The higher mortality in ICM patients remained significant after adjustment for covariates (hazard ratio [HR] 1.40; 95% confidence interval [CI] 1.36 to 1.45), and was consistent in subgroup analyses. These findings were consistent across the duration of the study. ICM patients were also significantly more likely to be readmitted for all causes (adjusted HR 1.15, CI 1.12 to 1.18) and for heart failure (adjusted HR 1.25, CI 1.21 to 1.31). In conclusion, the risks of mortality and hospital readmission after primary prevention ICD implantation were significantly higher in patients with ICM compared with NICM which was consistent across all patient subgroups tested and over the duration of the study.
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http://dx.doi.org/10.1016/j.amjcard.2020.07.035DOI Listing
October 2020

"When you're homeless, they look down on you": A qualitative, community-based study of homeless individuals with heart failure.

Heart Lung 2021 Jan - Feb;50(1):80-85. Epub 2020 Aug 10.

National Clinician Scholars Program, Yale School of Medicine, PO Box 208088, New Haven, CT 06520, USA; Yale School of Public Health, P.O. Box 208034, New Haven, CT 06520-0834, USA.

Background: Outpatient heart failure (HF) care involves intensive self-management (SM). Effective HF SM is associated with improved outcomes. Homelessness poses challenges to successful SM.

Objectives: To identify the ways in which homelessness may impede successful SM of HF and engagement with the healthcare system.

Methods: We conducted open-ended, semi-structured interviews with homeless adults with HF. Data were analyzed by a multidisciplinary team using a grounded theory approach.

Results: We interviewed 19 participants, 11 (58%) of whom were homeless at the time of interview. Interviews revealed a combination of influences on HF SM. Major themes included instability and lack of routine, tradeoffs between basic necessities and HF SM, and stigmatization by healthcare providers.

Conclusions: Anticipatory guidance aimed at the unique challenges faced by homeless individuals with HF may aid successful SM. HF providers should simlpify medication regimes and engage in non-stigmatizing discourse. Larger-scale interventions include the creation of medical respite programs.
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http://dx.doi.org/10.1016/j.hrtlng.2020.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738391PMC
August 2020

Lipoprotein(a) levels and association with myocardial infarction and stroke in a nationally representative cross-sectional US cohort.

J Clin Lipidol 2020 Sep - Oct;14(5):695-706.e4. Epub 2020 Jul 3.

Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA.

Background: Lipoprotein(a) (Lp(a)) has not been well-studied in a nationally representative US cohort.

Objective: The objective of this study was to investigate the distribution of Lp(a) and its associations with nonfatal cardiovascular events in a nationally representative cohort.

Methods: Cross-sectional analysis using the National Health and Nutrition Examination Survey III cohort (1991-1994). We compared Lp(a) levels across demographics and tested the associations between Lp(a) and patient-reported nonfatal myocardial infarction (MI) and/or stroke using multivariate logistic regression.

Results: Median Lp(a) was 14 mg/dL (interquartile range [IQR]: 3, 32) (n = 8214). 14.7% (95% CI: 13.6%-15.9%) had Lp(a) ≥50 mg/dL. Women had slightly higher median Lp(a) than men (14 mg/dL [IQR: 4, 33] vs 13 [(IQR: 3, 30], P = .001). Non-Hispanics blacks had the highest median Lp(a) (35 mg/dL [IQR: 21, 64]), followed by non-Hispanic whites (12 mg/dL [IQR: 3, 29]) and Mexican Americans (8 mg/dL [IQR:1, 21]). In multivariate analysis, Lp(a) was associated (odds ratio per SD increase [95% CI], P-value) with MI (1.41 [1.14-1.75], P = .001), but not stroke (1.14 [0.91-1.44], P = .26). Lp(a) associated with MI in men (1.52 [1.13-2.04], P = .006), non-Hispanic whites (1.60 [1.27-2.03], P < .001), and Mexican Americans (2.14 [1.29-3.55], P = .003), but not women or non-Hispanic blacks. Lp(a) was not associated with stroke among any subgroups.

Conclusion: In a nationally representative US cohort, 1 in 7 had Lp(a) ≥50 mg/dL, the guidelines-recommended threshold to consider Lp(a) a risk enhancing factor. Lp(a) was associated with nonfatal MI but not stroke, although there were differential associations by sex and race/ethnicity. Future nationally representative cohorts should test Lp(a) to get an updated estimation.
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http://dx.doi.org/10.1016/j.jacl.2020.06.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7641964PMC
July 2020

Trends and Predictors of Use of Digital Health Technology in the United States.

Am J Med 2021 01 24;134(1):129-134. Epub 2020 Jul 24.

Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Department of Health Policy and Management, Yale School of Public Health, New Haven, Conn. Electronic address:

Background: Digital health technology is becoming central to health care. A better understanding of the trends and predictors of its use could reflect how people engage with the health care system and manage their health care needs.

Methods: Using data from the National Health Interview Survey for years 2011 to 2018, we assessed the use of digital health technology among individuals aged ≥18 years in the United States across 2 domains: 1) search for health information online and 2) interaction with health care providers (eg, fill a prescription, schedule a medical appointment, or communicate with health care providers).

Results: Our study included 253,829 individuals; representing nearly 237 million adults in the United States annually; mean age 49.6 years (SD 18.4); 51.8% women; and 65.9% non-Hispanic white individuals. Overall, 49.2% of individuals reported searching for health information online and 18.5% reported at least 1 technology-based interaction with the health care system. Between 2011 and 2018, the proportion who searched for health information online increased from 46.5% to 55.3% (P < .001), whereas the proportion who used technology to interact with the health care system increased from 12.5% to 27.4% (P < .001). Although technology-based interaction with the health care system increased across most subgroups, there were significant disparities in the extent of increase across clinical and sociodemographic subgroups.

Conclusions: The use of digital health technologies increased between 2011 and 2018, however, the uptake of these technologies has been unequal across subgroups. Future innovations and strategies should focus on expanding the reach of digital heath technology across all subgroups of society to ensure that its expansion does not exacerbate the existing health inequalities.
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http://dx.doi.org/10.1016/j.amjmed.2020.06.033DOI Listing
January 2021

Association of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers with the Risk of Hospitalization and Death in Hypertensive Patients with Coronavirus Disease-19.

medRxiv 2020 May 19. Epub 2020 May 19.

Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT.

Background: Whether angiotensin-converting enzyme (ACE) Inhibitors and angiotensin receptor blockers (ARBs) mitigate or exacerbate SARS-CoV-2 infection remains uncertain. In a national study, we evaluated the association of ACE inhibitors and ARB with coronavirus disease-19 (COVID-19) hospitalization and mortality among individuals with hypertension.

Methods: Among Medicare Advantage and commercially insured individuals, we identified 2,263 people with hypertension, receiving ≥1 antihypertensive agents, and who had a positive outpatient SARS-CoV-2 test (outpatient cohort). In a propensity score-matched analysis, we determined the association of ACE inhibitors and ARBs with the risk of hospitalization for COVID-19. In a second study of 7,933 individuals with hypertension who were hospitalized with COVID-19 (inpatient cohort), we tested the association of these medications with in-hospital mortality. We stratified all our assessments by insurance groups.

Results: Among individuals in the outpatient and inpatient cohorts, 31.9% and 29.8%, respectively, used ACE inhibitors and 32.3% and 28.1% used ARBs. In the outpatient study, over a median 30.0 (19.0 - 40.0) days after testing positive, 12.7% were hospitalized for COVID-19. In propensity score-matched analyses, neither ACE inhibitors (HR, 0.77 [0.53, 1.13], P = 0.18), nor ARBs (HR, 0.88 [0.61, 1.26], P = 0.48), were significantly associated with risk of hospitalization. In analyses stratified by insurance group, ACE inhibitors, but not ARBs, were associated with a significant lower risk of hospitalization in the Medicare group (HR, 0.61 [0.41, 0.93], P = 0.02), but not the commercially insured group (HR: 2.14 [0.82, 5.60], P = 0.12; P-interaction 0.09). In the inpatient study, 14.2% died, 59.5% survived to discharge, and 26.3% had an ongoing hospitalization. In propensity score-matched analyses, neither use of ACE inhibitor (0.97 [0.81, 1.16]; P = 0.74) nor ARB (1.15 [0.95, 1.38]; P = 0.15) was associated with risk of in-hospital mortality, in total or in the stratified analyses.

Conclusions: The use of ACE inhibitors and ARBs was not associated with the risk of hospitalization or mortality among those infected with SARS-CoV-2. However, there was a nearly 40% lower risk of hospitalization with the use of ACE inhibitors in the Medicare population. This finding merits a clinical trial to evaluate the potential role of ACE inhibitors in reducing the risk of hospitalization among older individuals, who are at an elevated risk of adverse outcomes with the infection.
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http://dx.doi.org/10.1101/2020.05.17.20104943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273249PMC
May 2020

Heterogeneity in Trajectories of Systolic Blood Pressure among Young Adults in Qingdao Port Cardiovascular Health Study.

Glob Heart 2020 03 2;15(1):20. Epub 2020 Mar 2.

Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, US.

Background: Although increased age is associated with higher systolic blood pressure (SBP) in general, there may be variation across individuals in how SBP changes over time. The goal of this paper is to identify heterogeneity in SBP trajectories among young adults with similar initial values and identify personal characteristics associated with different trajectory patterns. This may have important implications for prevention and prognosis.

Methods: A cohort of 12,468 individuals aged 18-35 years in the Qingdao Port Cardiovascular Health Study in China was followed yearly during 2000-2011. Individuals were categorized into three strata according to their baseline SBP: ≤110 mmHg, 111-130 mmHg, and >130 mmHg. Within each stratum, group-based trajectory analyses were conducted to identify distinct SBP trajectory patterns, and their association with sociodemographic and baseline health characteristics was assessed by ordinal logistic regression.

Results: Five distinct groups of individuals exhibiting divergent patterns of increasing, stable or decreasing SBP trends were identified within each stratum. This is a first report to identify a subgroup with decreasing trend in SBP. Individuals with more advanced age, having less than high school education, family history of cardiovascular diseases, greater body mass index, greater waist circumference, and hyperlipidemia at baseline were more likely to experience trajectories of higher SBP within each stratum.

Conclusions: The diverging trajectories among young adults with similar initial SBP highlight the need for prevention and feasibility of effective blood pressure control, while the identified risk factors may inform targeted interventions.
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http://dx.doi.org/10.5334/gh.764DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7218791PMC
March 2020

Quality of informed consent documents among US. hospitals: a cross-sectional study.

BMJ Open 2020 05 19;10(5):e033299. Epub 2020 May 19.

Center for Outcomes Research and Evaluation, Yale New Haven Health System, New Haven, Connecticut, USA.

Objective: To determine whether informed consent for surgical procedures performed in US hospitals meet a minimum standard of quality, we developed and tested a quality measure of informed consent documents.

Design: Retrospective observational study of informed consent documents.

Setting: 25 US hospitals, diverse in size and geographical region.

Cohort: Among Medicare fee-for-service patients undergoing elective procedures in participating hospitals, we assessed the informed consent documents associated with these procedures. We aimed to review 100 qualifying procedures per hospital; the selected sample was representative of the procedure types performed at each hospital.

Primary Outcome: The outcome was hospital quality of informed consent documents, assessed by two independent raters using an eight-item instrument previously developed for this measure and scored on a scale of 0-20, with 20 representing the highest quality. The outcome was reported as the mean hospital document score and the proportion of documents meeting a quality threshold of 10. Reliability of the hospital score was determined based on subsets of randomly selected documents; face validity was assessed using stakeholder feedback.

Results: Among 2480 informed consent documents from 25 hospitals, mean hospital scores ranged from 0.6 (95% CI 0.3 to 0.9) to 10.8 (95% CI 10.0 to 11.6). Most hospitals had at least one document score at least 10 out of 20 points, but only two hospitals had >50% of their documents score above a 10-point threshold. The Spearman correlation of the measures score was 0.92. Stakeholders reported that the measure was important, though some felt it did not go far enough to assess informed consent quality.

Conclusion: All hospitals performed poorly on a measure of informed consent document quality, though there was some variation across hospitals. Measuring the quality of hospital's informed consent documents can serve as a first step in driving attention to gaps in quality.
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http://dx.doi.org/10.1136/bmjopen-2019-033299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247389PMC
May 2020

An instrument for assessing the quality of informed consent documents for elective procedures: development and testing.

BMJ Open 2020 05 19;10(5):e033297. Epub 2020 May 19.

Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.

Objective: To develop a nationally applicable tool for assessing the quality of informed consent documents for elective procedures.

Design: Mixed qualitative-quantitative approach.

Setting: Convened seven meetings with stakeholders to obtain input and feedback on the tool.

Participants: Team of physician investigators, measure development experts, and a working group of nine patients and patient advocates (caregivers, advocates for vulnerable populations and patient safety experts) from different regions of the country.

Interventions: With stakeholder input, we identified elements of high-quality informed consent documents, aggregated into three domains: content, presentation and timing. Based on this comprehensive taxonomy of key elements, we convened the working group to offer input on the development of an abstraction tool to assess the quality of informed consent documents in three phases: (1) selecting the highest-priority elements to be operationalised as items in the tool; (2) iteratively refining and testing the tool using a sample of qualifying informed consent documents from eight hospitals; and (3) developing a scoring approach for the tool. Finally, we tested the reliability of the tool in a subsample of 250 informed consent documents from 25 additional hospitals.

Outcomes: Abstraction tool to evaluate the quality of informed consent documents.

Results: We identified 53 elements of informed consent quality; of these, 15 were selected as highest priority for inclusion in the abstraction tool and 8 were feasible to measure. After seven cycles of iterative development and testing of survey items, and development and refinement of a training manual, two trained raters achieved high item-level agreement, ranging from 92% to 100%.

Conclusions: We identified key quality elements of an informed consent document and operationalised the highest-priority elements to define a minimum standard for informed consent documents. This tool is a starting point that can enable hospitals and other providers to evaluate and improve the quality of informed consent.
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http://dx.doi.org/10.1136/bmjopen-2019-033297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247404PMC
May 2020

Relationship of Age With the Hemodynamic Parameters in Individuals With Elevated Blood Pressure.

J Am Geriatr Soc 2020 07 25;68(7):1520-1528. Epub 2020 Mar 25.

Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.

Background: Age is known to be associated with the prevalence and pathophysiology of hypertension. However, there is little information on whether age stands as a good proxy for the specific hemodynamic profile of an individual with elevated blood pressure (BP), which could be important in the selection of therapy.

Design: This is a cross-sectional study.

Setting: People who underwent a noninvasive, hemodynamic assessment using impedance cardiography at 51 sites of iKang Health Checkup Centers throughout China between January 2012 and October 2018.

Participants: We included 116,851 individuals, aged 20 to 80 years.

Main Outcomes And Measures: Relationship between age and hemodynamic parameters (cardiac index, systemic vascular resistance index [SVRI]), among individuals with elevated BP (systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg).

Results: Final study population included 45,082 individuals with elevated BP: 29,194 men and 15,888 women with a mean (±SD) age of 48 (±13) and 54 (±12) years, respectively. Cardiac index was negatively associated with age with an adjusted, per decade decrease of 0.17 (95% confidence interval [CI] = 0.17-0.18) L/min/m in men and 0.24 (95% CI = 0.23-0.25) L/min/m in women. SVRI was positively associated with age with an adjusted, per-decade increase of 174.2 (95% CI = 168.8-179.7) dynes·s·cm ·m in men and 214.1 (95% CI = 204.3-223.8) dynes·s·cm ·m in women. However, there was substantial overlap in the distribution of these parameters across different age groups in both sexes.

Conclusions: In this large study, we observed that cardiac index decreased and SVRI increased with age among individuals with elevated BP. Even though there was a general trend with age, we observed heterogeneity within age strata, suggesting that age alone is inadequate to indicate the hemodynamic profile for an individual. J Am Geriatr Soc 68:1520-1528, 2020.
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http://dx.doi.org/10.1111/jgs.16411DOI Listing
July 2020

Leveraging the Electronic Health Records for Population Health: A Case Study of Patients With Markedly Elevated Blood Pressure.

J Am Heart Assoc 2020 04 23;9(7):e015033. Epub 2020 Mar 23.

Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT.

Background The digital transformation of medical data provides opportunities to perform digital population health surveillance and identify people inadequately managed in usual care. We leveraged the electronic health records of a large health system to identify patients with markedly elevated blood pressure and characterize their follow-up care pattern. Methods and Results We included 373 861 patients aged 18 to 85 years, who had at least 1 outpatient encounter in the Yale New Haven Health System between January 2013 and December 2017. We described the prevalence and follow-up pattern of patients with at least 1 systolic blood pressure (SBP) ≥160 mm Hg or diastolic blood pressure (DBP) ≥100 mm Hg and patients with at least 1 SBP ≥180 mm Hg or DBP ≥120 mm Hg. Of 373 861 patients included, 56 909 (15.2%) had at least 1 SBP ≥160 mm Hg or DBP ≥100 mm Hg, and 10 476 (2.8%) had at least 1 SBP ≥180 mm Hg or DBP ≥120 mm Hg. Among patients with SBP ≥160 mm Hg or DBP ≥100 mm Hg, only 28.3% had a follow visit within 1 month (time window of follow-up recommended by the guideline) and 19.9% subsequently achieved control targets (SBP <130 mm Hg and DBP <80 mm Hg) within 6 months. Follow-up rate at 1 month and control rate at 6 months for patients with SBP ≥180 mm Hg or DBP ≥120 mm Hg was 31.9% and 17.2%. Conclusions Digital population health surveillance with an electronic health record identified a large number of patients with markedly elevated blood pressure and inadequate follow-up. Many of these patients subsequently failed to achieve control targets.
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http://dx.doi.org/10.1161/JAHA.119.015033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428633PMC
April 2020

American Heart Association Goals Through a 20/20 Lens.

Authors:
Erica S Spatz

JAMA Cardiol 2020 05;5(5):504-506

Section of Cardiovascular Medicine, Yale Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut.

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http://dx.doi.org/10.1001/jamacardio.2020.0256DOI Listing
May 2020

Cardio-obstetrics: Recognizing and managing cardiovascular complications of pregnancy.

Cleve Clin J Med 2020 01 2;87(1):43-52. Epub 2020 Jan 2.

Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, New Haven, CT

Pregnancy can exacerbate known cardiovascular disorders and unmask previously unrecognized problems. Patients with congenital heart disorders, valvular disease, primary pulmonary hypertension, hypertensive disorders of pregnancy, and acquired peripartum cardiomyopathy need a collaborative interdisciplinary team that includes a cardiologist with specialty training in obstetrics.
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http://dx.doi.org/10.3949/ccjm.87a.18137DOI Listing
January 2020

Ideal cardiovascular health and resting heart rate in the Multi-Ethnic Study of Atherosclerosis.

Prev Med 2020 01 9;130:105890. Epub 2019 Nov 9.

The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, United States of America. Electronic address:

Elevated resting heart rate (RHR) is associated with an increased cardiovascular disease (CVD) risk, but little is known about its association with cardiovascular health (CVH), assessed by the Life's Simple 7 (LS7) metrics. We explored whether ideal CVH was associated with RHR in a cohort free from clinical CVD. We conducted a cross-sectional analysis of baseline data (2000-2002) of 6457 Multi-Ethnic Study of Atherosclerosis participants in 2018. Each LS7 metric (smoking, physical activity, diet, body mass index, blood pressure, cholesterol and glucose) was scored 0-2. Total score ranged from 0 to 14. Scores of 0-8 indicate inadequate, 9-10 average, and 11-14 optimal CVH. RHR was categorized as <60, 60-69, 70-79 and ≥80 bpm. We used multinomial logistic regression to determine associations between CVH score and RHR, adjusting for age, sex, race/ethnicity, education, income, health insurance, and atrioventricular nodal blockers. Mean age of participants (standard deviation) was 62 (10) years; 53% were women; 47% had inadequate CVH, 33% average, and 20% optimal. Favorable CVH was associated with lower odds of having higher RHR. Compared to RHR <60 bpm, participants with optimal CVH had adjusted odds ratio (95% CI) of 0.55 (0.46-0.64) for RHR of 60-69 bpm, 0.34 (0.28-0.43) for 70-79 bpm, and 0.14 (0.09-0.22) for ≥80 bpm. A similar pattern was observed in the stratified analysis by sex, race/ethnicity and age. Favorable CVH was less likely to be associated with elevated RHR irrespective of sex, race/ethnicity and age. More research is needed to explore the usefulness of promoting ideal CVH to reduce elevated RHR, a known risk factor for CVD.
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http://dx.doi.org/10.1016/j.ypmed.2019.105890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6930349PMC
January 2020

Phenotypes of Hypertensive Ambulatory Blood Pressure Patterns: Design and Rationale of the ECHORN Hypertension Study.

Ethn Dis 2019 17;29(4):535-544. Epub 2019 Oct 17.

Equity Research and Innovation Center, Yale School of Medicine; New Haven, CT.

Objective: To describe the rationale and design of a prospective study of ambulatory blood pressure measurement (ABPM) combined with measurement of contextual factors to identify hypertensive phenotypes in a Caribbean population with high rates of HTN and cardiovascular disease.

Design: Prospective, multi-center sub-study.

Setting: Eastern Caribbean Health Outcomes Research Network Cohort (ECHORN) Study, with study sites in Puerto Rico, the US Virgin Islands, Trinidad and Tobago, and Barbados.

Participants: Community-residing adults without a diagnosis of HTN and not taking antihypertensive medication.

Intervention: Ambulatory BP patterns are assessed using 24-hour ABPM. Contextual factors are assessed with: ecological momentary assessment (7-item survey of experiences, exposures and responses associated with daytime BP measurements); actigraphy (capturing physical activity and sleep quality); and self-report surveys (assessing physical and social health, environmental and social stressors and supports).

Main Outcome Measures: Phenotypes of contextual factors associated with hypertensive BP patterns (sustained HTN, masked HTN, and nocturnal non-dipping).

Methods And Results: This study will enroll 500 participants; assessments of blood pressure and contextual factors will be conducted during Waves 2 and 3 of the ECHORN parent study, occurring 2 years apart. In Wave 2, we will assess the association between contextual factors and ABPM patterns. Using advanced analytic clustering methods, we will identify phenotypes of contextual factors associated with hypertensive ABPM patterns. We will then test the stability of these phenotypes and their ability to predict change in ABPM patterns between Waves 2 and 3.

Conclusions: Assessment of ABPM, and the contextual factors influencing ABPM, can identify unique phenotypes of HTN, which can then be used to develop more precision-based approaches to the prevention, detection and treatment of HTN in high-risk populations.
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http://dx.doi.org/10.18865/ed.29.4.535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802166PMC
June 2020

Financial barriers in accessing medical care for peripheral artery disease are associated with delay of presentation and adverse health status outcomes in the United States.

Vasc Med 2020 02 11;25(1):13-24. Epub 2019 Oct 11.

Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA.

Patient-reported difficulties in affording health care and their association with health status outcomes in peripheral artery disease (PAD) have never been studied. We sought to determine whether financial barriers affected PAD symptoms at presentation, treatment patterns, and patient-reported health status in the year following presentation. A total of 797 United States (US) patients with PAD were identified from the Patient-centered Outcomes Related to TReatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) study, a prospective, multicenter registry of patients presenting to vascular specialty clinics with PAD. Financial barriers were defined as a composite of no insurance and underinsurance. Disease-specific health status was measured by Peripheral Artery Questionnaire (PAQ) and general health-related quality of life was measured by EuroQol 5 (EQ5D) dimensions at presentation and at 3, 6, and 12 months of follow-up. Among 797 US patients, 21% ( = 165) of patients reported financial barriers. Patients with financial barriers presented at an earlier age (64 ± 9.5 vs 70 ± 9.4 years), with longer duration of symptoms (59% vs 49%) (all ⩽ 0.05), were more depressed and had higher levels of perceived stress and anxiety. After multivariable adjustment, health status was worse at presentation in patients with financial barriers (PAQ: -7.0 [-10.7, -3.4]; < 0.001 and EQ5D: -9.2 [-12.74, -5.8]; < 0.001) as well as through 12 months of follow-up (PAQ: -8.4 [-13.0, -3.8]; < 0.001 and EQ5D: -9.7 [-13.2, -6.2]; < 0.001). In conclusion, financial barriers are associated with later presentation as well as poorer health status at presentation and at 12 months. .
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http://dx.doi.org/10.1177/1358863X19872542DOI Listing
February 2020

Prevalence, Awareness, and Treatment of Isolated Diastolic Hypertension: Insights From the China PEACE Million Persons Project.

J Am Heart Assoc 2019 10 28;8(19):e012954. Epub 2019 Sep 28.

NHC Key Laboratory of Clinical Research for Cardiovascular Medications National Clinical Research Center of Cardiovascular Diseases Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China.

Background Characterizing and assessing the prevalence, awareness, and treatment patterns of patients with isolated diastolic hypertension (IDH) can generate new knowledge and highlight opportunities to improve their care. Methods and Results We used data from the China PEACE (Patient-centered Evaluative Assessment of Cardiac Events) Million Persons Project, which screened 2 351 035 participants aged 35 to 75 years between 2014 and 2018. IDH was defined as systolic and diastolic blood pressure of <140 and ≥90 mm Hg; awareness as self-reported diagnosis of hypertension; and treatment as current use of antihypertensive medications. Of the 2 310 184 participants included (mean age 55.7 years; 59.5% women); 73 279 (3.2%) had IDH, of whom 63 112 (86.1%) were untreated, and only 6512 (10.3%) of the untreated were aware of having hypertension. When compared with normotensives, participants who were <60 years, men, at least college educated, had body mass index of >28 kg/m, consumed alcohol, had diabetes mellitus, and prior cardiovascular events were more likely to have IDH (all <0.01). Among those with IDH, higher likelihood of awareness was associated with increased age, women, college education, body mass index of >28 kg/m, higher income, diabetes mellitus, prior cardiovascular events, and Central or Eastern region (all <0.05). Most treated participants with IDH reported taking only 1 class of antihypertensive medication. Conclusions IDH affects a substantial number of people in China, however, few are aware of having hypertension and most treated participants are poorly managed, which suggests the need to improve the diagnosis and treatment of people with IDH.
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http://dx.doi.org/10.1161/JAHA.119.012954DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806046PMC
October 2019