Publications by authors named "Srinath Adusumalli"

40 Publications

Insourcing and scaling a telemedicine solution in under 2 weeks: Lessons for the digital transformation of health care.

Healthc (Amst) 2021 Jul 19;9(3):100568. Epub 2021 Jul 19.

University of Pennsylvania Health System, Penn Medicine Center for Health Care Innovation, 3400 Civic Center Blvd, 14(th) Floor South Pavilion, Philadelphia, PA, 19104, USA; University of Pennsylvania Health System, Office of the Chief Medical Information Officer, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA; University of Pennsylvania Health System, Cardiology, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA. Electronic address:

The Covid-19 pandemic required rapid scale of telemedicine as well as other digital workflows to maintain access to care while reducing infection risk. Both patients and clinicians who hadn't used telemedicine before were suddenly faced with a multi-step setup process to log into a virtual meeting. Unlike in-person examination rooms, locking a virtual meeting room was more error-prone and posed a risk of multiple patients joining the same online session. There was administrative burden on the practice staff who were generating and manually sending links to patients, and educating patients on device set up was time-consuming and unsustainable. A solution had to be deployed rapidly system-wide, without the usual roll out across months. Our answer was to design and implement a novel EHR-integrated web application called the Switchboard, in just two weeks. The Switchboard leverages a commercial, cloud-based video meeting platform and facilitates an end-to-end virtual care encounter workflow, from pre-visit reminders to post-visit SMS text message-based measurement of patient experience, with tools to extend contact-less workflows to in-person appointments. Over the first 11 months of the pandemic, the in-house platform has been adopted across 6 hospitals and >200 practices, scaled to 8,800 clinicians who at their peak conducted an average of 30,000 telemedicine appointments/week, and enabled over 10,000-20,000 text messages/day to be exchanged through the platform. Furthermore, it enabled our organization to convert from an average of 75% of telehealth visits being conducted via telephone to 75% conducted via video within weeks.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hjdsi.2021.100568DOI Listing
July 2021

Novel Digital Technologies for Blood Pressure Monitoring and Hypertension Management.

Curr Cardiovasc Risk Rep 2021 9;15(8):11. Epub 2021 Jun 9.

Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA.

Purpose Of Review: Hypertension is common, impacting an estimated 108 million US adults, and deadly, responsible for the deaths of one in six adults annually. Optimal management includes frequent blood pressure monitoring and antihypertensive medication titration, but in the traditional office-based care delivery model, patients have their blood pressure measured only intermittently and in a way that is subject to misdiagnosis with white coat or masked hypertension. There is a growing opportunity to leverage our expanding repository of digital technology to reimagine hypertension care delivery. This paper reviews existing and emerging digital tools available for hypertension management, as well as behavioral economic insights that could supercharge their impact.

Recent Findings: Digitally connected blood pressure monitors offer an alternative to office-based blood pressure monitoring. A number of cuffless blood pressure monitors are in development but require further validation before they can be deployed for widespread clinical use. Patient-facing hubs and applications offer a means to transmit blood pressure data to clinicians. Though artificial intelligence could allow for curation of this data, its clinical use for hypertension remains limited to assessing risk factors at this time. Finally, text-based and telemedicine platforms are increasingly being employed to translate hypertension data into clinical outcomes with promising results.

Summary: The digital management of hypertension shows potential as an avenue for increasing patient engagement and improving clinical efficiency and outcomes. It is important for clinicians to understand the benefits, limitations, and future directions of digital health to optimize management of hypertension.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12170-021-00672-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8188759PMC
June 2021

Statin Prescribing and Dosing-Failure Has Become an Option-Reply.

JAMA Cardiol 2021 Jul;6(7):855

Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamacardio.2021.0838DOI Listing
July 2021

Adoption of PCSK9 Inhibitors Among Patients With Atherosclerotic Disease.

J Am Heart Assoc 2021 May 27;10(9):e019331. Epub 2021 Apr 27.

Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.

Background PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors represent a promising class of lipid-lowering therapy, although their use has been limited by cost concerns. Methods and Results A retrospective cohort study was conducted using a nationwide commercial claims database comprising patients with atherosclerotic cardiovascular disease (ASCVD), aged 18 to 64 years. We identified the number of patients with ASCVD started on a PCSK9 inhibitor from the dates of US Food and Drug Administration approval in quarter 3 2015 through quarter 2 2019. Secondary objectives identified the proportions of patients started on a PCSK9 inhibitor in various ASCVD risk groups based on statin use and baseline low-density lipoprotein cholesterol. We identified 126 419 patients with ASCVD on either PCSK9 inhibitor or statin therapy. Among these patients, 1168 (0.9%) filled a prescription for a PCSK9 inhibitor. The number of patients initiating a PCSK9 inhibitor increased from 2 patients in quarter 3 2015 to 119 patients in quarter 2 2019, corresponding to an increase from 0.05% to 2.5% of patients with ASCVD already on statins who started PCSK9 inhibitor therapy. Of patients with ASCVD with high adherence to a high-intensity statin, 13 643 had low-density lipoprotein cholesterol ≥70 mg/dL, and in this subgroup, 119 (0.9%) patients initiated a PCSK9 inhibitor. Conclusions Few patients started PCSK9 inhibitors from 2015 through mid-2019, despite increasing trial evidence of efficacy, guidelines recommending PCSK9 inhibitors in high-risk patients with ASCVD, and price reductions during this period. The magnitude of price reductions may not yet be sufficient to influence use management strategies aimed to limit PCSK9 inhibitor use.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.120.019331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8200752PMC
May 2021

Association of Race/Ethnicity, Gender, and Socioeconomic Status With Sodium-Glucose Cotransporter 2 Inhibitor Use Among Patients With Diabetes in the US.

JAMA Netw Open 2021 Apr 1;4(4):e216139. Epub 2021 Apr 1.

Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

Importance: Sodium-glucose cotransporter 2 (SGLT2) inhibitors significantly reduce deaths from cardiovascular conditions, hospitalizations for heart failure, and progression of kidney disease among patients with type 2 diabetes. Black individuals have a disproportionate burden of cardiovascular and chronic kidney disease (CKD). Adoption of novel therapeutics has been slower among Black and female patients and among patients with low socioeconomic status than among White or male patients or patients with higher socioeconomic status.

Objective: To assess whether inequities based on race/ethnicity, gender, and socioeconomic status exist in SGLT2 inhibitor use among patients with type 2 diabetes in the US.

Design, Setting, And Participants: This retrospective cohort study of commercially insured patients in the US was performed from October 1, 2015, to June 30, 2019, using the Optum Clinformatics Data Mart. Adult patients with a diagnosis of type 2 diabetes, including those with heart failure with reduced ejection fraction (HFrEF), atherosclerotic cardiovascular disease (ASCVD), or CKD, were evaluated in the analysis.

Main Outcomes And Measures: Prescription of an SGLT2 inhibitor. Multivariable logistic regression models were used to assess the association of race/ethnicity, gender, and socioeconomic status with SGLT2 inhibitor use.

Results: Of 934 737 patients with type 2 diabetes (mean [SD] age, 65.4 [12.9] years; 50.7% female; 57.6% White), 81 007 (8.7%) were treated with an SGLT2 inhibitor during the study period. Between 2015 and 2019, the percentage of patients with type 2 diabetes treated with an SGLT2 inhibitor increased from 3.8% to 11.9%. Among patients with type 2 diabetes and cardiovascular or kidney disease, the rate of SGLT2 inhibitor use increased but was lower than that among all patients with type 2 diabetes (HFrEF: 1.9% to 7.6%; ASCVD: 3.0% to 9.8%; CKD: 2.1% to 7.5%). In multivariable analyses, Black race (adjusted odds ratio [aOR], 0.83; 95% CI, 0.81-0.85), Asian race (aOR, 0.94; 95% CI, 0.90-0.98), and female gender (aOR, 0.84; 95% CI, 0.82-0.85) were associated with lower rates of SGLT2 inhibitor use, whereas higher median household income (≥$100 000: aOR, 1.08 [95% CI, 1.05-1.10]; $50 000-$99 999: aOR, 1.05 [95% CI, 1.03-1.07] vs <$50 000) was associated with a higher rate of SGLT2 inhibitor use. These results were similar among patients with HFrEF, ASCVD, and CKD.

Conclusions And Relevance: In this cohort study, use of an SGLT2 inhibitor treatment increased among patients with type 2 diabetes from 2015 to 2019 but remained low, particularly among patients with HFrEF, CKD, and ASCVD. Black and female patients and patients with low socioeconomic status were less likely to receive an SGLT2 inhibitor, suggesting that interventions to ensure more equitable use are essential to prevent worsening of well-documented disparities in cardiovascular and kidney outcomes in the US.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2021.6139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050743PMC
April 2021

Bleeding risk by intensity of anticoagulation in critically ill patients with COVID-19: A retrospective cohort study.

J Thromb Haemost 2021 06 7;19(6):1533-1545. Epub 2021 May 7.

Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Background: Studies report hypercoagulability in coronavirus disease 2019 (COVID-19), leading many institutions to escalate anticoagulation intensity for thrombosis prophylaxis.

Objective: To determine the bleeding risk with various intensities of anticoagulation in critically ill patients with COVID-19 compared with other respiratory viral illnesses (ORVI).

Patients/methods: This retrospective cohort study compared the incidence of major bleeding in patients admitted to an intensive care unit (ICU) within a single health system with COVID-19 versus ORVI. In the COVID-19 cohort, we assessed the effect of anticoagulation intensity received on ICU admission on bleeding risk. We performed a secondary analysis with anticoagulation intensity as a time-varying covariate to reflect dose changes after ICU admission.

Results: Four hundred and forty-three and 387 patients were included in the COVID-19 and ORVI cohorts, respectively. The hazard ratio of major bleeding for the COVID-19 cohort relative to the ORVI cohort was 1.26 (95% confidence interval [CI]: 0.86-1.86). In COVID-19 patients, an inverse-probability treatment weighted model found therapeutic-intensity anticoagulation on ICU admission had an adjusted hazard ratio of bleeding of 1.55 (95% CI: 0.88-2.73) compared with standard prophylactic-intensity anticoagulation. However, when anticoagulation was assessed as a time-varying covariate and adjusted for other risk factors for bleeding, the adjusted hazard ratio for bleeding on therapeutic-intensity anticoagulation compared with standard thromboprophylaxis was 2.59 (95% CI: 1.20-5.57).

Conclusions: Critically ill patients with COVID-19 had a similar bleeding risk as ORVI patients. When accounting for changes in anticoagulation that occurred in COVID-19 patients, therapeutic-intensity anticoagulation was associated with a greater risk of major bleeding compared with standard thromboprophylaxis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jth.15310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8250316PMC
June 2021

Evolution and Outcomes of Premature Coronary Artery Disease.

Curr Cardiol Rep 2021 03 8;23(4):36. Epub 2021 Mar 8.

Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Purpose Of Review: The purpose of this review is to explore the evolution and outcomes of premature coronary artery disease (PCAD) while reviewing strategies for effective screening of those at high risk for developing this disease.

Recent Findings: Premature coronary artery disease (PCAD) affects a population of patients not typically identified as high risk by current risk stratification guidelines or traditional risk calculation tools. Not only does PCAD represent a large proportion of overall cardiovascular disease, it also afflicts a population in which the rate of mortality from cardiovascular disease has plateaued despite an overall declining population-wide cardiovascular mortality rate. There is ample opportunity for behavioral change strategies, screening tools, adapted imaging modalities, and precision pharmacotherapies to be more precisely targeted toward those at highest risk for premature coronary artery disease. Premature coronary artery disease (PCAD) is pervasive and not frequently represented within contemporary risk calculation models. Providers should pursue proactive screening and aggressive risk factor modification and deploy appropriate preventative therapies in caring for younger populations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11886-021-01457-8DOI Listing
March 2021

Predicting Cardiovascular Risk Using Social Media Data: Performance Evaluation of Machine-Learning Models.

JMIR Cardio 2021 Feb 19;5(1):e24473. Epub 2021 Feb 19.

Penn Medicine Center for Digital Health, University of Pennsylvania, Philadelphia, PA, United States.

Background: Current atherosclerotic cardiovascular disease (ASCVD) predictive models have limitations; thus, efforts are underway to improve the discriminatory power of ASCVD models.

Objective: We sought to evaluate the discriminatory power of social media posts to predict the 10-year risk for ASCVD as compared to that of pooled cohort risk equations (PCEs).

Methods: We consented patients receiving care in an urban academic emergency department to share access to their Facebook posts and electronic medical records (EMRs). We retrieved Facebook status updates up to 5 years prior to study enrollment for all consenting patients. We identified patients (N=181) without a prior history of coronary heart disease, an ASCVD score in their EMR, and more than 200 words in their Facebook posts. Using Facebook posts from these patients, we applied a machine-learning model to predict 10-year ASCVD risk scores. Using a machine-learning model and a psycholinguistic dictionary, Linguistic Inquiry and Word Count, we evaluated if language from posts alone could predict differences in risk scores and the association of certain words with risk categories, respectively.

Results: The machine-learning model predicted the 10-year ASCVD risk scores for the categories <5%, 5%-7.4%, 7.5%-9.9%, and ≥10% with area under the curve (AUC) values of 0.78, 0.57, 0.72, and 0.61, respectively. The machine-learning model distinguished between low risk (<10%) and high risk (>10%) with an AUC of 0.69. Additionally, the machine-learning model predicted the ASCVD risk score with Pearson r=0.26. Using Linguistic Inquiry and Word Count, patients with higher ASCVD scores were more likely to use words associated with sadness (r=0.32).

Conclusions: Language used on social media can provide insights about an individual's ASCVD risk and inform approaches to risk modification.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/24473DOI Listing
February 2021

The Cardiovascular Quality Improvement and Care Innovation Consortium: Inception of a Multicenter Collaborative to Improve Cardiovascular Care.

Circ Cardiovasc Qual Outcomes 2021 01 12;14(1):e006753. Epub 2021 Jan 12.

University of Colorado School of Medicine, Aurora (P.M.H.).

Despite decades of improvement in the quality and outcomes of cardiovascular care, significant gaps remain. Existing quality improvement strategies are often limited in scope to specific clinical conditions and episodic care. Health services and outcomes research is essential to inform gaps in care but rarely results in the development and implementation of care delivery solutions. Although individual health systems are engaged in projects to improve the quality of care delivery, these efforts often lack a robust study design or implementation evaluation that can inform generalizability and further dissemination. Aligning the work of health care systems and health services and outcomes researchers could serve as a strategy to overcome persisting gaps in cardiovascular quality and outcomes. We describe the inception of the Cardiovascular Quality Improvement and Care Innovation Consortium that seeks to rapidly improve cardiovascular care by (1) developing, implementing, and evaluating multicenter quality improvement projects using innovative care designs; (2) serving as a resource for quality improvement and care innovation partners; and (3) establishing a presence within existing quality improvement and care innovation structures. Success of the collaborative will be defined by projects that result in changes to care delivery with demonstrable impacts on the quality and outcomes of care across multiple health systems. Furthermore, insights gained from implementation of these projects across sites in Cardiovascular Quality Improvement and Care Innovation Consortium will inform and promote broad dissemination for greater impact.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCOUTCOMES.120.006753DOI Listing
January 2021

Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic.

JAMA Netw Open 2020 12 1;3(12):e2031640. Epub 2020 Dec 1.

Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has required a shift in health care delivery platforms, necessitating a new reliance on telemedicine.

Objective: To evaluate whether inequities are present in telemedicine use and video visit use for telemedicine visits during the COVID-19 pandemic.

Design, Setting, And Participants: In this cohort study, a retrospective medical record review was conducted from March 16 to May 11, 2020, of all patients scheduled for telemedicine visits in primary care and specialty ambulatory clinics at a large academic health system. Age, race/ethnicity, sex, language, median household income, and insurance type were all identified from the electronic medical record.

Main Outcomes And Measures: A successfully completed telemedicine visit and video (vs telephone) visit for a telemedicine encounter. Multivariable models were used to assess the association between sociodemographic factors, including sex, race/ethnicity, socioeconomic status, and language, and the use of telemedicine visits, as well as video use specifically.

Results: A total of 148 402 unique patients (86 055 women [58.0%]; mean [SD] age, 56.5 [17.7] years) had scheduled telemedicine visits during the study period; 80 780 patients (54.4%) completed visits. Of 78 539 patients with completed visits in which visit modality was specified, 35 824 (45.6%) were conducted via video, whereas 24 025 (56.9%) had a telephone visit. In multivariable models, older age (adjusted odds ratio [aOR], 0.85 [95% CI, 0.83-0.88] for those aged 55-64 years; aOR, 0.75 [95% CI, 0.72-0.78] for those aged 65-74 years; aOR, 0.67 [95% CI, 0.64-0.70] for those aged ≥75 years), Asian race (aOR, 0.69 [95% CI, 0.66-0.73]), non-English language as the patient's preferred language (aOR, 0.84 [95% CI, 0.78-0.90]), and Medicaid insurance (aOR, 0.93 [95% CI, 0.89-0.97]) were independently associated with fewer completed telemedicine visits. Older age (aOR, 0.79 [95% CI, 0.76-0.82] for those aged 55-64 years; aOR, 0.78 [95% CI, 0.74-0.83] for those aged 65-74 years; aOR, 0.49 [95% CI, 0.46-0.53] for those aged ≥75 years), female sex (aOR, 0.92 [95% CI, 0.90-0.95]), Black race (aOR, 0.65 [95% CI, 0.62-0.68]), Latinx ethnicity (aOR, 0.90 [95% CI, 0.83-0.97]), and lower household income (aOR, 0.57 [95% CI, 0.54-0.60] for income <$50 000; aOR, 0.89 [95% CI, 0.85-0.92], for $50 000-$100 000) were associated with less video use for telemedicine visits. These results were similar across medical specialties.

Conclusions And Relevance: In this cohort study of patients scheduled for primary care and medical specialty ambulatory telemedicine visits at a large academic health system during the early phase of the COVID-19 pandemic, older patients, Asian patients, and non-English-speaking patients had lower rates of telemedicine use, while older patients, female patients, Black, Latinx, and poorer patients had less video use. Inequities in accessing telemedicine care are present, which warrant further attention.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2020.31640DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772717PMC
December 2020

Building a Heart Failure Clinic: A Practical Guide from the Heart Failure Society of America.

J Card Fail 2021 Jan 24;27(1):2-19. Epub 2020 Oct 24.

University of Mississippi Medical Center, Jackson, Mississippi, USA. Electronic address:

Heart failure (HF) remains a leading cause of mortality and morbidity and a primary driver of health care resource use in the United States. As such, there continues to be much interest in the development and refinement of HF clinics that manage patients with HF in a guideline-directed, technology-enabled, and coordinated approach. Optimization of resource use and maintenance of collaboration with other providers are also important themes when considering implementation of HF clinics. Through this document, the Heart Failure Society of America aims to provide a contemporary, practical guide to creating and sustaining a HF clinic. The guide discusses (1) patient care considerations for delivering guideline-directed and patient-centered care, and (2) operational considerations including development of a HF clinic business plan, setting goals, leadership support, triggers for patient referral and patient follow-up, patient population served, optimal clinic staffing models, relationships with subspecialists, and continuous quality improvement. This document was developed to empower providers and clinicians who wish to build and sustain community-based, successful HF clinics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cardfail.2020.10.008DOI Listing
January 2021

Collaboration during Crisis: A Novel Point-of-Care Ultrasound Alliance among Emergency Medicine, Internal Medicine, and Cardiology in the COVID-19 Era.

J Am Soc Echocardiogr 2021 03 3;34(3):325-326. Epub 2020 Dec 3.

Perelman School of Medicine at the University of Pennsylvania, Department of Medicine, Philadelphia, Pennsylvania; Office of the Chief Medical Information Officer, University of Pennsylvania Health System, Philadelphia, Pennsylvania; Center for Healthcare Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.11.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710470PMC
March 2021

Cardiology Involvement in Patients with Breast Cancer Treated with Trastuzumab.

JACC CardioOncol 2020 Jun 16;2(2):179-189. Epub 2020 Jun 16.

Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

Background: There is limited evidence regarding the impact of cardiology involvement in the care of cancer patients.

Objectives: We evaluated the impact of cardiology involvement on guideline-adherent cardiovascular monitoring and risk factor management in breast cancer patients treated with trastuzumab.

Methods: In a single-center retrospective cohort study, we evaluated electronic health records from 1,047 breast cancer patients receiving trastuzumab between January 2009 and July 2018. A visit to a cardiology provider beginning from the 3 months prior to cancer therapy initiation until the last contact date defined cardiology involvement. Guideline-adherent monitoring, defined by echocardiography assessment within the 4 months prior to trastuzumab initiation and follow-up echocardiography at least every 4 months during therapy, was compared in patients with and without cardiology involvement prior to treatment initiation. Multivariable associations between cardiology involvement and time-varying risk factors blood pressure (BP) and body mass index (BMI) were assessed using generalized estimating equations.

Results: Cardiology involvement occurred in 293 (28%) patients. A higher proportion of patients with cardiology involvement prior to trastuzumab initiation had guideline-adherent monitoring (76.4% versus 60.1%, p=0.007). Cardiology involvement was associated with an average 1.5mmHg (95% CI -2.9,-0.1, p=0.035) lower systolic BP; which was more pronounced in those with hypertension (-2.7mmHg (95% CI -4.6,-0.7, p=0.007)). Cardiology involvement was associated with a lower BMI in patients with baseline BMI≥25 kg/m (mean difference; -0.5 (95% CI -1.0,-0.1, p=0.027)).

Conclusions: Cardiology involvement in breast cancer patients treated with trastuzumab is associated with greater adherence to cardiovascular monitoring and modest improvements in risk factor control.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaccao.2020.04.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7701353PMC
June 2020

Corrigendum to: Pulmonary Hypertension in Heart Failure Patients.

Card Fail Rev 2020 Mar 23;6:e30. Epub 2020 Oct 23.

Advanced Heart Failure/Transplantation Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US.

[This corrects the article DOI: 10.15420/cfr.2019.09.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.15420/cfr.2020.1.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607380PMC
March 2020

Effect of Passive Choice and Active Choice Interventions in the Electronic Health Record to Cardiologists on Statin Prescribing: A Cluster Randomized Clinical Trial.

JAMA Cardiol 2021 Jan;6(1):40-48

Penn Medicine, University of Pennsylvania, Philadelphia.

Importance: Statin therapy is underused for many patients who could benefit.

Objective: To evaluate the effect of passive choice and active choice interventions in the electronic health record (EHR) to promote guideline-directed statin therapy.

Design, Setting, And Participants: Three-arm randomized clinical trial with a 6-month preintervention period and 6-month intervention. Randomization conducted at the cardiologist level at 16 cardiology practices in Pennsylvania and New Jersey. The study included 82 cardiologists and 11 693 patients. Data were analyzed between May 8, 2019, and January 9, 2020.

Interventions: In passive choice, cardiologists had to manually access an alert embedded in the EHR to select options to initiate or increase statin therapy. In active choice, an interruptive EHR alert prompted the cardiologist to accept or decline guideline-directed statin therapy. Cardiologists in the control group were informed of the trial but received no other interventions.

Main Outcomes And Measures: Primary outcome was statin therapy at optimal dose based on clinical guidelines. Secondary outcome was statin therapy at any dose.

Results: The sample comprised 11 693 patients with a mean (SD) age of 63.8 (9.1) years; 58% were male (n = 6749 of 11 693), 66% were White (n = 7683 of 11 693), and 24% were Black (n = 2824 of 11 693). The mean (SD) 10-year atherosclerotic cardiovascular disease (ASCVD) risk score was 15.4 (10.0); 68% had an ASVCD clinical diagnosis. Baseline statin prescribing rates at the optimal dose were 40.3% in the control arm, 39.1% in the passive choice arm, and 41.2% in the active choice arm. In adjusted analyses, the change in statin prescribing rates at optimal dose over time was not significantly different from control for passive choice (adjusted difference in percentage points, 0.2; 95% CI, -2.9 to 2.8; P = .86) or active choice (adjusted difference in percentage points, 2.4; 95% CI, -0.6 to 5.0; P = .08). In adjusted analyses of the subset of patients with clinical ASCVD, the active choice intervention resulted in a significant increase in statin prescribing at optimal dose relative to control (adjusted difference in percentage points, 3.8; 95% CI, 1.0-6.4; P = .008). No other subset analyses were significant. There were no significant changes in statin prescribing at any dose for either intervention.

Conclusions And Relevance: The passive choice and active choice interventions did not change statin prescribing. In the subgroup of patients with clinical ASCVD, the active choice intervention led to a small increase in statin prescribing at the optimal dose, which could inform the design or targeting of future interventions.

Trial Registration: ClinicalTrials.gov Identifier: NCT03271931.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamacardio.2020.4730DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542520PMC
January 2021

Nudges and the meaningful adoption of digital health.

Per Med 2020 11 7;17(6):429-433. Epub 2020 Oct 7.

Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2217/pme-2020-0071DOI Listing
November 2020

A Model for the Career Advancement of Women Fellows and Cardiologists.

J Am Coll Cardiol 2020 08;76(8):996-1000

Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2020.07.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733708PMC
August 2020

COVID-19 and cardiac arrhythmias.

Heart Rhythm 2020 Sep 22;17(9):1439-1444. Epub 2020 Jun 22.

Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: Early studies suggest that coronavirus disease 2019 (COVID-19) is associated with a high incidence of cardiac arrhythmias. Severe acute respiratory syndrome coronavirus 2 infection may cause injury to cardiac myocytes and increase arrhythmia risk.

Objectives: The purpose of this study was to evaluate the risk of cardiac arrest and arrhythmias including incident atrial fibrillation (AF), bradyarrhythmias, and nonsustained ventricular tachycardia (NSVT) in a large urban population hospitalized for COVID-19. We also evaluated correlations between the presence of these arrhythmias and mortality.

Methods: We reviewed the characteristics of all patients with COVID-19 admitted to our center over a 9-week period. Throughout hospitalization, we evaluated the incidence of cardiac arrests, arrhythmias, and inpatient mortality. We also used logistic regression to evaluate age, sex, race, body mass index, prevalent cardiovascular disease, diabetes, hypertension, chronic kidney disease, and intensive care unit (ICU) status as potential risk factors for each arrhythmia.

Results: Among 700 patients (mean age 50 ± 18 years; 45% men; 71% African American; 11% received ICU care), there were 9 cardiac arrests, 25 incident AF events, 9 clinically significant bradyarrhythmias, and 10 NSVTs. All cardiac arrests occurred in patients admitted to the ICU. In addition, admission to the ICU was associated with incident AF (odds ratio [OR] 4.68; 95% confidence interval [CI] 1.66-13.18) and NSVT (OR 8.92; 95% CI 1.73-46.06) after multivariable adjustment. Also, age and incident AF (OR 1.05; 95% CI 1.02-1.09) and prevalent heart failure and bradyarrhythmias (OR 9.75; 95% CI 1.95-48.65) were independently associated. Only cardiac arrests were associated with acute in-hospital mortality.

Conclusion: Cardiac arrests and arrhythmias are likely the consequence of systemic illness and not solely the direct effects of COVID-19 infection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrthm.2020.06.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7307518PMC
September 2020

Telemedicine and the Forgotten America.

Circulation 2020 07 11;142(4):312-314. Epub 2020 Jun 11.

Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (H.M.J, L.A.E., S.A.).

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.120.048535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382527PMC
July 2020

Telemedicine Outpatient Cardiovascular Care During the COVID-19 Pandemic: Bridging or Opening the Digital Divide?

Circulation 2020 08 8;142(5):510-512. Epub 2020 Jun 8.

Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., H.M.J., S.A.).

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.120.048185DOI Listing
August 2020

Clinical Practice and Research in Cardio-Oncology: Finding the "Rosetta Stone" for Establishing Program Excellence in Cardio-oncology.

J Cardiovasc Transl Res 2020 06 22;13(3):495-505. Epub 2020 May 22.

Cardio-Oncology Center of Excellence, Division of Cardiovascular Medicine, Washington University in St Louis, 660 South Euclid Avenue, Campus box 8086, St. Louis, MO, 63110-1093, USA.

The burgeoning field of cardio-oncology (C-O) is now necessary for the delivery of excellent care for patients with cancer. Many factors have contributed to this increasing population of cancer survivors or those being treated with novel and targeted cancer therapies. There is a tremendous need to provide outstanding cardiovascular (CV) care for these patients; however, current medical literature actually provides a paucity of guidance. C-O therefore provides a novel opportunity for clinical, translational, and basic research to advance patient care. This review aims to be a primer for cardio-oncologists on how to develop a vibrant and comprehensive C-O program, use practical tools to assist in the construction of C-O services, and to proactively incorporate translational and clinical research into the training of future leaders as well as enhance clinical care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12265-020-10010-xDOI Listing
June 2020

Pulmonary Hypertension in Heart Failure Patients.

Card Fail Rev 2020 Mar 9;6:e05. Epub 2020 Apr 9.

Advanced Heart Failure/Transplantation Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US.

The development of pulmonary hypertension (PH) in patients with heart failure is associated with increased morbidity and mortality. In this article, the authors examine recent changes to the definition of PH in the setting of left heart disease (PH-LHD), and discuss its epidemiology, pathophysiology and prognosis. They also explore the complexities of diagnosing PH-LHD and the current evidence for the use of medical therapies, promising clinical trials and the role of left ventricular assist device and transplantation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.15420/cfr.2019.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199161PMC
March 2020

Outcomes of catheter-directed versus systemic thrombolysis for the treatment of pulmonary embolism: A real-world analysis of national administrative claims.

Vasc Med 2020 08 27;25(4):334-340. Epub 2020 Apr 27.

Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Catheter-directed thrombolysis (CDT) and systemic thrombolysis (ST) are used to treat intermediate/high-risk pulmonary embolism (PE) in the absence of comparative safety and effectiveness data. We utilized a large administrative database to perform a comparative safety and effectiveness analysis of catheter-directed versus systemic thrombolysis. From the Optum Clinformatics Data Mart private-payer insurance claims database, we identified 100,744 patients hospitalized with PE between 2004 and 2014. We extracted demographic characteristics, high-risk PE features, components of the Elixhauser Comorbidity Index, and outcomes including intracranial hemorrhage (ICH), all-cause bleeding, and mortality among all patients receiving CDT and ST. We used propensity score methods to compare outcomes between matched cohorts adjusted for observed confounders. A total of 1915 patients (1.9%) received either CDT ( = 632) or ST ( = 1283). Patients in the CDT group had fewer high-risk features including less shock (5.4 vs 11.1%; < 0.001) and cardiac arrest (6.8 vs 11.0%; = 0.004). In 1:1 propensity-matched groups, ICH rates were 1.9% in both the CDT and ST groups ( = 1.0). All-cause bleeding was higher in the CDT group (15.9 vs 8.7%; < 0.001), while in-hospital mortality was lower (6.5 vs 10.0%; = 0.02). Among a nationally representative cohort of patients with PE at higher risk for mortality, CDT was associated with similar ICH rates, increased all-cause bleeding, and lower short and intermediate-term mortality when compared with ST. The competing risks and benefits of CDT in real-world practice suggest the need for large-scale randomized clinical trials with appropriate comparator arms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1358863X20903371DOI Listing
August 2020

Usability of Wearable Devices to Remotely Monitor Sleep Patterns Among Patients With Ischemic Heart Disease: Observational Study.

JMIR Form Res 2020 Apr 7;4(4):e14508. Epub 2020 Apr 7.

Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States.

Background: There is growing interest in using wearable devices to remotely monitor patient behaviors. However, there has been little evaluation of how often these technologies are used to monitor sleep patterns over longer term periods, particularly among more high-risk patients.

Objective: The goal of the research was to evaluate the proportion of time that patients with ischemic heart disease used wearable devices to monitor their sleep and identify differences in characteristics of patients with higher versus lower use.

Methods: We evaluated wearable device data from a previously conducted clinical trial testing the use of wearable devices with personalized goal-setting and financial incentives. Patients with ischemic heart disease established a sleep baseline and were then followed for 24 weeks. The proportion of days that sleep data was collected was compared over the 24 weeks and by study arm. Characteristics of patients were compared to groups with high, low, or no sleep data.

Results: The sample comprised 99 patients with ischemic heart disease, among which 79% (78/99) used the wearable device to track their sleep. During the 6-month trial, sleep data were collected on 60% (10,024/16,632) of patient-days. These rates declined over time from 77% (4292/5544) in months 1 and 2 to 58% (3188/5544) in months 3 and 4 to 46% (2544/5544) in months 5 and 6. Sleep data were collected at higher rates among the intervention group compared with control (67% vs 55%, P<.001). In the main intervention period (months 3 and 4), patients with higher rates of sleep data were on average older (P=.03), had a history of smoking (P=.007), and had higher rates of commercial health insurance (P=.03).

Conclusions: Among patients with ischemic heart disease in a physical activity trial, a high proportion used wearable devices to track their sleep; however, rates declined over time. Future research should consider larger evaluations coupled with behavioral interventions.

Trial Registration: ClinicalTrials.gov NCT02531022; https://clinicaltrials.gov/ct2/show/NCT02531022.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/14508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7175186PMC
April 2020

Catheter-Directed Thrombolysis With Ultrasound Assistance for Acute Pulmonary Embolism: Time to Curb the Enthusiasm?

Chest 2020 03;157(3):491-492

Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; The Cardiovascular Quality, Outcomes, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.chest.2019.11.027DOI Listing
March 2020

Implementing a Women's Cardiovascular Health Training Program in a Cardiovascular Disease Fellowship: The MUCHACHA Curriculum.

JACC Case Rep 2020 Jan 15;2(1):164-167. Epub 2020 Jan 15.

Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Sex- and gender-specific training for cardiovascular clinicians is essential to enhance knowledge and quality of women's cardiovascular health care. In 2016, the University of Pennsylvania cardiovascular fellowship program established a dedicated women's cardiovascular health curriculum, motivated by the fellow-in-training desire to gain formal and focused training in this emerging field.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaccas.2019.11.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8301516PMC
January 2020

Comprehensive Assessment of Changes in Left Ventricular Diastolic Function With Contemporary Breast Cancer Therapy.

JACC Cardiovasc Imaging 2020 01 18;13(1 Pt 2):198-210. Epub 2019 Sep 18.

Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Objectives: This study determined the effects of doxorubicin and/or trastuzumab on diastolic function and the relationship between diastolic function and systolic dysfunction.

Background: Doxorubicin and trastuzumab can result in left ventricular ejection fraction (LVEF) declines. However, the effects of these therapies on diastolic function remain incompletely defined.

Methods: In a rigorously phenotyped, longitudinal cohort study of 362 breast cancer participants treated with doxorubicin, doxorubicin followed by trastuzumab, or trastuzumab alone, changes in diastolic function were evaluated using linear models estimated via generalized estimating equations. Associations between baseline and changes in diastolic function with LVEF and longitudinal strain were also determined using generalized estimating equations. The Kaplan-Meier estimator derived the proportion of participants who experienced incident diastolic dysfunction. Cox proportional hazards models estimated the associations between participant characteristics and diastolic dysfunction risk, and between diastolic function and cancer therapy-related cardiac dysfunction risk, defined by an LVEF decline of ≥10% to <50%.

Results: Over a median of 2.1 years (interquartile range [IQR]: 1.3 to 4.2 years), participants treated with doxorubicin or doxorubicin followed by trastuzumab demonstrated a persistent worsening in diastolic function, with reductions in the E/A ratio, lateral and septal e' velocities, and increases in E/e' (p < 0.01). These changes were not observed with trastuzumab alone. Incident abnormal diastolic function grade occurred in 60% at 1 year, 70% by 2 years, and 80% by 3 years. Abnormal diastolic function grade was associated with a subsequent decrease in LVEF (-2.1%; 95% confidence intervals [CI]: -3.1 to -1.2; p < 0.001) and worsening in longitudinal strain (0.6%; 95% CI: 0.1 to 1.1; p = 0.013) over time. Changes in E/e' ratio were modestly associated with worsening longitudinal strain (0.1%; 95% CI: 0.0 to 0.2; p = 0.022).

Conclusions: A modest, persistent worsening of diastolic function is observed with contemporary breast cancer therapy. Abnormal and worsening diastolic dysfunction is associated with a small risk of subsequent systolic dysfunction. (Cardiotoxicity of Cancer Therapy [CCT]; NCT01173341).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcmg.2019.07.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236624PMC
January 2020
-->