DIL - A CONVERSATIONAL AGENT FOR HEART FAILURE PATIENTS

There is an exceptionally high rate of readmissions and rehospitalizations for patients suffering from chronic diseases especially Heart Failure. Best efforts to address this alarming problem from the Care giver community have fallen short due to a number of factors most notably resource constraints like shortage of trained clinical staff, and money. Using a Design Science Research framework, this work designed and evaluated DIL , a Conversational Agent that complements the work of clinicians in achieving the desired behavioral and clinical outcomes. The aim is to provide the hospital with an information system that could bridge the current gap in care that occurs when the patient transitions from the hospital environment to the home environment. The expected contribution is to produce a novel artifact and demonstrate the efficacy and utility of the tool to assist patients with heart failure in improving their self-care. The study conclusions were extremely positive. DIL scored high on User engagement and satisfaction. Every patient felt significantly more positive after their interaction with DIL during the trial period, and had a positive outlook on their quality of life going forward. The patients in the trial found DIL to be helpful in keeping them motivated to follow a healthy lifestyle by controlling their diet, and adhering to clinical guidelines of regular exercise, and taking medications on a timely manner. Given the extremely positive experience of the patients, there is definitely room for such an IT artifact in supporting patients as they make the transition from hospital to the home setting

Lipid metabolite biomarkers in cardiovascular disease: Discovery and biomechanism translation from human studies

Lipids represent a valuable target for metabolomic studies since altered lipid metabolism is known to drive the pathological changes in cardiovascular disease (CVD). Metabolomic technologies give us the ability to measure thousands of metabolites providing us with a metabolic fingerprint of individual patients. Metabolomic studies in humans have supported previous findings into the pathomechanisms of CVD, namely atherosclerosis, apoptosis, inflammation, oxidative stress, and insulin resistance. The most widely studied classes of lipid metabolite biomarkers in CVD are phos-pholipids, sphingolipids/ceramides, glycolipids, cholesterol esters, fatty acids, and acylcarnitines. Technological advancements have enabled novel strategies to discover individual biomarkers or panels that may aid in the diagnosis and prognosis of CVD, with sphingolipids/ceramides as the most promising class of biomarkers thus far. In this review, application of metabolomic profiling for biomarker discovery to aid in the diagnosis and prognosis of CVD as well as metabolic abnormalities in CVD will be discussed with particular emphasis on lipid metabolites

Lipid metabolite biomarkers in cardiovascular disease: Discovery and biomechanism translation from human studies

Lipids represent a valuable target for metabolomic studies since altered lipid metabolism is known to drive the pathological changes in cardiovascular disease (CVD). Metabolomic technologies give us the ability to measure thousands of metabolites providing us with a metabolic fingerprint of individual patients. Metabolomic studies in humans have supported previous findings into the pathomechanisms of CVD, namely atherosclerosis, apoptosis, inflammation, oxidative stress, and insulin resistance. The most widely studied classes of lipid metabolite biomarkers in CVD are phos-pholipids, sphingolipids/ceramides, glycolipids, cholesterol esters, fatty acids, and acylcarnitines. Technological advancements have enabled novel strategies to discover individual biomarkers or panels that may aid in the diagnosis and prognosis of CVD, with sphingolipids/ceramides as the most promising class of biomarkers thus far. In this review, application of metabolomic profiling for biomarker discovery to aid in the diagnosis and prognosis of CVD as well as metabolic abnormalities in CVD will be discussed with particular emphasis on lipid metabolites

Exercise in heart failure

IntroductionIn ambulatory patients with chronic stable heart failure, the cardinal symptom of exercise intolerance is not fully resolved despite optimal medical treatment. Identifying other treatments to improve exercise intolerance may improve quality of life.MethodsI investigated 2 treatments that may improve exercise intolerance in patients with heart failure. First, I conducted a review of oxygen supplementation in cardiovascular disease and then investigated the exercise capacity of 46 patients (mean age 75 years, 63% male and median N-terminal pro-B type natriuretic peptide 1432 (interquartile range: 543-2378 ng/l)) with heart failure and normal ejection fraction (HeFNEF), using different oxygen supplementation (21%, 28% and 40%). Second, I conducted a literature review on the acute effects of water immersion (WI) and swimming in patients with heart failure and reduced ejection fraction (HeFREF) and then investigated the haemodynamic and echocardiographic changes during warm WI in 17 patients with HeFREF (NYHA I and II; mean age 67 years, 88% male and mean left ventricular ejection fraction 33%) and 10 normal subjects.ResultsIn patients with HeFREF, high doses of oxygen have negative haemodynamics effects however low doses may improve exercise tolerance. In patients with HeFNEF, increasing oxygen supplementation during exertion leads to a small increase in exercise time. In patients with HeFREF, although exercise in water appears to be safe, the studies conducted have been small, very heterogeneous and inconclusive. In patients with HeFREF, warm WI causes an acute increase in cardiac output and a fall in systemic vascular resistance.ConclusionWarm WI is well tolerated; however, whether swimming can be recommended as alternative to other forms of exercise or rehabilitation in patients with HeFREF needs further studies. In patients with HeFNEF, a disproportionate increase in left atrial pressure on exercise contributes to symptoms. However extra-cardiac mechanisms may also contribute to impaired exercise tolerance. Studies should also focus on treatment of co morbidities

Improving Quality and Achieving Equity: A Guide for Hospital Leaders

Outlines the need to address racial/ethnic disparities in health care, highlights model practices, and makes step-by-step recommendations on creating a committee, collecting data, setting quality measures, evaluating, and implementing new strategies

Healthier hearts for life: an inpatient support group for individuals with congestive heart failure

Congestive heart failure (CHF) is a prevalent disease that leads to frequent hospital admissions secondary to its disabling symptoms (Shafazand et al., 2015). Despite a substantial amount of research available regarding CHF, this disease is still perplexing because it remains one of the most prevalent and costly diseases worldwide (Jonkman et al., 2016; Shao, et al., 2013). Even though many interventions have been researched for CHF, it is often poorly managed. Almost 25% of patients are readmitted to hospitals within 30 days from their initial admission (Kilgore et al., 2017) and approximately 50% are readmitted within 6 months (O’Connor, 2017). Research studies have typically focused on outpatient, home, and post-inpatient settings which neglects the inpatient setting where patients often spend much time. Therefore, this setting should be a focal interest for research. Consequently, the Healthier Hearts for Life Pilot Program was developed to address this gap. This program is an interprofessional, inpatient support group for patients with CHF that are considered high risk for readmission. This program is led by occupational therapists but involves many other healthcare professionals. The program’s overall goal is to increase participants’ feelings of self-efficacy for managing their CHF by providing participants with education and hands-on learning opportunities. This program adopts a Social Cognitive Theory (Bandura, 1989) lens to understand the problem, while interventions were guided by the Transtheoretical Model (Prochaska & DiClemente, 1983). Additionally, interventions were based on advantageous, evidence-based findings from the literature of the various medical professions. Overall, this program was designed to support patients to be more competent in the management of their CHF by targeting ‘heart healthy’ behaviors and lifestyle changes in order to reduce readmissions

Strategic Intelligence Monitor on Personal Health Systems (SIMPHS): Market Structure and Innovation Dynamics

Personal Health Systems (PHS) and Remote Patient Monitoring and Treatment (RMT) have the potential to alter the way healthcare is provided by increasing the quantity and quality of care. This report explores the current status of PHS and, more specifically of the RMT market in Europe. It addresses the question of how these technologies can contribute facing some of the challenges standing in front of the European healthcare delivery systems causes by higher demand pressures through chronic diseases and demographic change combined with diminishing resources for health care. An uptake and diffusion of these services would potentially lead to benefits through a reduction in death rates, and avoid recurring hospitalisation in a cost-effective manner. Yet the report identifies different categories of barriers hampering a full deployment of RMT in Europe. In the concluding part the reports provides a number of tentative policy options specifically aimed at fostering EU-wide deployment of RMT/PHS.JRC.DDG.J.4-Information Societ

Optimisation of Pacemaker Therapy for Cardiac Function

Patients with right ventricular (RV) pacemakers are at increased risk of left ventricular (LV) systolic dysfunction (LVSD) and chronic heart failure (CHF). I aimed 1) to establish the prevalence of LVSD in patients with long-term RV pacemakers listed for pulse generator replacement (PGR), 2) to evaluate the effects on LV function of reprogramming existing pacemakers to reduce RV pacing (RVP) and 3) to investigate whether upgrade to cardiac resynchronization therapy (CRT) at the time of PGR is beneficial in patients with unavoidable RV pacing and LVSD. Data were collected on 491 patients listed for PGR. Reduced left ventricular ejection fraction (LVEF) <50% was observed in 40%. Multivariable analysis revealed %RVP, serum creatinine and previous myocardial infarction (MI) to be independently related to the presence of LVSD. An audit was performed to investigate the effects of optimising pacemaker programming to avoid RV pacing in 66 patients. At 6m, RV pacing was reduced by a mean of 49%, with a mean improvement in LVEF of 6% and no reduction in exercise capacity, NT-pro-BNP or quality of life. Fifty patients with unavoidable RV pacing, LVSD, and mild symptoms of CHF, listed for PGR were randomized 1:1 to either standard RV-PGR or CRT. At 6 months there was a difference in change in median LVEF, improvements in exercise capacity, quality of life, and NT-proBNP in those randomized to CRT. After 809 days, 17 patients had died or been hospitalized (6 CRT and 11 PGR) and two patients in the PGR arm required CRT for deteriorating CHF. In summary, LVSD is common in patients with standard RV pacemakers and relates to cardiovascular co-morbidities, careful reprogramming to avoid unnecessary RV pacing can improve LVEF without adversely affecting exercise capacity and quality of life and upgrading patients with unavoidable RV pacing to CRT at PGR improves LV function, and exercise tolerance and may reduce admissions and further upgrades

Comparative Effectiveness Research (CER) ‒ A Case Study

Background: The Australian healthcare system is complex. Assessing the quality of the care provided in the management of acute coronary syndromes (ACS) is problematic because of disparate systems that constrain an integrated reporting approach. Registry data reported within a comparative effectiveness research (CER) framework establishes the case for clinical process indicators to measure and report hospital performance. Objectives: To aggregate data from The Global Registry of Acute Coronary Events (GRACE) and the Cooperative National Registry of Acute Coronary Care Guideline Adherence and Clinical Events (CONCORDANCE) to describe temporal trends in the management of ACS and associations with in-hospital events, hospital readmission and six month mortality; to develop a composite score of hospital performance quality; to determine associations between adherence to the quality composite score and in-hospital events, hospital readmission and six month mortality and develop a benchmarked stakeholder hospital performance report. Methods: A single case study embedding three units of analysis was used to explore and explain how data reported in a CER framework measures hospital performance in the management of ACS. Analysis: Descriptive analyses of prospectively collected data on the management and outcomes of over 7000 patients admitted to 46 hospitals from 1999 to 2016. Findings: The first Unit of Analysis reports temporal trends in the management of ACS across 11 hospitals in the GRACE registry from 2000 to 2007 which informed the design of the CONCORDANCE registry; The second Unit of Analysis combines both GRACE and CONCORDANCE registries and reports on the management of ST-elevation acute myocardial infarction (STEMI ) from 1999 to 2016 revealing gains in pre-hospital care and fewer in-hospital clinical events, and readmission for urgent revascularisation without a significant reduction in in-hospital or six month mortality. The third Unit of Analysis reports the observed and risk-adjusted association between adherence to the quality composite score and reduced in-hospital events, and increased survival at hospital discharge and at six months post discharge. Conclusion: Case-study analysis of CER in the context of ACS registries provides evidence on adherence to evidence-based care and a quality composite measure of hospital performance in the management of ACS