Impact of Systematizing the Evaluation of Patients with Acute Heart Failure Presenting to the Emergency Department

Title from PDF of title page viewed June 15, 2020Thesis advisor: John A. SpertusVitaIncludes bibliographical references (pages 47-55)Thesis (M.S.)--School of Medicine. University of Missouri--Kansas City, 2020The huge burden of acute heart failure (HF) on the emergency department (ED) warrants the need for a systemized method of management. The lack of a standardized care path for acute HF patients presenting to the ED has resulted in wide variability in care and high hospital admission rates. An evidence-based, patient-centered clinical decision support pathway implemented within the ED, can systematize the management of acute HF and tailor management to patients’ needs. From January 2017 to February 2020, using an implementation planning framework, a standardized care path called the ‘Code Heart Failure’ (CodeHF) was developed, implemented, and validated within a tertiary care center. The care path rapidly identifies patients with a history of HF presenting to the ED with a chief complaint of shortness of breath and uses an evidence-based risk stratification tool to identify those who are eligible for discharge. Outcomes of acute HF patients who were treated by the CodeHF pathway were compared to those treated through usual care. The completeness of implementation was assessed by the proportion of eligible patients treated using the CodeHF pathway. The pathway’s impact on processes of care was evaluated by admission/discharge time in the ED and the proportion of discharged patients seen in cardiology clinic within 7 days. The primary outcome was the proportion of ED discharges, with safety and efficiency assessed by 30-day readmission rates after ED discharge and the proportion of short hospitalizations (<48 hours). Among 1100 eligible patients (mean [SD] age, 72.3 [15.2] years; 48.7% male), 149 (13.5%) were managed using CodeHF, with wide physician-level variability. Of those on the pathway, 74 (49.6%) had a high, and 75 (50.3%) a low, risk of 7-day mortality. CodeHF was associated with 54 minutes (294 vs 240 minutes) less time in the ED and a greater proportion of patients with a cardiology clinic visit within 7 days of ED discharge (25.9% vs 50%). Use of the pathway was associated with a greater rate of ED discharge (37.9% vs. 25.2%) and fewer 30-day readmissions after ED discharge (16.0% vs. 21.3%) and short inpatient stays (9.0% vs. 11.4%). In this detailed report, I describe the need, process of development, implementation, and validation of the CodeHF program which is an evidence-based clinical decision support tool used to systemize the management of acute HF in the ED.Introduction -- Review of literature -- Methodology -- Results -- Discussion -- Appendi

Adaptation to heat stress: a qualitative study from Eastern India

Heat stress adversely impacts a growing proportion of individuals in India. The heat-related lived experiences of Indians in smaller towns and villages are largely unknown. We conducted seven structured focus group discussions in the town of Dalkhola, West Bengal, India; with 5–10 participants in each group. All conversations were digitally audio recorded, transcribed into Bengali, and then translated to English. Two researchers separately performed a thematic analysis of the transcripts to identify common themes pertaining to the ‘effects of heat’ and ‘coping strategies’ used by participants. A total of 56 (mean age 48.9 ± 17.6; female 61%; Scheduled Tribe 9%) individuals participated. There was wide variation in individual experiences of heat, with some people preferring to work in the winter while others preferred the summer. Housing characteristics, nature of work, gender and access to water and green spaces heavily influenced an individual’s vulnerability to heat stress. Trees were seen as the primary coping strategy for heat stress (regardless of vulnerability), though many participants noted a loss of tree cover in their vicinity. Cool drinking water from public taps and electric fans (particularly table fans) were other preferred coping mechanisms. Many participants did not have adequate access to cool drinking water or electric fans, leading to increased adverse experiences from heat. Based on participant input, several action items were identified for municipal and state/central governments, schools, and private organizations. Individuals affected by heat have a clear preference for nature-based solutions. This is in contrast with the current design of most heat action plans in India, which put more emphasis on infrastructure, information dissemination and behavioral solutions. Various agencies (governments, schools, private organizations) seeking to adapt to increasing heat stress need to better integrate citizen perspectives into their heat action plans

Use of non‐LDL‐C lipid‐lowering medications in patients with type 2 diabetes

BackgroundA number of non-low-density lipoprotein cholesterol lipid abnormalities are associated with type 2 diabetes and insulin resistance, which may lead practitioners to use medications targeting these abnormal lipid fractions despite a lack of evidence or guideline recommendations.Methods and resultsAmong 382&nbsp;921 US patients with type 2 diabetes (69% with cardiovascular disease, 76% on a statin), 95&nbsp;995 (26%) were on some nonstatin lipid-lowering medication-19&nbsp;265 (5%) on niacin, 32&nbsp;919 (9%) on a fibrate and 69&nbsp;513 (18%) on fish oil. Use of all three medications was stable over time and higher in patients with cardiovascular disease and with higher triglyceride levels, although even among patients with triglyceride levels &lt;2.3&nbsp;mmol/L, 6% were on a fibrate and 17% were on fish oil.ConclusionAs clinical trials demonstrate little to no cardiovascular benefit from taking these medications, greater attention is needed to focus the use of lipid-lowering medications to those with proven benefit

The burden of premature mortality from coal-fired power plants in India is high and inequitable

Prior mortality estimates of air pollution from coal-fired power plants in India use PM _2.5 exposure-response functions from settings that may not be representative, and do not include other potentially harmful effects of these plants, such as fly ash pollution and heavy freshwater consumption. We use a national, district level dataset to assess the impact of coal-fired power plants on all-cause mortality (15–69 years) in 2014. We compare districts with coal-fired power plants (total capacity >1000 MW) to districts without a coal-fired power plant, estimating the effect of these power plants on all-cause mortality within districts that have these plants. Out of 597 districts in India in 2014, 60 districts had a coal-fired power plant. When compared to districts without a coal-fired power plant, districts with a coal-fired power plant (>1000 MW) had higher rates of age-standardized mortality in both women (0.38, 95% CI: −0.14–0.90) and men (0.55, −0.17–1.27). Similarly, these districts had higher rates of conditional probability of premature death in both women (2.22, −0.13–4.56) and men (2.12, −0.54–4.77). The point estimates for total excess deaths were 19 320 for women and 27 727 for men. In affected districts, the proportion of premature adult deaths attributable to coal-fired power plants was 5.8% (−0.3%–11.9%) in women and 4.3% (−1.1%–9.6%) in men. We estimate that ∼47 000 premature adult deaths can be attributed to large coal-fired power plants in India in 2014. These deaths are concentrated in the ∼10% of districts that have the nation’s power plants, where they are associated with 1 out of 20 premature adult deaths. Effective regulation of emissions from these plants, coupled with a phaseout of coal-fired power plants, can help decrease this burden of inequitable and premature adult mortality

Relationship between district-level conditional probability of death (women and men) with access to electricity.

Relationship between district-level conditional probability of death (women and men) with access to electricity.</p

Map of India showing districts with <50% of its households having access to electricity.

Map of India showing districts with <50% of its households having access to electricity.</p

S1 Dataset -

BackgroundThe impact of electricity access on all-cause premature mortality is unknown.MethodsWe use a national dataset from India to compare districts with high access to electricity (>90% of households) to districts with middle (50–90%) and low (ResultsIn 2014, out of 597 districts in India, 174 districts had high access, 228 had middle access, and 195 had low access to electricity. When compared to districts with high access, districts with low access had higher rates of age-standardized premature mortality in both women (2.09, 95% CI: 1.43–2.74) and men (0.99, 0.10–1.87). Similarly, these districts had higher rates of conditional probability of premature death in both women (9.16, 6.19–12.13) and men (4.04, 0.77–7.30). Middle access districts had higher rates of age-standardized premature mortality and premature death in women, but not men. The total excess deaths attributable to reduced electricity access were 444,225 (45,195 in middle access districts and 399,030 in low access districts). In low access districts, the proportion of premature adult deaths attributable to low electricity access was 21.3% (14.4%– 28.1%) in women and 7.9% (1.5%– 14.3%) in men.ConclusionPoor access to electricity is associated with nearly half a million premature adult deaths. One out of five premature deaths in adult women were linked to low electricity access making it a major social determinant of health.</div

Effect of low electricity access on mortality rates and probability of premature death.

Effect of low electricity access on mortality rates and probability of premature death.</p

Change in mortality rates and probability of premature death in comparison with established social determinants of health.

Change in mortality rates and probability of premature death in comparison with established social determinants of health.</p