Inappropriate statin therapy according to ASCVD risk: Can we do better?

Background: Statin therapy targeted at reducing 10-year risk of ASCVD has become a cornerstone of preventative health in the outpatient setting. Appropriate statin prescription can lead to improved morbidity and mortality as outlined by current American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Methods: In this empiric observational study performed in August 2018, we calculated the 10-year ASCVD risk for patients visiting the Henry Ford Hospital Academic Internal Medicine Clinic between January and December 2017, and compared the ACC/AHA guideline recommended statin intensity with the one currently prescribed. Our aim was to assess appropriateness of statin therapy based on ASCVD risk calculation and ACC/AHA guidelines. Results: Of the 2994 patients assessed, approximately 1548 patients were prescribed an inappropriate intensity of statin based on 10-year ASCVD risk calculation (p \u3c 0.001). For female patients, the odds of appropriate statin dose prescription increased by approximately 81.9% (odds ratio 1-1.819) when compared to male patients (95% CI 1.559-2.124). For black patients, the odds of appropriate statin prescription decreased by 32.2% (odds ratio 1-0.678) when compared to white patients (95% CI 0.532-0.864). Approximately 1245 patients currently taking high-intensity statin did not qualify for one as compared to 484 patients (p \u3c 0.001). Conclusion: Calculation of 10-year ASCVD risk is an integral part of guiding statin prescription and preventative health therapy in the outpatient setting, However, an increasing percentage of patients are not managed adequately according to ACC/AHA guidelines. Race, gender, and income disparities appear to be major factors influencing appropriateness of statin prescription. This demonstrates a major opportunity for potential intervention to improve statin prescription and patient health outcomes.https://scholarlycommons.henryford.com/merf2019hcd/1000/thumbnail.jp

EHR Visual Overlay Promises to Improve Hypertension Guideline Implementation

Background: Primary care management of essential hypertension (HTN) has become increasingly challenging since recently published guidelines integrate atherosclerotic cardiovascular disease (ASCVD) risk stratification into decision making. Our objective was to measure whether overlay of visualdecision support (VDS) with standard electronic health record (EHR) platform improves guideline-based treatment, and reduces time burden associated with EHR use, in management of essential HTN. Methods: This was a quality improvement project. We interviewed primary care physicians and tasked each with two simulated patient encounters for HTN: (1) using standard EHR to guide treatment, and (2) using VDS to guide treatment. The VDS included graphical blood pressure (BP) trends, target BP with recommended interventions, ASCVD risk score, and information on the patient’s social determinants of health. We assessed whether treatment selection was congruent with guidelines and tracked time physicians consulted the EHR. Results: We evaluated 70 case simulations in total. Use of VDS compared to usual EHR was associated with: higher proportion of correct guideline prescribing (94% vs. 60%, p\u3c0.01), more ASCVD risk determination (100% vs. 23, p\u3c0.01), and more correct BP target identification (97% vs. 60%, p\u3c0.01). Time clinicians spent consulting the EHR fell an average of 121 seconds with use of VDS (p\u3c0.01). On a 10-point scale, clinicians rated the VDS 9.2 vs. 5.9 (p\u3c0.01) for ease of gathering necessary information to treat HTN. Conclusions: The integration video decision support tools to standard EHR can reduce physician time spent per patient encounter, while increasing adherence to guidelines and improving patient outcomes. Further testing in clinical practice is indicated.https://scholarlycommons.henryford.com/merf2019qi/1009/thumbnail.jp

Compression wraps as adjuvant therapy in the management of acute systolic heart failure

BACKGROUND: Guidelines recommend targeting decongestion in management of decompensated HF, with lower extremity edema often serving as the clinical target. LECW are seldom used in the acute setting, with a paucity of data on efficacy in HF, despite serving as a cornerstone of chronic lymphedema management. PRIMARY OBJECTIVE: Study the efficacy and safety of LECW in acute decompensated HF. METHODS: Open-label, randomized, parallel-group clinical trial. PRIMARY OUTCOMES: Days on intravenous (IV) diuretic therapy, total hospital length of stay (LOS), and 30-day all-cause readmission. RESULTS: 32 patients were enrolled, with 29 patients completing the study. Enrollment was suspended due to the COVID-19 pandemic. Overall LOS was shorter in the intervention group (3.5 vs 6 days, p = 0.05), with no significant difference in total days on IV diuresis or 30-day readmission rate with use of LECW. Fewer patients required continuous diuretic infusion after treatment with LECW (0 vs 7 patients, p = 0.027). The intervention group scored significantly better on the MLWHF (55.5 vs 65, p = 0.021), including both the physical and emotional dimension scores. No adverse events were reported with use of LECW, including a significantly lower incidence of AKI (1 vs 13 patients, p = 0.005). CONCLUSION: The use of LECW resulted in reduced hospital LOS compared to standard therapy, with no difference in days of IV diuresis administration or 30-day readmission. Treatment with LECW also resulted in less continuous IV diuretic therapy, fewer incidence of AKI, and improved quality of life. Trends toward less escalation of diuresis, and greater reduction in edema were also observed

Derivation and validation of the ED-SAS score for very early prediction of mortality and morbidity with acute pancreatitis: a retrospective observational study

BACKGROUND: Existing scoring systems to predict mortality in acute pancreatitis may not be directly applicable to the emergency department (ED). The objective of this study was to derive and validate the ED-SAS, a simple scoring score using variables readily available in the ED to predict mortality in patients with acute pancreatitis. METHODS: This retrospective observational study was performed based on patient data collected from electronic health records across 2 independent health systems; 1 was used for the derivation cohort and the other for the validation cohort. Adult patients who were eligible presented to the ED, required hospital admission, and had a confirmed diagnosis of acute pancreatitis. Patients with chronic or recurrent episodes of pancreatitis were excluded. The primary outcome was 30-day mortality. Analyses tested and derived candidate variables to establish a prediction score, which was subsequently applied to the validation cohort to assess odds ratios for the primary and secondary outcomes. RESULTS: The derivation cohort included 599 patients, and the validation cohort 2011 patients. Thirty-day mortality was 4.2 and 3.9%, respectively. From the derivation cohort, 3 variables were established for use in the predictive scoring score: ≥2 systemic inflammatory response syndrome (SIRS) criteria, age \u3e 60 years, and SpO2 \u3c 96%. Summing the presence or absence of each variable yielded an ED-SAS score ranging from 0 to 3. In the validation cohort, the odds of 30-day mortality increased with each subsequent ED-SAS point: 4.4 (95% CI 1.8-10.8) for 1 point, 12.0 (95% CI 4.9-29.4) for 2 points, and 41.7 (95% CI 15.8-110.1) for 3 points (c-statistic = 0.77). CONCLUSION: An ED-SAS score that incorporates SpO2, age, and SIRS measurements, all of which are available in the ED, provides a rapid method for predicting 30-day mortality in acute pancreatitis

Visual Analytics Dashboard Promises to Improve Hypertension Guideline Implementation

BACKGROUND: Primary care management of hypertension under new guidelines incorporates assessment of cardiovascular disease risk and commonly requires review of electronic health record (EHR) data. Visual analytics can streamline the review of complex data and may lessen the burden clinicians face using the EHR. This study sought to assess the utility of a visual analytics dashboard in addition to EHR in managing hypertension in a primary care setting. METHODS: Primary care physicians within an urban, academic internal medicine clinic were tasked with performing two simulated patient encounters for HTN management: the first using standard EHR, and the second using EHR paired with a visual dashboard. The dashboard included graphical blood pressure trends with guideline-directed targets, calculated ASCVD risk score, and relevant medications. Guideline-appropriate antihypertensive prescribing, correct target blood pressure goal, and total encounter time were assessed. RESULTS: We evaluated 70 case simulations. Use of the dashboard with the EHR compared to use of the EHR alone was associated with greater adherence to prescribing guidelines (95% vs. 62%, p\u3c0.001) and more correct identification of BP target (95% vs. 57%, p\u3c0.01). Total encounter time fell an average of 121 seconds (95% CI 69 - 157 seconds, p\u3c0.001) in encounters that used the dashboard combined with the EHR. CONCLUSIONS: The integration of a hypertension-specific visual analytics dashboard with EHR demonstrates the potential to reduce time and improve hypertension guideline implementation. Further widespread testing in clinical practice is warranted

Infliximab-Induced Arthralgia

Case Presentation: A 23-year-old Caucasian female with a history of ulcerative colitis (UC) presented with erythematous, painful metacarpal joints and jaw pain; she had associated symptoms of fatigue, chills, and dyspnea. Additional history included Crohn’s disease status post-proctocolectomy, primary sclerosing cholangitis, and hypothyroidism. Physical exam showed a fatigued female with bilateral metacarpal joint arthralgias and erythema along with shoulder weakness. She was diagnosed with UC 2 years prior and failed previous treatments; therefore, she was given infliximab 9 days before her presentation. She had previously received infliximab 12 years prior for her Crohn’s disease. Prior to initiating treatment she had no antibodies to infliximab. Laboratory findings were negative for antinuclear antibodies and weakly positive for anti-histone antibodies. She recovered within 36 hours from IV hydration and supportive care. Discussion: Recognizing tumor necrosis factor-α’s role in the inflammatory response, inhibitors have been effective treatments in various rheumatologic conditions. Infusion reactions with infliximab are the most common adverse effects and can be subdivided into acute or delayed infusion reactions. Acute reactions represent type 1 hypersensitivity reactions mediated by immunoglobulin E, although true anaphylactic reactions to infliximab are uncommon. Delayed infusion reactions resemble type 3 hypersensitivity reactions, usually between 1-14 days after start of treatment. Immune complexes can cause systemic effects such as acute serum sickness, resulting in fever, pruritic rash, and arthralgias. Conclusion: Infusion reactions can occur with or without preexisting antibodies to infliximab. Although there are recommendations for dampening infusion reactions, prevention is not guaranteed. Clinicians should monitor patients for 1-3 weeks after infliximab infusions.https://scholarlycommons.henryford.com/merf2019caserpt/1114/thumbnail.jp

Impact of Social Determinants on Outcomes in Patients with Left Ventricular Assist Devices

Background: Durable, continuous flow Left Ventricular Assist Devices (LVAD) used as a bridge to transplantation and destination therapy continue to have improved survival. Despite ongoing advances in technology, LVADs continue to be associated with significant adverse events. Socioeconomic determinants are known to be associated with worse outcomes in patients with chronic heart failure. We sought to examine the association of social determinants with outcomes after LVAD implantation. Methods: Using electronic medical records, we conducted a retrospective chart review of 358 patients undergoing LVAD (HeartMate II, HeartMate III, HeartWare) implantation from January 2006 to October 2018 at a tertiary care center. We collected data including median household income, comorbid conditions, self-identified substance use, and cognitive assessment determined by the Montreal Cognitive Assessment tool. We examined the association between 30-day readmission rate, right ventricular failure (RVF), need for hemodialysis (HD), and occurrence of driveline infection post LVAD implantation with the pre-specified covariates. Univariate two-group comparisons using analysis of variance (ANOVA) for continuous variables or chi-square or Fisher\u27s exact tests for categorical variables was used. Results: The study population was comprised of 74.9% males, with a mean age of 55 ± 12, 52% Caucasians, and 39.1% African Americans. The mean household income was $53,298. There was no significant difference between substance use (p=0.684), median household income (p=0.696), co-morbid conditions and occurrence of RVF after LVAD implantation. Similar comparison showed no significant differences between substance use (p=0.522), median household income (p=0.534), and occurrence of HD after LVAD placement. History of chronic kidney disease (CKD) was found predominantly in patients who ended up on dialysis compared to those with no past medical history of CKD (p=0.044). There were no significant differences between substance use (p=0.323), median household income (p=0.564), co-morbidities and occurrence of driveline infection after LVAD implantation. There was also no significant difference noted between the presence of RVF after LVAD implantation, the need for HD or the occurrence of a driveline infection and the clinical status (defined as ongoing LVAD support, transplant, or death). There was a significant difference between 30-day readmission rate and clinical status (p=0.001) such that increased mortality was associated in patients with ongoing LVAD support and patients who received a transplant if they had a hospital readmission. Conclusion: Management of heart failure is not only dependent on disease process but also upon access to health care, education, and resources. This study demonstrated that social determinants did not impact outcomes related to LVAD support. Due to complexity of LVAD patients, health care providers need to carefully take into consideration the complex interaction of health and social factors which directly affect patient care

Impact of Social Determinants on Outcomes in Patients with Left Ventricular Assist Devices

Background: Durable, continuous flow Left Ventricular Assist Devices (LVAD) used as a bridge to transplantation and destination therapy continue to have improved survival. Despite ongoing advances in technology, LVADs continue to be associated with significant adverse events. Socioeconomic determinants are known to be associated with worse outcomes in patients with chronic heart failure. We sought to examine the association of social determinants with outcomes after LVAD implantation. Methods: Using electronic medical records, we conducted a retrospective chart review of 358 patients undergoing LVAD (HeartMate II, HeartMate III, HeartWare) implantation from January 2006 to October 2018 at a tertiary care center. We collected data including median household income, comorbid conditions, self-identified substance use, and cognitive assessment determined by the Montreal Cognitive Assessment tool. We examined the association between 30-day readmission rate, right ventricular failure (RVF), need for hemodialysis (HD), and occurrence of driveline infection post LVAD implantation with the pre-specified covariates. Univariate two-group comparisons using analysis of variance (ANOVA) for continuous variables or chi-square or Fisher\u27s exact tests for categorical variables was used. Results: The study population was comprised of 74.9% males, with a mean age of 55 ± 12, 52% Caucasians, and 39.1% African Americans. The mean household income was $53,298. There was no significant difference between substance use (p=0.684), median household income (p=0.696), co-morbid conditions and occurrence of RVF after LVAD implantation. Similar comparison showed no significant differences between substance use (p=0.522), median household income (p=0.534), and occurrence of HD after LVAD placement. History of chronic kidney disease (CKD) was found predominantly in patients who ended up on dialysis compared to those with no past medical history of CKD (p=0.044). There were no significant differences between substance use (p=0.323), median household income (p=0.564), co-morbidities and occurrence of driveline infection after LVAD implantation. There was also no significant difference noted between the presence of RVF after LVAD implantation, the need for HD or the occurrence of a driveline infection and the clinical status (defined as ongoing LVAD support, transplant, or death). There was a significant difference between 30-day readmission rate and clinical status (p=0.001) such that increased mortality was associated in patients with ongoing LVAD support and patients who received a transplant if they had a hospital readmission. Conclusion: Management of heart failure is not only dependent on disease process but also upon access to health care, education, and resources. This study demonstrated that social determinants did not impact outcomes related to LVAD support. Due to complexity of LVAD patients, health care providers need to carefully take into consideration the complex interaction of health and social factors which directly affect patient care

Inappropriate Statin Therapy According to Atherosclerotic Cardiovascular Disease (ASCVD) Risk: Can We Do Better?

Background: Statin therapy targeted at reducing 10-year risk of stroke and heart attack has become a cornerstone for preventative health in the outpatient setting. Appropriate statin intensity prescription based on 10-year ASCVD risk calculation can lead to improved morbidity and mortality as outlined by current American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Methods: We conducted an empiric observational study in August 2018 based on lab Results of patients visiting the Henry Ford Hospital Academic Internal Medicine Clinic between January 2017 and December 2017. We calculated the 10-year ASCVD risk for the patients based on this data, and compared the ACC/AHA guideline recommended statin therapy with the one currently prescribed. The primary outcome was appropriateness of statin therapy based on ASVCD risk calculation. Our aim was to assess whether patients in the clinic setting are being adequately managed for ASCVD risk according to ACC/AHA guidelines. Results: Of the 2994 patients assessed, approximately 1548 patients were prescribed an inappropriate intensity of statin based on 10-year ASCVD risk calculation (p \u3c 0.001). For female patients, the odds of appropriate statin dose prescription increased by approximately 81.9% (odds ratio 1-1.819) when compared to male patients (95% CI 1.559-2.124). For black patients, the odds of appropriate statin dose prescription decreased by 32.2% (odds ratio 1-0.678) when compared to white patients (95% CI 0.532-0.864). Asian patients were more likely to be on an appropriate statin dose as compared to non-Asians (p = 0.022), and Hispanic patients were more likely to be on an appropriate statin dose as compared to non-Hispanics (p = 0.005). Approximately 1245 patients currently taking high-intensity statin did not qualify for one based on 10-year ASCVD risk calculation as compared to 484 patients (p \u3c 0.001). Conclusions: There is marked discrepancy in the guideline recommended statin therapy (based on 10-year ASCVD risk calculation) and currently prescribed statin, with gender and race serving as major variables. This data demonstrates a major opportunity for intervention on the part of primary care internists to improve patient outcomes in the outpatient setting

Derivation and validation of the ED-SAS score for early prediction of mortality in acute pancreatitis

Background and Objectives: Existing scoring systems to predict mortality in acute pancreatitis largely account for variables present within the first 24 or more hours of hospital admission. The objective of this study was to derive and validate a simple predictive score using variables readily available in the emergency department (ED) to predict mortality in acute pancreatitis. Methods: We performed a retrospective observational study across 2 independent health systems, one used for the derivation cohort and one for the validation cohort. The health systems encompassed 10 community and academic EDs. Adult patients were eligible who presented to the ED, required hospital admission, and were confirmed to have a final diagnosis of acute pancreatitis. We excluded patients with chronic pancreatitis or hepatic failure and those with a recurrent episode of pancreatitis. We standardized and validated data collection instruments across sites. The analysis consisted of multivariable logistic regression, and candidate variables in the derivation cohort of a prediction score were selected a priori based on reliable availability in the ED and the existing literature. We applied the score to the validation cohort and report odds ratios associated with the primary outcome of 30-day mortality. Results: The derivation cohort included 599 patients (mean age 53 years, 47% female), and the validation cohort 2,011 patients (mean age 56 years, 51% female). Thirty-day mortality in the derivation cohort was 4.2% and 3.9% in the validation cohort. From the derivation cohort, 3 variables were retained in a prediction score: ≥2 SIRS criteria, age \u3e60 years, and SpO2 \u3c96%. Summing the presence (1 point) or absence (0 points) of each variable yielded an ED-SAS score (SIRS, age, SpO2), ranging from 0 to 3. In the derivation cohort, mortality based on scores from 0 to 3 was 0%, 1.3%, 10.4%, and 15.4% respectively. Applied to the validation cohort, the OR for death increased substantially for each additional ED-SAS point: 4.4 (95% CI 1.8 - 10.8) for 1 point, 12.0 (95% CI 4.9 - 29.4) for 2 points, and 41.7 (95% CI 15.8 - 110.0) for 3 points. Model discrimination in the derivation and validation cohort for predicting mortality was good (C-statistic 0.80 and 0.77 respectively). Conclusion: An ED-SAS score that incorporates age, SIRS, and ED SpO2 measurement provides a rapid method for predicting mortality in acute pancreatitis earlier than existing score systems