Implementation of a Cardiovascular Implantable Electronic Device Heart Failure Prediction Tool-Guided Management Pathway.

Cardiovascular implantable electronic devices (CIEDs) monitor physiologic variables that could identify subacute heart failure (HF) decompensation and impending HF hospitalization. One such algorithm uses measurements from the previous 30 days of CIED remote monitoring data to predict low-, medium-, or high-probability of HF hospitalization in the next 30 days. We sought to understand how to prospectively implement the use of such algorithms in routine HF care. From January 18, 2024 to April 19, 2024, HF risk categories were predicted from scheduled remote transmissions every 30 days and from unscheduled transmissions for all patients at 2 distinct cardiology clinics. Clinicians contacted and assessed patients at high risk regarding symptoms and then provided an empiric 3-day diuretic intervention (initiation or dose augmentation), adjusted guideline-directed medical therapy, or performed other clinical action as appropriate. Among 358 patients with 1,140 remote transmissions, 72 (20%) had ≥1 transmission categorized as high-risk. The mean patient age was 72.8 years, 346 (97%) were male, and 221 (62%) had a pre-existing diagnosis of HF. Of these 72 patients, 67 (93%) were successfully contacted, 34 (51%) had no HF symptoms, 24 (36%) had mild to moderate symptoms, and 2 (3%) had severe symptoms. A total of 46 patients (69%) had clinical action taken, including 28 (42%) with a diuretic intervention and 12 (18%) with guideline-directed medical therapy augmented. In this implementation study, clinicians contacted and assessed nearly all patients at high risk for HF decompensation based on CIED remote monitoring data and intervened in more than 2/3s. A randomized clinical trial is needed to determine whether this algorithm and subsequent intervention improves clinical outcomes.

Informational letters or postcards to initiate remote monitoring among veterans with pacemakers and implantable cardioverter-defibrillators: A randomized, controlled trial.

BACKGROUND: Remote monitoring (RM) of pacemakers and implantable cardioverter-defibrillators (ICDs) is a Class 1, Level of Evidence A recommendation because of its multitude of clinical benefits. However, RM adherence rates are suboptimal, precluding patients from achieving these benefits. There is a need for direct-to-patient efforts to improve adherence. METHODS: In this national randomized, controlled trial conducted in the Veterans Health Administration (VHA), 2120 patients with a pacemaker or ICD who had not sent an RM transmission for ≥1 year (and usually ≥3 years) while under VHA care for their device were randomly assigned to be mailed a postcard (n = 1076) or a detailed letter (n = 1044). The postcard described what RM does and its key benefits (reduced mortality and fewer in-person visits). The letter provided a similar message but included more details about RM benefits and the process. The primary outcome was an RM transmission sent within 90 days of mailing, and a secondary outcome was an RM transmission sent within 365 days. RESULTS: The primary outcome was achieved in 121 (11.3%) in the postcard and 96 patients (9.2%) in the letter group (p = .12). The secondary outcome was achieved in 266 (24.7%) and 239 (22.9%), respectively (p = .32). CONCLUSIONS: This randomized trial showed no significant difference in the proportion of chronically non-adherent patients who sent an RM transmission after receiving a low-cost postcard or a detailed, higher-cost letter encouraging their participation in RM. However, as only a minority of patients responded to either, further work is needed to engage patients in the life-saving benefits of RM.

National Hospital Initiatives to Improve Performance on Heart Failure Readmission Metrics.

BACKGROUND: The passage of the Hospital Readmissions Reduction Program (HRRP) has been associated with been associated with decreased risk-standardized readmission rates for heart failure (HF) patients. However, some quantitative analyses have shown association between HRRP and increased mortality for hospitalized HF patients. Qualitative information on what hospital programs were actually implemented can help us understand if this trend is a causal effect of the law or an unrelated trend. PURPOSE: To perform a systematic literature review to synthesize evidence on what clinical programs American hospitals implemented in response to HRRP. METHODS: Following PRISMA guidelines, we conducted a systematic review in April 2020 that included a search of PubMed, the Cochrane Library and Cumulative Index to Nursing and Allied Literature (CINAHL) for studies related to hospital strategies to reduce HF readmissions. RESULTS: Of 20 included articles, 8 were qualitative (survey and interviews), 3 were systematic reviews, 5 were single site quality improvement (QI) initiatives, 2 were plans for ongoing randomized control trials (RCTs), one was a plan for a future RCT and one was an observational analysis. We found that interventions hospitals undertook in response to HRRP to reduce HF readmissions fell into four categories: inpatient care, discharge, transitional care and data collection/administration. The majority of interventions were related to transitional care, most commonly scheduling follow up appointments within 7-14 days of discharge, performing post-discharge phone calls and partnering with community physicians. CONCLUSIONS: We did not find any published evidence of practices that could mechanistically be linked to harm to HF patients enacted by hospitals in response to HRRP. For example, no programs encouraged emergency department providers to discharge patients from emergency departments. We found QI initiatives, improved discharge planning and increased post-discharge follow up.

HIV Cure Research: Risks Patients Expressed Willingness to Accept.

Despite doing well on antiretroviral therapy, many people living with HIV have expressed a willingness to accept substantial risks for an HIV cure. To date, few studies have assessed the specific quantitative maximal risk that future participants might take; probed whether, according to future participants, the risk can be offset by the benefits; and examined whether taking substantial risk is a reasonable decision. In this qualitative study, we interviewed 22 people living with HIV and used standard gamble methodology to assess the maximum chance of death a person would risk for an HIV cure. We probed participants' reasoning behind their risk-taking responses. Conventional inductive content analysis was used to categorize key themes regarding decision-making. We found that some people would be willing to risk even death for an HIV cure, and some of their reasons were plausible and went far beyond the health-related utility of an HIV cure. We contend that people's expressed willingness to take substantial risk for an HIV cure should not be dismissed out of hand.

What risk of death would people take to be cured of HIV and why? A survey of people living with HIV.

People living with HIV (PLWHIV) can reasonably expect near-normal longevity, yet many express a willingness to assume significant risks to be cured. We surveyed 200 PLWHIV who were stable on antiretroviral therapy (ART) to quantify associations between the benefits they anticipate from a cure and their risk tolerance for curative treatments. Sixty-five per cent expected their health to improve if cured of HIV, 41% predicted the virus would stop responding to medications over the next 20 years and 54% predicted experiencing serious medication side effects in the next 20 years. Respondents' willingness to risk death for a cure varied widely (median 10%, 75th percentile 50%). In multivariate analyses, willingness to risk death was associated with expected long-term side effects of ART, greater financial resources and being employed (all P < 0.05) but was not associated with perceptions of how their health would improve if cured.

Assessing preferences for a university-based smoking cessation program in Lebanon: a discrete choice experiment.

INTRODUCTION: Smoking prevalence rates in Lebanon are among the highest in the Eastern Mediterranean region. Few smoking cessation programs are offered in Lebanon and little is known about the preferences of Lebanese smokers for cessation treatment programs. OBJECTIVE: To establish which attributes of smoking cessation programs are most important to Lebanese smokers. METHODS: Smokers at the American University of Beirut were surveyed to elicit their preferences for, and tradeoffs between the attributes of a hypothetical university-based smoking cessation program. Preferences for medication type/mechanism, risk of benign side effects, availability of support, distance traveled to obtain medication, and price of complete treatment were assessed using the discrete choice experiment method. RESULTS: The smokers' responses (N = 191) to changes in attributes were statistically significant. Smokers were willing to make trade-offs between attributes. On average, smokers were willing to pay LBP 103,000 (USD 69) for cessation support. Respondents were willing to give up LBP 105,000 (USD 70) to avoid an additional 10% risk of minor side effects and LBP 18,000 (USD 12) to avoid an addition kilometer of travel to the nearest pharmacy. Heavy smokers were the least responsive group and had the lowest demand elasticities. CONCLUSIONS: Student smokers were willing to participate in a relatively complex exercise that weighs the advantages and disadvantages of a hypothetical smoking cessation program. Overall they were less interested in the pill form of smoking cessation treatment, but they were willing to make tradeoffs to be smoke-free.