Applying the lessons of design thinking: a unique programme of care for acutely unwell, community-dwelling COVID-19 patients.

BACKGROUND: The COVID-19 pandemic limited access to primary care and in-person assessments requiring healthcare providers to re-envision care delivery for acutely unwell outpatients. Design thinking methodology has the potential to support the robust evolution of a new clinical model. AIM: To demonstrate how design thinking methodology can rapidly and rigorously create and evolve a safe, timely, equitable and patient-centred programme of care, and to share valuable lessons for effective implementation of design thinking solutions to address complex problems. METHOD: We describe how design thinking methodology was employed to create a new clinical model of care. Using the example of a novel telemedicine programme to support acutely unwell, community-dwelling COVID-19-positive patients called the London Urgent COVID-19 Care Clinic (LUC3), we show how continuous quality outcomes (safety, timeliness, equity and patient-centredness), as well as patient experience survey responses, can drive iterative changes in programme delivery. RESULTS: The inspiration phase identified four key needs for this patient population: monitoring COVID-19 signs and symptoms; self-managing COVID-19 symptoms; managing other comorbidities in the setting of COVID-19; and escalating care as needed. Guided by these needs, a cross-disciplinary stakeholder group was engaged in the ideation and implementation phases to create a unique and comprehensive telemedicine programme (LUC3). During the implementation phase, LUC3 assessed 2202 community-based patients diagnosed with acute COVID-19; the collected quality outcomes and end-user feedback led to evolution of programme delivery. CONCLUSION: Design thinking methodology provided an essential framework and valuable lessons for the development of a safe, equitable, timely and patient-centred telemedicine care programme. The lessons learnt here-the importance of inclusive collaboration, using empathy to guide equity-focused interventions, leveraging continuous metrics to drive iteration and aiming for good-if-not-perfect plans-can serve as a road map for using design thinking for targeted healthcare problems.

Enhancing Physician Managerial Capabilities: Partnership between Medicine and Business.

This article was migrated. The article was marked as recommended. Background Physicians are typically appointed to leadership roles within health care organizations on the basis of individual accomplishments in research, education, and/or clinical care. However, these types of achievements seldom provide the requisite management capabilities to lead within health organizations. In this manuscript, we described our initial experience in developing an in-house program to provide current and aspiring physician leaders with the managerial capabilities to enhance the quality of health care delivery within their respective organization. Methods In a partnership established between a Medical School and a Business School, we designed two series of weekend workshops to provide current and aspiring physician leaders with the financial capabilities to assist them in their future healthcare leadership careers. This course was then expanded to a Management Principles for Physician workshop with open enrollment to physicians at all levels. Baseline demographics and participant evaluations of each course were recorded. In the open enrollment Management Principles for Physician workshop, we examined the relationship between participant background and their course evaluations as well as their areas of interest for further training. Results All 3 workshops received excellent evaluations by participants. The positive impact of the open enrollment program, based on participants' self-evaluations, was the highest in female physicians, as well as early to mid-career physicians. Additionally, physicians who do not currently hold leadership positions and those who are leading at Divisional levels were the most interested in further training in finance. Conclusion In summary, this series of workshops demonstrated the feasibility of an in-house physician leadership program and yielded important information for the design of future leadership development curriculum.

Design of a bilevel clinical trial targeting adherence in heart failure patients and their providers: The Congestive Heart Failure Adherence Redesign Trial (CHART).

BACKGROUND: Socioeconomically disadvantaged patients are at an increased risk for adverse heart failure (HF) outcomes based upon nonadherence to medications and diet. Physicians are also suboptimally adherent to prescribing evidence-based therapy for HF. METHODS: Congestive Heart Failure Adherence Redesign Trial (CHART) (NCT01698242) is a multicenter, bilevel, cluster randomized behavioral efficacy trial designed to assess the impact of intervening simultaneously on physicians and their socioeconomically disadvantaged patients (annual income <$30,000) having HF with reduced ejection fraction. Treatment arm physicians received individualized feedback on their adherence to prescribing evidence-based therapy. Their patients received weekly home visits from community health workers aimed at promoting understanding of HF and integrating adherence into daily life. Control arm physicians received regular updates on advances in HF management, and patients received monthly HF educational tip sheets produced by the American Heart Association. The primary outcome was all-cause hospital days over 30 months. RESULTS: A total of 72 physicians (treatment, 35; control, 37) and their 320 patients (treatment, 157; control, 163) were recruited within 2 years. Randomization of physicians with all of their patients being assigned to the same arm was feasible and did not compromise the comparability of patients by arm. Using 5 recruiting hospitals located within disadvantaged neighborhoods produced a cohort that was primarily African American and representative of low-income urban patients with HF with reduced ejection fraction. CONCLUSION: CHART will determine the value of intervening on low adherence simultaneously in physicians and their socioeconomically disadvantaged patients in reducing all-cause hospitalization days.

Traumatic stress and cardiopulmonary disease burden among low-income, urban heart failure patients.

BACKGROUND: Traumatic events and posttraumatic stress disorder (PTSD) are associated with increased risk for cardiopulmonary disease (CPD) in veterans, men, and primarily White populations. Less is known about trauma, PTSD, and CPD burden among low-income, racial minority residents who are at elevated risk for trauma and PTSD. It was hypothesized that traumatic events and PTSD would be significantly associated with CPD burden among low-income, racial minority residents. METHODS: We evaluated cross-sectional relationships between traumatic events, PTSD, depression, and CPD burden in 251 low-income, urban, primarily Black adults diagnosed with heart failure. Data were analyzed using bivariate analyses, logistic and linear regression. RESULTS: Forty-three percent endorsed at least one traumatic event. Twenty-one percent endorsed two or more traumatic events. In logistic regression analyses, traumatic events were associated with increased prevalence of coronary artery disease (adjusted odds=1.33, p<.05), hypertension (adjusted odds=1.28, p<.05), chronic obstructive pulmonary disease (adjusted odds=1.52, p<.01), and cardiac arrest (adjusted odds=1.27, p<.05). PTSD was also related to increased risk for chronic obstructive pulmonary disease (adjusted odds=1.22, p<.05) and was associated with earlier onset of heart failure (ß=-.13, p<.05). LIMITATIONS: The study utilizes cross-sectional, self-report data. CONCLUSIONS: Findings support the link between traumatic events, PTSD, and CPD burden in low-income, primarily Black patients with heart failure. Depression appears to be less closely linked to CPD burden, despite receiving significant attention in the literature. The accumulation of traumatic events may exacerbate CPD burden among urban, low-income, racial minority residents with heart failure; findings highlight the importance of PTSD screening.

Posttraumatic stress and depression: potential pathways to disease burden among heart failure patients.

BACKGROUND AND OBJECTIVES: Posttraumatic stress disorder (PTSD) and Major Depressive Disorder (MDD) are associated with high disease burden. Pathways by which PTSD and MDD contribute to disease burden are not understood. DESIGN: Path analysis was used to examine pathways between PTSD symptoms, MDD symptoms, and disease burden among 251 low-income heart failure patients. METHODS: In Model 1, we explored the independent relationship between PTSD and MDD symptoms on disease burden. In Model 2, we examined the association of PTSD symptoms and disease burden on MDD symptoms. We also examined indirect associations of PTSD symptoms on MDD symptoms, mediated by disease burden, and of PTSD symptoms on disease burden mediated by MDD symptoms. RESULTS: Disease burden correlated with PTSD symptoms (r = .41; p < .001) and MDD symptoms (r = .43; p < .001) symptoms. Both models fit the data well and displayed comparable fit. MDD symptoms did not mediate the association of PTSD symptoms with disease burden. Disease burden did mediate the relationship between PTSD symptoms and MDD symptoms. CONCLUSIONS: Results support the importance of detection of PTSD in individuals with disease. Results also provide preliminary models for testing longitudinal data in future studies.

Congestive heart failure adherence redesign trial: a pilot study.

OBJECTIVE: Heart failure (HF) continues to be a leading cause of hospital admissions, particularly in underserved patients. We hypothesised that providing individualised self-management support to patients and feedback on use of evidence-based HF therapies (EBT) to physicians could lead to improvements in care and decrease hospitalisations. To assess the feasibility of conducting a larger trial testing the efficacy of this dual-level intervention, we conducted the Congestive Heart failure Adherence Redesign Trial Pilot (CHART-P), a proof-of-concept, quasi-experimental, feasibility pilot study. SETTING: A large tertiary care medical centre in Chicago. PARTICIPANTS: Low-income patients (80% of interventions at 1 month and by study completion, respectively. Median sodium intake declined (3.5 vs 2.0 g; p<0.01). There was no statistically significant change in medication adherence based on electronic pill cap monitoring or the Morisky Medication Adherence Scale (MMAS); however, there was a trend towards improved adherence based on MMAS. All physicians received timely intervention. CONCLUSIONS: This pilot study demonstrated that the protocol was feasible. It provided important insights about the need for intervention and the difficulties in treating patients with a variety of psychosocial problems that undercut their effective care.

Does self-management counseling in patients with heart failure improve quality of life? Findings from the Heart Failure Adherence and Retention Trial (HART).

PURPOSE: Heart failure (HF) is associated with poor health-related quality of life (HRQOL). The purpose of our study is to determine the effect of a self-management intervention on HRQOL domains across time, overall, and in prespecified demographic, clinical, and psychosocial subgroups of HF patients. METHODS: HART was a single-center, multi-hospital randomized trial. Patients (n = 902) were randomized either to a self-management intervention with provision of HF educational information or an enhanced education control group which received the same HF educational materials. HRQOL was measured by the Quality of Life Index, Cardiac Version, modified, and the Medical Outcomes Study 36-item Short-Form Health Survey physical functioning scale. Analyses included descriptive statistics and mixed-effects regression models. RESULTS: In general, overall, study participants' HRQOL improved over time. However, no significant differences in HRQOL domain were detected between treatment groups at baseline or across time (p > 0.05). Subgroup analyses demonstrated no differences by treatment arm for change in HRQOL from baseline to 3 years later. CONCLUSIONS: We conclude that in our cohort of patients, the self-management intervention had no benefit over enhanced education in improving domains of HRQOL and HRQOL for specified HF subgroups.

Comparison of predictors of heart failure-related hospitalization or death in patients with versus without preserved left ventricular ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) is recognized as a major cause of cardiovascular morbidity and mortality. An ability to identify patients with HFpEF who are at increased risk for adverse outcomes can facilitate their more careful management. We studied the patients having heart failure (HF) using data from the Heart Failure Adherence and Retention Trial (HART). HART enrolled 902 patients in the New York Heart Association (NYHA) class II or III who had been recently hospitalized for HF to study the impact of self-management counseling on the primary outcome of death or HF hospitalization. In HART, 208 patients had HFpEF and 692 had HF with reduced ejection fraction (HFrEF) and were followed for a median of 1,080 days. Two final multivariate models were developed. In patients having HFpEF, predictors of primary outcome were male gender (odds ratio [OR] 3.45, p = 0.004), NYHA class III (OR 3.05, p = 0.008), distance covered on a 6-minute walk test (6-MWT) of <620 feet (OR 2.81, p = 0.013), and <80% adherence to prescribed medications (OR 2.61, p = 0.018). In patients having HFrEF, the predictors were being on diuretics (OR 3.06, p = 0.001), having ≥3 co-morbidities (OR 2.11, p = 0.0001), distance covered on a 6-MWT of <620 feet (OR 1.94, p = 0.001), NYHA class III (OR 1.90, p = 0.001), and age >65 years (OR 1.63, p = 0.01). In conclusion, indicators of functional status (6-MWT and NYHA class) were common to both patients with HFpEF and those with HFrEF, whereas gender and adherence to prescribed therapy were unique to patients having HFpEF in predicting death or HF hospitalization.

Attenuation of the side effect profile of regadenoson: a randomized double-blinded placebo-controlled study with aminophylline in patients undergoing myocardial perfusion imaging. "The ASSUAGE trial".

BACKGROUND: It is unknown whether the standardized intravenous aminophylline administration following regadenoson-stress can prevent the gastrointestinal and other adverse effects associated with regadenoson. METHODS: In a randomized, double-blinded, placebo-controlled clinical trial we compared the frequency and severity of regadenoson adverse effects in those who received 75 mg of intravenous aminophylline versus a matching placebo administered 2 minutes after regadenoson or 90 seconds post-radioisotope injection. RESULTS: 248 patients [44.8% women, mean age 62.2 (± 13.3) years] were randomized to receive aminophylline (124) or placebo (124). In the aminophylline arm, there was 50% reduction in the incidence of the primary endpoint of diarrhea and abdominal discomfort [11 (8.9%) vs 22 (17.7%), P = .04] and 70% reduction in the incidence of diarrhea [4 (3.2%) vs 13 (10.5%), P = .02]. Additionally, aminophylline use was associated with 34% reduction in the secondary endpoint of any regadenoson adverse effects [55 (44.4%) vs 83 (66.9%), P < .001] and 71% reduction in headache [9 (7.3%) vs 31 (25%), P < .001]. The stress protocol was better tolerated in the aminophylline group (P = .007). The quantitative summed difference score was similar in both study groups (P = .92). There were no excess adverse events in the aminophylline arm. CONCLUSIONS: This trial supports the routine administration of IV-aminophylline to reduce the frequency and severity of adverse effects associated with regadenoson-stress.

Adherence to evidence-based guidelines for heart failure in physicians and their patients: lessons from the Heart Failure Adherence Retention Trial (HART).

The Heart Failure Adherence and Retention Trial (HART) provided an opportunity to determine adherence to evidence-based guidelines (EBG) in patients with heart failure (HF). Ten hospitals were the source of 692 patients with HF (EF < 40%). Physicians of patients with HF were classified as adherent to EBG if the patient chart audit showed they were on a beta-blocker, ACE-inhibitor (ACE-I), or angiotensin receptor blocker (ARB). Patients were classified as adherent to EBG if MEMS pill caps were used appropriately more than 80% of the time. Sixty-three percent of physicians prescribed evidence-based medications that were adherent to clinical practice guidelines. New York Heart Association (NYHA) III patients were less likely to be adherent (P < 0.001), as were those with renal disease (P < 0.001) and asthmatics (P < 0.001). Nonadherent physicians were less likely to treat patients with beta-blockers (39% vs 98%, P < 0.001) and ACE-I or ARBs (71% vs 98% P < 0.001). Thirty-seven percent of patients prescribed evidence-based therapy failed to use the MEMS pill cap bottles appropriately and were more likely a minority or higher NYHA class. Adherence to evidence-based therapy is less than optimal in HF patients based on a combination of both physician and patient nonadherence.

Depression predicts repeated heart failure hospitalizations.

OBJECTIVE: Management of depression, if it is independently associated with repeated hospitalizations for heart failure (HF), offers promise as a viable and cost-effective strategy to improve health outcomes and reduce health care costs for HF. The objective of this study was to assess the association between depression and the number of HF-related hospitalizations in patients with low-to-moderate systolic or diastolic dysfunction, after controlling for illness severity, socioeconomic factors, physician adherence to evidence-based medications, patient adherence to HF drug therapy, and patient adherence to salt restrictions. METHODS AND RESULTS: The Heart Failure Adherence and Retention Trial (HART) was a randomized behavioral trial to evaluate whether patient self-management skills coupled with HF education improved patient outcomes. Depression was measured at baseline with the Geriatric Depression Scale (GDS). The number of hospitalizations was analyzed with a negative binomial regression model that included an offset term to account for the differential duration of follow-up for individual subjects. The average unadjusted number of hospitalizations per year was 0.40 in the depressed group (GDS ≥10) and 0.33 in the nondepressed group (GDS <10). Depression was a strong predictor (incident rate ratio 1.45; P = .006) after adjusting for physician adherence to evidence-based medication use, patient adherence to HF drug therapy, patient adherence to salt restriction, illness severity, HF severity (6-minute walk <620 feet), and socioeconomic factors. CONCLUSIONS: Depression is a strong psychosocial predictor of repeated hospitalizations for HF. Compared with nondepressed individuals, those with depression were hospitalized for HF 1.45 times more often, even after controlling for physician adherence to evidence-based medications and patient adherence to HF drug therapy and salt restrictions. This finding suggests that clinicians should screen for depression early in the course of HF management.

Achieving high quality in ST-segment elevation myocardial infarction care: one urban academic medical center experience.

Management of acute myocardial infarction with ST elevation (STEMI) remains a challenge for academic institutions. There are numerous factors at play from the time electrocardiogram is obtained to the time the patient arrives to a catheterization laboratory and the balloon is inflated. Academic hospitals that are located in large urban centers have to deal with staff living long distances from the facility, and therefore, assembling the catheterization team after-hours and on the weekends becomes a difficult task to achieve. There are other factors that contribute to time delays, such as, administering electrocardiograms in timely fashion, having emergency physicians activate the catheterization team, instead of contacting the cardiologist to discuss the case, and other time-sensitive factors. All of the aforementioned issues contribute to the delay. Yet, primary percutaneous coronary intervention is clearly demonstrated as the modality of choice in treatment of STEMI, which improves patient's morbidity and mortality. Therefore, it is imperative that institutions do all they can to improve their protocols and meet the core measures in the treatment of STEMI patients, including the door-to-balloon time of less than 90 minutes. Our institution started a quality improvement program for STEMI care in 1993 and has showed progressive improvement in use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and other medication, culminating in 95% to 100% use of these medications in 2003-2004, when we operated in accordance with the Get With The Guidelines program. Door-to-balloon time in less than 90 minutes became a new phase in our quality improvement process, and we achieved 100% compliance in the last 2 years.

QSAR models for the removal of organic micropollutants in four different river water matrices.

Ozonation is an advanced water treatment process used to remove organic micropollutants (OMPs) such as pharmaceuticals and personal care products (PPCPs). In this study, Quantitative Structure Activity Relationship (QSAR) models, for ozonation and advanced oxidation process (AOP), were developed with percent-removal of OMPs by ozonation as the criterion variable. The models focused on PPCPs and pesticides elimination in bench-scale studies done within natural water matrices: Colorado River, Passaic River, Ohio River and Suwannee synthetic water. The OMPs removal for the different water matrices varied depending on the water quality conditions such as pH, DOC, alkalinity. The molecular descriptors used to define the OMPs physico-chemical properties range from one-dimensional (atom counts) to three-dimensional (quantum-chemical). Based on a statistical modeling approach using more than 40 molecular descriptors as predictors, descriptors influencing ozonation/AOP were chosen for inclusion in the QSAR models. The modeling approach was based on multiple linear regression (MLR). Also, a global model based on neural networks was created, compiling OMPs from all the four river water matrices. The chemically relevant molecular descriptors involved in the QSAR models were: energy difference between lowest unoccupied and highest occupied molecular orbital (E(LUMO)-E(HOMO)), electron-affinity (EA), number of halogen atoms (#X), number of ring atoms (#ring atoms), weakly polar component of the solvent accessible surface area (WPSA) and oxygen to carbon ratio (O/C). All the QSAR models resulted in a goodness-of-fit, R(2), greater than 0.8. Internal and external validations were performed on the models.

Vitamin D is associated with atheroprotective high-density lipoprotein profile in postmenopausal women.

BACKGROUND: Low vitamin D has been associated with low levels of high-density lipoprotein (HDL) cholesterol, a marker of coronary risk. Whether atheroprotective HDL particle composition accounts for this association and whether fat affects this association is not known. OBJECTIVE: To explore the association between HDL particle composition and 25-hydroxy vitamin D (25[OH]D) in post-menopausal women. METHODS: Vitamin D levels and lipoprotein composition were assessed in fasting blood samples of apparently healthy women from a diverse Chicago community. Visceral (VAT) and subcutaneous (SAT) abdominal fat area were assessed using computed tomography. Total body fat mass was measured by dual-energy X-ray absorptiometry. RESULTS: We enrolled 78 women (50% black; 50% white), age 48 to 64 years, all of whom were participants in a longitudinal study of fat patterning. They had a mean 25[OH]D of 31 ± 15 µg/L, HDL cholesterol 57±11 mg/dL, and large HDL particle subclass 8.6±3.4 µmol/L. In a multivariable-adjusted regression model, each 5 µg/L higher 25[OH]D predicted 0.57 µmol/L (95%CI 0.20-0.95) higher large HDL particles, independent of race, season, and total HDL particle concentration. This association was only partially confounded by total body fat mass (0.49, 95%CI 0.10-0.89), SAT (0.50, 95%CI 0.11-0.90), or VAT (0.37, 95%CI 0.01-0.74). Age did not significantly influence the strength of associations. CONCLUSIONS: Higher 25[OH]D levels are associated with large HDL particles. This association is stronger than that of HDL cholesterol and only partially confounded by body fat. Theoretically, vitamin D may protect against cardiovascular risk by promoting formation of large HDL particles, affecting reverse cholesterol transport.

Self-management counseling in patients with heart failure: the heart failure adherence and retention randomized behavioral trial.

CONTEXT: Motivating patients with heart failure to adhere to medical advice has not translated into clinical benefit, but past trials have had methodological limitations. OBJECTIVE: To determine the value of self-management counseling plus heart failure education, compared with heart failure education alone, for the primary end point of death or heart failure hospitalization. DESIGN, SETTING, AND PATIENTS: The Heart Failure Adherence and Retention Trial (HART), a single-center, multiple-hospital, partially blinded behavioral efficacy randomized controlled trial involving 902 patients with mild to moderate heart failure and reduced or preserved systolic function, randomized from the Chicago metropolitan area between October 2001 and October 2004 and undergoing follow-up for 2 to 3 subsequent years. INTERVENTIONS: All patients were offered 18 contacts and 18 heart failure educational tip sheets during the course of 1 year. Patients randomized to the education group received tip sheets in the mail and telephone calls to check comprehension. Patients randomized to the self-management group received tip sheets in groups and were taught self-management skills to implement the advice. MAIN OUTCOME MEASURE: Death or heart failure hospitalization during a median of 2.56 years of follow-up. RESULTS: Patients were representative of typical clinical populations (mean age, 63.6 years; 47% women, 40% racial/ethnic minority, 52% with annual family income less than $30,000, and 23% with preserved systolic function). The rate of the primary end point in the self-management group was no different from that in the education group (163 [40.1%)] vs 171 [41.2%], respectively; odds ratio, 0.95 [95% confidence interval, 0.72-1.26]). There were no significant differences on any secondary end points, including death, heart failure hospitalization, all-cause hospitalization, or quality of life. CONCLUSIONS: Compared with an enhanced educational intervention alone, the addition of self-management counseling did not reduce death or heart failure hospitalization in patients with mild to moderate heart failure. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00018005.

The incremental value of troponin biomarkers in risk stratification of acute coronary syndromes: is the relationship multiplicative?

OBJECTIVE: To emphasize the importance of troponin in the context of a new score for risk stratifying acute coronary syndromes (ACS) patients. Although troponins have powerful prognostic value, current ACS scores do not fully capitalize this prognostic ability. Here, we weigh troponin status in a multiplicative manner to develop the TRACS score from previously published Rush score risk factors (RRF). METHODS: 2,866 ACS patients (46.7% troponin positive) from 9 centers comprising the TRACS registry, were randomly split into derivation (n=1,422) and validation (n=1,444) cohorts. In the derivation sample, RRF sum was multiplied by 3 if troponins were positive to yield the TRACS score, which was grouped into five categories of 0-2, 3-5, 6-8, 9-11, 12-15 (multiples of 3). Predictive performance of this score to predict hospital death was ascertained in the validation sample. RESULTS: The TRACS score had ROC AUC of 0.71 in the validation cohort. Logistic regression, Kaplan-Meier analysis, likelihood-ratio and Bayesian Information Criterion (BIC) test indicated that weighing troponin status with 3 in the TRACS score improved the prediction of mortality. Hosmer-Lemeshow test indicated sound model fit. CONCLUSIONS: We demonstrate that weighing troponin as a multiple of 3 yields robust prognostication of hospital mortality in ACS patients, when used in the context of the TRACS score.

Quality of life in a diverse population of patients with heart failure: BASELINE FINDINGS FROM THE HEART FAILURE ADHERENCE AND RETENTION TRIAL (HART).

PURPOSE: The exact role of psychosocial status in quality of life (QOL) of patients with heart failure (HF) is not fully clarified. This report investigates the association of depression and social support in 2 subdomains of QOL, overall satisfaction with QOL (S-QOL) and limitations in physical functioning (PF-QOL) in a diverse group of HF patients. METHODS: Baseline data were used from a behavioral clinical trial, with complete information on 695 HF patients, of whom 33% were black and 24% had diastolic dysfunction. Data were collected via structured questionnaires, medical record review, and a 6-minute walk test. QOL outcomes included the Quality of Life Index (QLI) as a measure of S-QOL and the 36-item Short-Form Health Survey Physical Functioning (SF-36 PF) scale as a measure of PF-QOL. RESULTS: After adjustment for sociodemographic variables, clinical and functional characteristics of disease status accounted for 19% of the variance in the QLI. Depressive symptoms and social support were significantly associated with QLI scores (P < .001) and accounted for an additional 26% of the variance. Clinical and functional characteristics accounted for 33% of the variance in SF-36 PF scores, whereas depressive symptoms and social support accounted for an additional 1% of the variance. CONCLUSION: Depression and social support play a substantially greater role in S-QOL than in perceived limitations in basic physical functions. Targeting depression and low social support may be more important to improve overall QOL, whereas medical management of HF symptoms and functional capacity may have a greater impact on reducing basic physical limitations.

The Heart Failure Adherence and Retention Trial (HART): design and rationale.

BACKGROUND: Heart failure (HF) is increasing in prevalence and is associated with prolonged morbidity, repeat hospitalizations, and high costs. Drug therapies and lifestyle changes can reduce hospitalizations, but nonadherence is high, ranging from 30% to 80%. There is an urgent need to identify cost-effective ways to improve adherence and reduce hospitalizations. TRIAL DESIGN: The Heart Failure Adherence and Retention Trial (HART) evaluated the benefit of patient self-management (SM) skills training in combination with HF education, over HF education alone, on the composite end points of death/HF hospitalizations and death/all-cause hospitalizations in patients with mild to moderate systolic or diastolic dysfunction. Secondary end points included progression of HF, quality of life, adherence to drug and lifestyle regimens, and psychosocial function. The HART cohort was composed of 902 patients including 47% women, 40% minorities, and 23% with diastolic dysfunction. After a baseline examination, patients were randomized to SM or education control, received 18 treatment contacts over 1 year, annual follow-ups, and 3-month phone calls to assess primary end points. Self-management treatment was conducted in small groups and aimed to activate the patient to implement HF education through training in problem-solving and 5 SM skills. The education control received HF education in the mail followed by a phone call to check comprehension. CONCLUSIONS: The significance of HART lies in its ability to determine the clinical value of activating the patient to collaborate in his or her care. Support for the trial hypotheses would encourage interdisciplinary HF treatment, drawing on an evidence base not only from medicine but also from behavioral medicine.

Patterns of transfer for patients with non-ST-segment elevation acute coronary syndrome from community to tertiary care hospitals.

BACKGROUND: Practice guidelines for non-ST-segment elevation acute coronary syndromes (NSTE ACS) recommend early invasive management (cardiac catheterization and revascularization within 48 hours of hospital presentation) for high-risk patients, but interhospital transfer is necessary to provide rapid access to revascularization procedures for patients who present to community hospitals without revascularization capabilities. METHODS: We analyzed patterns and factors associated with interhospital transfer among 19,238 patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) from 124 community hospitals without revascularization capabilities in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines quality improvement initiative from January 2001 through June 2004. RESULTS: Less than half of the patients (46.3%) admitted to community hospitals were transferred to tertiary hospitals, and fewer (20%) were transferred early (within 48 hours of presentation). Early transfer rates increased by 16% over 10 quarters in patients with a predicted low or moderate risk of inhospital mortality, compared with 5% in high-risk patients. By the last quarter of the analysis, 41.4% of low-risk patients were transferred early versus 12.5% of high-risk patients. Factors significantly associated with early transfer included younger age, lack of prior heart failure, cardiology inpatient care, and ischemic ST-segment electrocardiographic changes. Among patients who were not transferred, 29% had no further risk stratification performed with stress testing, ejection fraction measurement, or diagnostic cardiac catheterization (at hospitals with catheterization laboratories). CONCLUSIONS: Most patients with NSTE ACS presenting to community hospitals without revascularization capabilities are not rapidly transferred to tertiary hospitals, and lower-risk patients appear to be preferentially transferred early. Further investigation is needed to determine if improved risk-based triage at community hospitals can optimize transfer decision making for high-risk patients with NSTE ACS.