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1.
Europace ; 26(7)2024 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-39001864

RESUMO

AIMS: Wearable cardioverter-defibrillators (WCDs) are indicated in patients at risk of sudden cardiac arrest who are not immediate candidates for implantable defibrillator therapy. Limitations of existing WCDs include poor compliance and high false alarm rates. The Jewel is a novel patch-WCD (P-WCD) that addresses these limitations with an adhesive-based design for near-continuous wear and a machine learning algorithm designed to minimize inappropriate detections. This was a first-in-human study of the Jewel P-WCD conducted in an electrophysiology (EP) lab to determine the safety and effectiveness of the device in terminating ventricular tachycardia/ventricular fibrillation (VT/VF) with a single shock. The aim was to evaluate the safety and effectiveness of terminating VT/VF with a single shock using the Jewel P-WCD. METHODS AND RESULTS: This was a first-in-human, prospective, single-arm, single-centre study in patients scheduled for an EP procedure in which VT/VF was expected to either spontaneously occur or be induced. The Jewel P-WCD was placed on consented patients; upon confirmation of VT/VF, a single shock (150 J) was delivered via the device. A group sequential design and Pocock alpha spending function was used to measure the observed proportion of successful VT/VF single-shock terminations. The endpoint was achieved if the lower confidence limit exceeded the performance goal of 62%, using a one-sided lower 97.4% exact confidence bound. Of 18 eligible subjects, 16 (88.9%, 97.4% confidence bound: 65.4%) were successfully defibrillated with a single shock, exceeding the primary endpoint performance goal with no adverse events. CONCLUSION: This first-in-human evaluation of the Jewel P-WCD demonstrated the safety and effectiveness of terminating VT/VF. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov/; Unique identifier: NCT05490459.


Assuntos
Desfibriladores , Cardioversão Elétrica , Taquicardia Ventricular , Fibrilação Ventricular , Dispositivos Eletrônicos Vestíveis , Humanos , Masculino , Feminino , Fibrilação Ventricular/terapia , Fibrilação Ventricular/diagnóstico , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/efeitos adversos , Pessoa de Meia-Idade , Taquicardia Ventricular/terapia , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatologia , Estudos Prospectivos , Resultado do Tratamento , Idoso , Desenho de Equipamento , Adulto , Morte Súbita Cardíaca/prevenção & controle
2.
Circulation ; 136(8): 765-772, 2017 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-28827221

RESUMO

Behavioral challenges are often present in human illness, so behavioral economics is increasingly being applied in healthcare settings to better understand why patients choose healthy or unhealthy behaviors. The application of behavioral economics to healthcare settings parallels recent shifts in policy and reimbursement structures that hold providers accountable for outcomes that are dependent on patient behaviors. Numerous studies have examined the application of behavioral economics principles to policy making and health behaviors, but there are limited data on applying these concepts to the management of chronic conditions, such as heart failure (HF). Given its increasing prevalence and high associated cost of care, HF is a paradigm case for studying novel approaches to improve health care; therefore, if we can better understand why patients with HF make the choices they do, then we may be more poised to help them manage their medications, influence daily behaviors, and encourage healthy decision making. In this article, we will give a brief explanation of the core behavioral economics concepts that apply to patients with HF. We will also examine how to craft these concepts into tools such as financial incentives and social networks that may improve the management of patients with HF. We believe that behavioral economics can help us understand barriers to change, encourage positive behaviors, and offer additional approaches to improving the outcomes of patients with HF.


Assuntos
Atenção à Saúde/métodos , Economia Comportamental , Comportamentos Relacionados com a Saúde , Insuficiência Cardíaca/terapia , Atenção à Saúde/economia , Atenção à Saúde/tendências , Economia Comportamental/tendências , Insuficiência Cardíaca/economia , Humanos , Resultado do Tratamento
3.
Circulation ; 132(14): 1347-53, 2015 Oct 06.
Artigo em Inglês | MEDLINE | ID: mdl-26316616

RESUMO

BACKGROUND: Guidelines for heart failure (HF) recommend prescription of guideline-directed medical therapy before hospital discharge; some of these therapies are included in publicly reported performance measures. The burden of new medications for individual patients has not been described. METHODS AND RESULTS: We used Get With The Guidelines-HF registry data from 2008 to 2013 to characterize prescribing, indications, and contraindications for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, ß-blockers, aldosterone antagonists, hydralazine/isosorbide dinitrate, and anticoagulants. The difference between a patient's medication regimen at hospital admission and that recommended by HF quality measures at discharge was calculated. Among 158 922 patients from 271 hospitals with a primary discharge diagnosis of HF, initiation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was indicated in 18.1% of all patients (55.5% of those eligible at discharge were not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers at admission), ß-blockers in 20.3% (50.5% of eligible), aldosterone antagonists in 24.1% (87.4% of eligible), hydralazine/isosorbide dinitrate in 8.6% (93.1% of eligible), and anticoagulants in 18.0% (58.0% of eligible). Cumulatively, 0.4% of patients were eligible for 5 new medication groups, 4.1% for 4 new medication groups, 9.4% for 3 new medication groups, 10.1% for 2 new medication groups, and 22.7% for 1 new medication group; 15.0% were not eligible for new medications because of adequate prescribing at admission; and 38.4% were not eligible for any medications recommended by HF quality measures. Compared with newly indicated medications (mean, 1.45 ± 1.23), actual new prescriptions were lower (mean, 1.16 ± 1.00). CONCLUSIONS: A quarter of patients hospitalized with HF need to start >1 medication to meet HF quality measures. Systems for addressing medication initiation and managing polypharmacy are central to HF transitional care.


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Prescrições de Medicamentos/normas , Substituição de Medicamentos/estatística & dados numéricos , Fidelidade a Diretrizes , Insuficiência Cardíaca/tratamento farmacológico , Hospitais/normas , Guias de Prática Clínica como Assunto , Garantia da Qualidade dos Cuidados de Saúde , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Fármacos Cardiovasculares/classificação , Comorbidade , Contraindicações , Estudos Transversais , Hipersensibilidade a Drogas/epidemiologia , Prescrições de Medicamentos/estatística & dados numéricos , Quimioterapia Combinada , Uso de Medicamentos , Medicina Baseada em Evidências , Feminino , Insuficiência Cardíaca/classificação , Insuficiência Cardíaca/epidemiologia , Humanos , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Polimedicação
4.
J Card Fail ; 22(8): 589-97, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26975941

RESUMO

BACKGROUND: Higher rates of obesity and heart failure have been observed in African Americans, but associations with mortality are not well-described. We examined intermediate and long-term clinical implications of obesity in African Americans and associations between obesity and all-cause mortality, heart failure, and heart failure hospitalization. METHODS AND RESULTS: We conducted a retrospective analysis of a community sample of 5292 African Americans participating in the Jackson Heart Study between September 2000 and January 2013. The main outcomes were associations between body mass index (BMI) and all-cause mortality at 9 years and heart failure hospitalization at 7 years using Cox proportional hazards models and interval development of heart failure (median 8 years' follow-up) using a modified Poisson model. At baseline, 1406 (27%) participants were obese and 1416 (27%) were morbidly obese. With increasing BMI, the cumulative incidence of mortality decreased (P= .007), whereas heart failure increased (P < .001). Heart failure hospitalization was more common among morbidly obese participants (9.0%; 95% confidence interval [CI] 7.6-11.7) than among normal-weight patients (6.3%; 95% CI 4.7-8.4). After risk adjustment, BMI was not associated with mortality. Each 1-point increase in BMI was associated with a 5% increase in the risk of heart failure (hazard ratio 1.05; 95% CI 1.03-1.06; P < .001) and the risk of heart failure hospitalization for BMI greater than 32 kg/m(2) (hazard ratio 1.05; 95% CI 1.03-1.07; P < .001). CONCLUSIONS: Obesity and morbid obesity were common in a community sample of African Americans, and both were associated with increased heart failure and heart failure hospitalization.


Assuntos
Negro ou Afro-Americano , Índice de Massa Corporal , Disparidades em Assistência à Saúde , Insuficiência Cardíaca/etnologia , Hospitalização/tendências , Obesidade Mórbida/etnologia , Medição de Risco , Adulto , Idoso , Causas de Morte/tendências , Feminino , Seguimentos , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Obesidade Mórbida/complicações , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências
5.
Am Heart J ; 169(6): 847-53, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26027623

RESUMO

BACKGROUND: Million Hearts is a national initiative to prevent 1 million heart attacks and strokes over 5 years by improving cardiovascular prevention. An important tool in the success of programs like Million Hearts is public ranking on the quality of practices, yet different measures may provide different rankings, so the true quality of practices is difficult to discern. We evaluated the quality of ambulatory cardiology care using performance measure metrics. METHODS: We compared rankings of practices participating in the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence Registry using measures from (1) the physician quality reporting system and (2) the American College of Cardiology/American Heart Association/Physician Consortium for Performance Improvement. We compared achievement rates for measures between the 2 frameworks and determined correlations in rankings using Spearman correlation coefficients. RESULTS: From January 1, 2008 to December 31, 2012, there were 1,711,326 patients enrolled from 111 US practices. Among eligible patients, the physician quality reporting system and American College of Cardiology/American Heart Association/Physician Consortium for Performance Improvement measures were achieved in 76.1% versus 77.4% for antiplatelet prescription (P < .001), 68.3% versus 90.8% for blood pressure control (P < .001), 26.9% versus 43.4% for cholesterol control (P < .001), and 37.4% versus 40.6% for smoking cessation (P = .383). Practice rankings were strongly correlated for antiplatelet prescription (correlation coefficient 0.98) and cholesterol control (0.92) but poorly correlated for blood pressure control (0.39) and smoking cessation (0.22). CONCLUSIONS: Evaluation of preventive care and individual practice rankings vary significantly depending on how measures are defined. Publicly reported measures need to be validly associated with outcomes to avoid incorrectly evaluating practice performance and failing to achieve public health goals.


Assuntos
Cardiologia/normas , Serviços Preventivos de Saúde/normas , Indicadores de Qualidade em Assistência à Saúde , Idoso , Assistência Ambulatorial/normas , Feminino , Humanos , Masculino , Sistema de Registros , Estados Unidos
6.
J Card Fail ; 21(8): 667-73, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26009012

RESUMO

The management of acute heart failure is shifting toward treatment approaches outside of a traditional hospital setting. Many heart failure providers are now treating patients in less familiar health care settings, such as acute care clinics, emergency departments, and skilled nursing facilities. In this review we describe the current pressures driving change in the delivery of acute heart failure and summarize the evidence regarding treatments for acute heart failure outside of the inpatient setting. We also provide considerations for the design of future treatment strategies to be implemented in alternative care settings.


Assuntos
Atenção à Saúde/métodos , Insuficiência Cardíaca/terapia , Hospitalização/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Gerenciamento Clínico , Hospitais , Humanos
7.
Am Heart J ; 167(3): 369-375.e2, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24576522

RESUMO

BACKGROUND: The relative impact of atrial fibrillation on early outcomes of patients with heart failure with reduced or preserved ejection fraction (EF) is unknown. METHODS: We conducted a retrospective cohort study of clinical registry data linked to Medicare claims for patients with heart failure with reduced or preserved EF stratified by presence of atrial fibrillation at admission. Outcomes of interest were all-cause mortality and readmission at 30days. We used Kaplan-Meier methods to estimate mortality and calculated cumulative incidence estimates of readmission. We used Cox proportional hazards models to examine associations between atrial fibrillation and 30-day outcomes. RESULTS: Among 66,357 patients admitted to 283 hospitals between January 2001 and March 2006, 46% had atrial fibrillation (44% of patients with reduced EF and 48% of patients with preserved EF). After adjustment for other patient characteristics, atrial fibrillation was associated with a modestly higher risk of 30-day mortality (HR, 1.08; 95% CI, 1.03-1.14) and readmission (HR, 1.06; 95% CI, 1.02-1.11). In subgroup analyses, atrial fibrillation was associated with a higher risk of 30-day mortality (HR, 1.16; 95% CI, 1.08-1.25) among patients with preserved EF but not among patients with reduced EF. The association of atrial fibrillation with readmission did not differ by heart failure type (P=.37 for the interaction). CONCLUSIONS: Atrial fibrillation was associated with higher 30-day mortality among patients with heart failure with preserved EF but not reduced EF. The association of atrial fibrillation with 30-day readmission was modest and did not differ by heart failure type.


Assuntos
Fibrilação Atrial/mortalidade , Insuficiência Cardíaca/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Sistema de Registros , Volume Sistólico , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Estudos de Casos e Controles , Causas de Morte , Estudos de Coortes , Feminino , Insuficiência Cardíaca/complicações , Humanos , Estimativa de Kaplan-Meier , Masculino , Medicare , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Estados Unidos/epidemiologia
8.
Am Heart J ; 168(3): 398-404, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25173553

RESUMO

BACKGROUND: Million Hearts is a national initiative to prevent 1 million heart attacks and strokes over 5 years. The degree to which outpatient providers are controlling risk factors has not been fully described. METHODS: We examined adherence to the Million Hearts clinical quality measures using The Guideline Advantage, a nationwide quality improvement program for outpatient care. Specifically, we determined the proportion of patients with (1) ischemic vascular disease who were prescribed an antiplatelet drug; (2) hypertension whose blood pressure was controlled; (3) diabetes mellitus whose most recent low-density lipoprotein cholesterol level was <100 mg/dL; and 4) a tobacco use screening and who received a smoking cessation intervention as needed. RESULTS: From January 1, 2010, to March 31, 2012, there were 147,038 patients enrolled from 25 US practices. At the practice level, antiplatelet prescription ranged from 50.0% to 82.3% (median 71.9%, interquartile range [IQR] 66.7-82.1), hypertension control ranged from 48.6% to 75.3% (median 66.6%, IQR 60.1-70.9), hyperlipidemia control among patients with diabetes mellitus ranged from 53.3% to 100.0% (median 75.8%, IQR 65.8-83.0), and tobacco use screening and intervention ranged from 31.0% to 98.8% (median 79.8%, IQR 72.0-83.2). Black and people of color races were associated with a lower likelihood of blood pressure control and cholesterol control. Female gender was associated with a lower likelihood of antiplatelet prescription and cholesterol control. CONCLUSIONS: Compliance with quality measures for the Million Hearts initiative varies widely and is notable for racial and gender disparities. Our findings identify multiple opportunities to improve the quality of cardiovascular prevention.


Assuntos
Promoção da Saúde , Infarto do Miocárdio/prevenção & controle , Melhoria de Qualidade , Acidente Vascular Cerebral/prevenção & controle , Idoso , Doenças Cardiovasculares/prevenção & controle , Registros Eletrônicos de Saúde , Feminino , Fidelidade a Diretrizes , Comportamentos Relacionados com a Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto
9.
Am Heart J ; 168(5): 721-30, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25440801

RESUMO

BACKGROUND: Studies on outcomes among patients with heart failure (HF) with preserved left ventricular ejection fraction (HFpEF), borderline left ventricular ejection fraction (HFbEF), and reduced left ventricular ejection fraction (HFrEF) remain limited. We sought to characterize mortality and readmission in patients with HF in the contemporary era. METHODS: Get With The Guidelines-HF was linked to Medicare data for longitudinal follow-up. Patients were grouped into HFpEF (left ventricular ejection fraction [EF] ≥ 50%), HFbEF (40% ≤ EF < 50%), and HFrEF (EF < 40%). Multivariable models were constructed to examine the relationship between EF and outcomes at 30 days and 1 year and to study trends over time. RESULTS: A total of 40,239 patients from 220 hospitals between 2005 and 2011 were included in the study: 18,897 (47%) had HFpEF, 5,626 (14%) had HFbEF, and 15,716 (39%) had HFrEF. In crude survival analysis, patients with HFrEF had slightly increased mortality compared with HFbEF and HFpEF. After risk adjustment, mortality at 1 year was not significantly different for HFrEF, HFbEF, and HFpEF (HFrEF vs HFpEF, hazard ratio [HR] 1.040 [95% CI 0.998-1.084], and HFbEF vs HFpEF, HR 0.967 [95% CI 0.917-1.020]). Patients with HFpEF had increased risk of all-cause readmission compared with HFrEF. Conversely, risk of cardiovascular and HF readmissions were higher in HFrEF and HFbEF compared with HFpEF. CONCLUSIONS: Among patients hospitalized with HF, patients with HFpEF and HFbEF had slightly lower mortality and higher all-cause readmission risk than patients with HFrEF, although the mortality differences did not persist after risk adjustment. Irrespective of EF, these patients experience substantial mortality and readmission highlighting the need for new therapeutic strategies.


Assuntos
Insuficiência Cardíaca/fisiopatologia , Volume Sistólico/fisiologia , Disfunção Ventricular/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Medicare , Análise Multivariada , Readmissão do Paciente/estatística & dados numéricos , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Estados Unidos , Disfunção Ventricular/mortalidade
10.
J Card Fail ; 20(1): 23-30, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24275703

RESUMO

BACKGROUND: Postdischarge adherence and long-term persistence in the use of warfarin among patients with heart failure and atrial fibrillation without contraindications have not been fully described. METHODS AND RESULTS: We identified patients with heart failure and atrial fibrillation who were ≥ 65 years old, eligible for warfarin, and discharged home from hospitals in the Get With the Guidelines-Heart Failure registry from January 1, 2006, to December 31, 2009. We used linked Medicare prescription drug event data to measure adherence and persistence. The main outcome measures were rates of prescription at discharge, outpatient dispensing, discontinuation, and adherence as measured by the medication possession ratio. We hypothesized that adherence to warfarin would differ according to whether patients received the prescription at discharge. Among 2,691 eligible patients, 1,856 (69.0%) were prescribed warfarin at discharge. Patients prescribed warfarin at discharge had significantly higher prescription fill rates within 90 days (84.5% vs 12.3%; P < .001) and 1 year (91.6% vs 16.8%; P < .001) and significantly higher medication possession ratios (0.78 vs 0.63; P < .001). Among both previous nonusers and existing users, fill rates at 90 days and 1 year and possession ratios were significantly higher among those prescribed warfarin at discharge. CONCLUSIONS: One-third of eligible patients with heart failure and atrial fibrillation were not prescribed warfarin at discharge from a heart failure hospitalization, and few started therapy as outpatients. In contrast, most patients who were prescribed warfarin at discharge filled the prescription within 90 days and remained on therapy at 1 year.


Assuntos
Fibrilação Atrial , Insuficiência Cardíaca , Adesão à Medicação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Acidente Vascular Cerebral/prevenção & controle , Varfarina/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Causalidade , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Medicare/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Pacientes Ambulatoriais/estatística & dados numéricos , Sistema de Registros , Acidente Vascular Cerebral/etiologia , Estados Unidos/epidemiologia
11.
J Am Coll Cardiol ; 84(6): 525-536, 2024 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-39084827

RESUMO

BACKGROUND: For many patients, sudden cardiac arrest (SCA) risk is elevated temporarily. Wearable cardioverter-defibrillators (WCDs) can monitor and treat SCA during these temporary periods. Traditional WCDs can be uncomfortable, require frequent maintenance, and cannot be used when showering, resulting in poor compliance and avoidable SCA deaths. The Jewel is a novel, water-resistant patch-wearable cardioverter-defibrillator (P-WCD) with a machine learning detection algorithm designed to improve compliance and protection against SCA. OBJECTIVES: This study aims to demonstrate the safety and clinical effectiveness of a novel P-WCD. METHODS: The Jewel IDE Study, a prospective, single-arm study conducted at 30 U.S. sites, enrolled patients at SCA risk due to ventricular tachycardia/ventricular fibrillation who were not candidates for or refused an implantable defibrillator. The primary safety endpoint was <15% patients with clinically significant cutaneous adverse device effects and the primary effectiveness endpoint was <2 inappropriate shocks/100 patient-months. Secondary endpoints were ≥1 successful ventricular tachycardia/ventricular fibrillation conversion and wear time compliance of >14.1 h/d. RESULTS: A total of 305 patients (mean age: 57.9 years; 30.2% female, 27.9% non-White) were enrolled, of which 290 had available device data. The clinically significant cutaneous adverse device effect rate was 2.30% (upper 1-sided 98% CI: 4.80); none were severe. No device-related deaths or serious adverse events were reported. The inappropriate shock rate was 0.36/100 patient-months (upper 1-sided 98% CI: 1.53). Of 11 shocks in 9 patients, 9 shocks were adjudicated to be appropriate. Eight of 9 shocks were successful with a single shock. Median wear time compliance was 23.5 (20.7-23.9) h/d. CONCLUSIONS: The novel P-WCD is a safe and effective WCD with high patient compliance. There were no deaths due to noncompliance and a high number of successful conversions (Jewel IDE study [A Clinical Evaluation of the Jewel P-WCD in Subjects at High Risk for Sudden Cardiac Arrest]; NCT05201495).


Assuntos
Morte Súbita Cardíaca , Desfibriladores , Dispositivos Eletrônicos Vestíveis , Humanos , Morte Súbita Cardíaca/prevenção & controle , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/etiologia , Feminino , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Idoso , Taquicardia Ventricular/terapia , Fibrilação Ventricular/terapia , Desenho de Equipamento , Adulto , Cooperação do Paciente
12.
Circulation ; 126(24): 2819-25, 2012 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-23124031

RESUMO

BACKGROUND: The transition of scientific knowledge from discovery into practice is less than ideal. A key step in this translation occurs when presentations from major meetings are published in peer-reviewed literature, yet the completeness and speed of this process are not known. We performed a systematic and automated evaluation of rates, timing, and correlates of publication from scientific abstracts presented at 3 major cardiovascular conferences. METHODS AND RESULTS: Using an automated computer algorithm, we searched the ISI Web of Science to identify peer-reviewed publications of abstracts presented at the American Heart Association (AHA), American College of Cardiology (ACC), and European Society of Cardiology (ESC) scientific sessions from 2006 to 2008. We compared abstract publication rates and journal impact factor between the 3 meetings using multivariable logistic regression modeling. From 2006 to 2008, 11 365, 5005, and 10 838 abstracts were presented at the AHA, ACC, and ESC meetings, respectively. Overall, 30.6% of presented abstracts were published within 2 years of the conference; ranging from 34.5% for AHA to 29.5% for ACC to 27.0% for ESC (P<0.0001). Five years after conference presentation in 2005, these rates had risen slightly to 49.7% for AHA, 42.6% for ACC, and 37.6% for ESC (P<0.0001). After adjustment for abstract characteristics and contributing countries, abstracts presented at the AHA meeting remained more likely for publication relative to the ESC (adjusted odds ratio, 1.24; 95% confidence interval, 1.16-1.34) and the ACC (adjusted odds ratio, 1.20; 95% confidence interval, 1.11-1.29). Median impact factors for subsequent publications varied from 4.8 (interquartile range, 3.8-10.1) for AHA to 4.0 (interquartile range, 3.1-7.5) for ACC and 3.9 (quartile 1-3, 2.5-5.8) for ESC (P for difference between groups <0.01). Clinical science and population science were less likely to be published compared with basic science. CONCLUSIONS: One third of abstracts were translated into publications by 2 years after presentation and less than one half by 5 years after presentation. Our findings suggest that efforts to understand the barriers to publication and to facilitate the rapid dissemination of new knowledge are needed to speed up the transition of scientific discovery into clinical practice.


Assuntos
Indexação e Redação de Resumos/métodos , Indexação e Redação de Resumos/estatística & dados numéricos , Algoritmos , Cardiologia , Revisão da Pesquisa por Pares/métodos , Editoração/estatística & dados numéricos , Congressos como Assunto , Humanos , Disseminação de Informação/métodos , Modelos Logísticos
13.
Am Heart J ; 166(6): 1063-1071.e3, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24268222

RESUMO

BACKGROUND: In heart failure (HF), there are known differences in plasma B-type natriuretic peptide (BNP) levels between reduced and preserved ejection fraction (EF), but few HF studies have explored sex differences. We sought to evaluate the relationship between sex, EF, and BNP in HF patients and determine prognostic significance of BNP as it relates to sex and EF. METHODS: We included hospitals in Get With The Guidelines-Heart Failure that admitted 99,930 HF patients with reduced (EF <40%), borderline (EF 40%-49%), or preserved (EF ≥50%) EF. The primary end point was inhospital mortality. Multivariate models were used to compute odds ratios while accounting for hospital clustering. RESULTS: There were 47,025 patients with reduced (37% female), 13,950 with borderline (48% female), and 38,955 with preserved (65% female) EF. Women compared with men had higher admission median BNP levels with the greatest difference among reduced EF and smallest difference among preserved EF (median BNP in women vs men: EF reduced 1,259 vs 1,113 pg/mL, borderline 821 vs 732 pg/mL, and preserved 559 vs 540 pg/mL; P < .001 all comparisons). Ejection fraction and sex were independently associated with BNP. Inhospital mortality was 2.7%, and patients above the median BNP level had higher mortality than those below. After adjusting for over 20 clinical variables, the ability of BNP to predict inhospital mortality was similar among all subgroups (P for heterogeneity = .47). CONCLUSIONS: In a large registry, we found that despite sex/EF differences in BNP values, there was no significant difference in the ability of BNP to predict inhospital mortality among these subgroups.


Assuntos
Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/fisiopatologia , Peptídeo Natriurético Encefálico/sangue , Sistema de Registros , Volume Sistólico/fisiologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Insuficiência Cardíaca/mortalidade , Mortalidade Hospitalar , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Prognóstico , Fatores Sexuais
14.
Am Heart J ; 165(6): 837-47, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23708153

RESUMO

Numerous challenges-financial, regulatory, and cultural-are hindering US participation and performance in multinational clinical trials. Consequently, it is increasingly unclear how the results of these trials should be applied to American patients, practice patterns, and systems of care. Both incremental and transformative changes are needed to revitalize US participation as well as the broader clinical trial enterprise. To promote consensus around the solutions needed to address the adverse trends in clinical research, the Duke Clinical Research Institute convenedstakeholders from academia, industry, and government. article summarizes the proceedings of this meeting and addresses: (1) adverse trends in the United States and multinational clinical trials, (2) the key issues that underlie these adverse trends, and (3) potential solutions to these problems.


Assuntos
Pesquisa Biomédica/organização & administração , Comitês de Monitoramento de Dados de Ensaios Clínicos/organização & administração , Programas Governamentais , Melhoria de Qualidade/tendências , Humanos , Estados Unidos
15.
Am Heart J ; 165(6): 862-8, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23708156

RESUMO

Sudden cardiac arrest (SCA) is one of the most impactful public health problems in the United States. Despite the progress made in reducing the number of cardiac deaths, the incidence of sudden cardiac death remains high. Studies of life-saving interventions for prevention and treatment of SCA, like ß-blockers, aldosterone antagonists, implantable cardioverter defibrillator therapy, automated external defibrillators, and cardiopulmonary resuscitation, have brought to light substantial underutilization, variations in care, and disparities. Thus, a comprehensive systems-based approach to addressing these gaps in care should be implemented. In addition to educating stakeholders about SCA and its prevention and developing tools that could help physicians identify patients who could benefit from primary prevention of SCA, robust performance measures with strong, evidence-based association between process performance and patient outcomes are needed. In this article, we review the burden of SCA and highlight the need to develop performance measures related to the prevention and treatment of SCA.


Assuntos
Reanimação Cardiopulmonar/normas , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/prevenção & controle , Serviços Médicos de Emergência/normas , Saúde Pública , Melhoria de Qualidade , Humanos , Incidência , Taxa de Sobrevida , Estados Unidos/epidemiologia
16.
J Card Fail ; 19(6): 401-7, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23743489

RESUMO

BACKGROUND: Patients with heart failure are at higher risk for thromboembolic events, even in the absence of atrial fibrillation, but the effect of anticoagulation therapy on outcomes is uncertain. METHODS AND RESULTS: With data from a clinical registry linked to Medicare claims, we estimated the adjusted associations between anticoagulation and 1-year outcomes with the use of inverse probability of treatment weighting. Eligible patients had an ejection fraction ≤35%, had no concurrent atrial fibrillation, were alive at discharge, and had not received anticoagulation therapy before admission. Of 13,217 patients in 276 hospitals, 1,140 (8.6%) received anticoagulation therapy at discharge. Unadjusted rates of thromboembolic events and major adverse cardiovascular events did not differ by receipt of anticoagulation therapy. Patients discharged on anticoagulation therapy had lower unadjusted rates of all-cause mortality (27.2% vs 32.3%; P < .001) and readmission for heart failure (29.4% vs 35.4%; P < .001) and higher rates of bleeding events (5.2% vs 2.8%; P < .001). After adjustment for probability of treatment and discharge medications, there were no differences in all-cause mortality (hazard ratio 0.92; 95% confidence interval 0.80-1.06) or readmission for heart failure (0.91, 0.81-1.02), but patients receiving anticoagulation therapy were at higher risk for bleeding events (2.09, 1.47-2.97). CONCLUSIONS: Anticoagulation therapy at discharge is infrequent among older patients with heart failure and without atrial fibrillation. There were no statistically significant propensity-weighted associations between anticoagulation therapy and 1-year outcomes, except for a higher risk of bleeding.


Assuntos
Anticoagulantes/uso terapêutico , Insuficiência Cardíaca/epidemiologia , Tromboembolia/prevenção & controle , Varfarina/uso terapêutico , Idoso , Feminino , Hemorragia/epidemiologia , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Alta do Paciente , Readmissão do Paciente/estatística & dados numéricos , Sistema de Registros , Estados Unidos/epidemiologia
17.
J Card Fail ; 19(9): 611-20, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24054337

RESUMO

BACKGROUND: The Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF) randomly assigned 7,141 participants to nesiritide or placebo. Dyspnea improvement was more often reported in the nesiritide group, but there were no differences in 30-day all-cause mortality or heart failure readmission rates. We compared medical resource use, costs, and health utilities between the treatment groups. METHODS AND RESULTS: There were no significant differences in inpatient days, procedures, and emergency department visits reported for the first 30 days or for readmissions to day 180. EQ-5D health utilities and visual analog scale ratings were similar at 24 hours, discharge, and 30 days. Billing data and regression models were used to generate inpatient costs. Mean length of stay from randomization to discharge was 8.5 days in the nesiritide group and 8.6 days in the placebo group (P = .33). Cumulative mean costs at 30 days were $16,922 (SD $16,191) for nesiritide and $16,063 (SD $15,572) for placebo (P = .03). At 180 days, cumulative costs were $25,590 (SD $30,344) for nesiritide and $25,339 (SD $29,613) for placebo (P = .58). CONCLUSIONS: The addition of nesiritide contributed to higher short-term costs and did not significantly influence medical resource use or health utilities compared with standard care alone.


Assuntos
Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/economia , Peptídeo Natriurético Encefálico/economia , Qualidade de Vida , Doença Aguda , Idoso , Estudos de Coortes , Feminino , Seguimentos , Insuficiência Cardíaca/psicologia , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/uso terapêutico , Qualidade de Vida/psicologia , Resultado do Tratamento
18.
Am Heart J ; 163(6): 994-1001, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22709752

RESUMO

BACKGROUND: Patients hospitalized with heart failure (HF) have elevated B-type natriuretic peptide (BNP) levels and increased risk for thromboembolic events. Associations between BNP level and thromboembolic events in patients with HF without atrial fibrillation (AF) are not well studied. METHODS: We linked data from the ADHERE registry for 2003 through 2006 with Medicare claims to identify patients ≥65 years who were hospitalized with HF, did not have AF, and did not receive warfarin at discharge. We estimated rates of all-cause mortality, thromboembolic events, myocardial infarction (MI), and stroke using Kaplan-Meier methods and the cumulative incidence function. We used Cox models to assess associations between log BNP level and each outcome after adjustment for potential confounders. RESULTS: The study population included 11,679 patients from 146 sites. Patients in the highest quartile of BNP level were older and more often male and African American. They had higher rates of coronary artery disease, renal insufficiency, and peripheral vascular disease and lower rates of diabetes mellitus and chronic obstructive pulmonary disease. After multivariable adjustment, each 30% increase in BNP level was associated with increased risks of death (hazard ratio 1.07, 95% CI 1.05-1.08) and MI (1.07, 1.04-1.10) but not thromboembolism or stroke. CONCLUSION: Higher BNP level upon admission with HF among older patients without AF was associated with increased risks of MI and mortality; however, higher BNP level was not associated with subsequent thromboembolism or stroke.


Assuntos
Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/complicações , Peptídeo Natriurético Encefálico/sangue , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Comorbidade , Coleta de Dados , Feminino , Insuficiência Cardíaca/mortalidade , Hospitalização , Humanos , Estimativa de Kaplan-Meier , Masculino , Análise Multivariada , Infarto do Miocárdio/epidemiologia , Sistema de Registros , Acidente Vascular Cerebral/epidemiologia , Tromboembolia Venosa/epidemiologia
20.
Am Heart J ; 161(5): 916-22, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-21570523

RESUMO

BACKGROUND: Policy makers have proposed bundling payments for all heart failure (HF) care within 30 days of an HF hospitalization in an effort to reduce costs. Disease management (DM) programs can reduce costly HF readmissions but have not been economically attractive for caregivers under existing fee-for-service payment. Whether a bundled payment approach can address the negative financial impact of DM programs is unknown. METHODS: Our study determined the cost-neutral point for the typical DM program and examined whether published HF DM programs can be cost saving under bundled payment programs. We used a decision analytic model using data from retrospective cohort studies, meta-analyses, 5 randomized trials evaluating DM programs, and inpatient claims for all Medicare beneficiaries discharged with an HF diagnosis from 2001 to 2004. We determined the costs of DM programs and inpatient care over 30 and 180 days. RESULTS: With a baseline readmission rate of 22.9%, the average cost for readmissions over 30 days was $2,272 per patient. Under base-case assumptions, a DM program that reduced readmissions by 21% would need to cost $477 per patient to be cost neutral. Among evaluated published DM programs, 2 of the 5 would increase provider costs (+$15 to $283 per patient), whereas 3 programs would be cost saving (-$241 to $347 per patient). If bundled payments were broadened to include care over 180 days, then program saving estimates would increase, ranging from $419 to $1,706 per patient. CONCLUSIONS: Proposed bundled payments for HF admissions provide hospitals with a potential financial incentive to implement DM programs that efficiently reduce readmissions.


Assuntos
Gerenciamento Clínico , Planos de Pagamento por Serviço Prestado/economia , Gastos em Saúde , Insuficiência Cardíaca/terapia , Hospitalização/economia , Medicare/economia , Método Duplo-Cego , Feminino , Seguimentos , Insuficiência Cardíaca/economia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estados Unidos
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