Prevalence of Angina Among Primary Care Patients With Coronary Artery Disease.

Importance: Angina pectoris is associated with morbidity and mortality. Angina prevalence and frequency among contemporary US populations with coronary artery disease (CAD) remain incompletely defined. Objective: To ascertain the angina prevalence and frequency among stable outpatients with CAD. Design, Setting, and Participants: This cross-sectional survey study involved telephone-based administration of the Seattle Angina Questionnaire-7 (SAQ-7) between February 1, 2017, and July 31, 2017, to a nonconvenience sample of adults with established CAD who receive primary care through a large US integrated primary care network. Data analysis was performed from August 2017 to August 2019. Exposure: SAQ-7 administration. Main Outcomes and Measures: Angina prevalence and frequency were assessed using SAQ-7 question 2. Covariates associated with angina were assessed in univariable and multivariable regression. Results: Of 4139 eligible patients, 1612 responded to the survey (response rate, 38.9%). The mean (SD) age of the respondents was 71.8 (11.0) years, 577 (35.8%) were women, 1447 (89.8%) spoke English, 147 (9.1%) spoke Spanish, 1336 (82.8%) were White, 76 (4.7%) were Black, 92 (5.7%) were Hispanic, 974 (60.4%) had Medicare, and 83 (5.2%) had Medicaid. Among respondents, 342 (21.2%) reported experiencing angina at least once monthly; among those, 201 (12.5%) reported daily or weekly angina, and 141 respondents (8.7%) reported monthly angina. The mean (SD) SAQ-7 score was 93.7 (13.7). After multivariable adjustment, speaking a language other than Spanish or English (odds ratio [OR], 5.07; 95% CI, 1.39-18.50), Black race (OR, 2.01; 95% CI, 1.08-3.75), current smoking (OR, 1.88; 95% CI, 1.27-2.78), former smoking (OR, 1.69; 95% CI, 1.13-2.51), atrial fibrillation (OR, 1.52; 95% CI, 1.02-2.26), and chronic obstructive pulmonary disease (OR, 1.61; 95% CI, 1.18-2.18) were associated with more frequent angina. Male sex (OR, 0.63; 95% CI, 0.47-0.86), peripheral artery disease (OR, 0.63; 95% CI, 0.44-0.90), and novel oral anticoagulant use (OR, 0.19; 95% CI, 0.08-0.48) were associated with less frequent angina. Conclusions and Relevance: Among stable outpatients with CAD receiving primary care through an integrated primary care network, 21.2% of surveyed patients reported experiencing angina at least once monthly. Several objective demographic and clinical characteristics were associated with angina frequency. Proactive assessment of angina symptoms using validated assessment tools and estimation of patients at higher risk of suboptimally controlled angina may be associated with reduced morbidity.

Chronic disease outcomes from primary care population health program implementation.

OBJECTIVES: We implemented a health information technology-enabled population health management program for chronic disease management in academic hospital-affiliated primary care practices, then compared quality-of-care outcome measures among practices assigned a central population health coordinator (PHC) and those not assigned a PHC. STUDY DESIGN: Quasi-experimental. METHODS: Central PHCs were nonrandomly assigned to 8 of 18 practices. They met with physicians, managed lists of patients not at goal in chronic disease registries, and performed administrative tasks. In non-PHC practices, existing staff remained responsible for these tasks. The primary outcome was difference-in-differences over the 6-month follow-up period between PHC and non-PHC practices for outcome measures for diabetes (low-density lipoprotein cholesterol [LDL-C], glycated hemoglobin [A1C], and blood pressure [BP] goal attainment), cardiovascular disease (LDL-C goal attainment), and hypertension (BP goal attainment). Secondary outcomes included process measures only (obtaining LDL-C, A1C, and BP readings) and cancer screening test completion. RESULTS: The difference in the percentage point (PP) increase in outcome measures over follow-up was greater in PHC practices than non-PHC practices for all measures among patients with diabetes (LDL-C, 4.6 PP; A1C, 4.8 PP; BP, 4.7 PP), cardiovascular disease (LDL-C, 3.3 PP), and hypertension (BP, 2.3 PP) (adjusted P all <.001). Changes in cancer screening outcomes, which were not a focus of PHC efforts, were similar between PHC and non-PHC practices. CONCLUSIONS: Use of central PHCs led to greater improvement in short-term chronic disease outcome measures compared with patients in practices not assigned a central PHC.

Using a Self-Reported Global Health Measure to Identify Patients at High Risk for Future Healthcare Utilization.

BACKGROUND: Research studies have shown that patient-reported outcome measures (PROMs) that assess global health are helpful for predicting health care utilization, but less evidence exists that collection of PROMs in routine care can identify patients with high health care needs. OBJECTIVE: To investigate the association between the PROMIS Global Health (PGH) scores and subsequent health care utilization among patients in a large accountable care organization (ACO). DESIGN: Retrospective cohort study of individuals in the Partners HealthCare ACO who completed at least one PGH during a primary care visit. PARTICIPANTS: A total of 2639 individuals who completed at least one PGH and who also had 12 months of ACO membership and/or claims data prior to the PROM completion and at least one month of claims data post-PGH completion. MAIN MEASURES: The main outcomes were the rates of emergency department (ED) visits and hospitalizations by quartile of PGH physical and mental health scores. We also compared the predictive accuracy of administrative data models with and without the PGH scores to identify the highest utilizers. KEY RESULTS: The group with the worst (lowest) physical and mental health scores had significantly higher rates of hospitalization (RR 5.14, 95% CI 2.37, 11.15; and 2.27, 95% CI 1.06, 4.85, respectively) than those with higher scores. After adjustment for demographic and clinical factors, only the group with lower physical health scores had higher rates of hospitalization (RR 3.15, 95% CI 1.30, 7.90). The addition of the physical health subscore to administrative data increased the sensitivity to detect the top 5% of hospital utilizers compared with administrative data alone (44.0% vs. 36.0% respectively). CONCLUSIONS: Worse self-reported physical health, measured during routine primary care, is associated with significantly higher rates of hospitalization. It is not associated with increased rates of ED visits. Self-reported physical health modestly increases the sensitivity to detect the highest hospital utilizers.

Implementing patient-reported outcome surveys as part of routine care: lessons from an academic radiation oncology department.

Patient reported outcomes (PROs) are reports of health conditions that come directly from patients. Use of PROs has been associated with improved patient outcomes, enhanced quality of life, and reduced end-of-life spending. Yet there are still outstanding questions regarding the process of implementing PRO collection in routine practice. In this article, we describe the experience of selecting and implementing PROs in a multisite, multidisease academic medical center-based radiation oncology practice and demonstrate that such large-scale rollout is feasible. We establish that PROs can be implemented with minimal to no workflow delays, are generally seen as valuable by clinicians, and can enhance patient-doctor communication. We additionally detail the challenges involved in selecting clinically relevant PRO questionnaires and the centrality of physician buy-in, easy data access, and clear workflows to successful implementation.

Feasibility of a Tablet Computer System to Collect Patient-reported Symptom Severity in Patients Undergoing Diagnostic Coronary Angiography.

BACKGROUND: Percutaneous coronary intervention is the most commonly performed revascularization modality for chronic stable angina, but does not improve survival or reduce major adverse cardiovascular event. Percutaneous coronary intervention in this population is performed primarily for symptomatic benefit; therefore, symptom reduction is an important marker of quality. Patient-reported outcome measures (PROMs) have been developed for chest pain and dyspnea which are valid and responsive to treatment; however, they are not widely used in routine care. We present a model for use of PROMs in routine care. METHODS: Partners Health System funded a tablet computer software platform to collect PROMs and include them in the medical record. We implemented this platform in the catheterization laboratory at Massachusetts General Hospital, targeting patients presenting for coronary angiography. Patients are assessed using the SAQ-7, the Rose dyspnea scale, the PHQ-2, and the PROMIS-10. We used a phased implementation, with the final program including preprocedure measurement, presentation of data to clinical providers, and follow up using an email platform. RESULTS: We successfully captured measures from 474 patients, 53.5% of outpatient visits. Key success factors included high-level leadership support and resources, a user-friendly interface for patients and staff, easily interpretable measures, and clinical relevance. CONCLUSIONS: We have demonstrated that routine capture of patient-reported symptom severity is technically feasible in a real-world care environment. We share our experiences to provide others with a model for similar programs, and to accelerate implementation nationwide by helping others avoid pitfalls. We believe expansion of similar programs nationally may lead to more robust quality infrastructure.

Small-molecule inhibitors of phosphatidylcholine transfer protein/StarD2 identified by high-throughput screening.

Phosphatidylcholine transfer protein (PC-TP, also referred to as StarD2) is a highly specific intracellular lipid-binding protein that catalyzes the transfer of phosphatidylcholines between membranes in vitro. Recent studies have suggested that PC-TP in vivo functions to regulate fatty acid and glucose metabolism, possibly via interactions with selected other proteins. To begin to address the relationship between activity in vitro and biological function, we undertook a high-throughput screen to identify small-molecule inhibitors of the phosphatidylcholine transfer activity of PC-TP. After adapting a fluorescence quench assay to measure phosphatidylcholine transfer activity, we screened 114,752 compounds of a small-molecule library. The high-throughput screen identified 14 potential PC-TP inhibitors. Of these, 6 compounds exhibited characteristics consistent with specific inhibition of PC-TP activity, with IC(50) values that ranged from 4.1 to 95.0muM under conditions of the in vitro assay. These compounds should serve as valuable reagents to elucidate the biological function of PC-TP. Because mice with homozygous disruption of the PC-TP gene (Pctp) are sensitized to insulin action and relatively resistant to the development of atherosclerosis, these inhibitors may also prove to be of value in the management of diabetes and atherosclerotic cardiovascular diseases.

Interacting proteins dictate function of the minimal START domain phosphatidylcholine transfer protein/StarD2.

The Star (steroidogenic acute regulatory protein)-related transfer (START) domain superfamily is characterized by a distinctive lipid-binding motif. START domains typically reside in multidomain proteins, suggesting their function as lipid sensors that trigger biological activities. Phosphatidylcholine transfer protein (PC-TP, also known as StarD2) is an example of a START domain minimal protein that consists only of the lipid-binding motif. PC-TP, which binds phosphatidylcholine exclusively, is expressed during embryonic development and in several tissues of the adult mouse, including liver. Although it catalyzes the intermembrane exchange of phosphatidylcholines in vitro, this activity does not appear to explain the various metabolic alterations observed in mice lacking PC-TP. Here we demonstrate that PC-TP function may be mediated via interacting proteins. Yeast two-hybrid screening using libraries prepared from mouse liver and embryo identified Them2 (thioesterase superfamily member 2) and the homeodomain transcription factor Pax3 (paired box gene 3), respectively, as PC-TP-interacting proteins. These were notable because the START domain superfamily contains multidomain proteins in which the START domain coexists with thioesterase domains in mammals and with homeodomain transcription factors in plants. Interactions were verified in pulldown assays, and colocalization with PC-TP was confirmed within tissues and intracellularly. The acyl-CoA thioesterase activity of purified recombinant Them2 was markedly enhanced by recombinant PC-TP. In tissue culture, PC-TP coactivated the transcriptional activity of Pax3. These findings suggest that PC-TP functions as a phosphatidylcholine-sensing molecule that engages in diverse regulatory activities that depend upon the cellular expression of distinct interacting proteins.