Disparities in PCSK9 Initiation Among US Veterans with Peripheral Arterial Disease or Cerebrovascular Disease.

BACKGROUND: Effective lipid lowering is essential in patients with peripheral arterial disease (PAD) and cerebrovascular disease (CeVD). Proprotein convertase subtilsin/kexin type 9 inhibitors (PCSK9i) efficiently lower low-density lipoprotein (LDL) levels; however, use in PAD and CeVD patients is limited. Therefore, our aim was to evaluate the use of PCSK9i among US Veterans and compare rates between patients with PAD, CeVD, and coronary artery disease (CAD). METHODS: We evaluated PCSK9i initiation (2016-2019) in US Veterans with CAD, PAD, or CeVD treated at 124 Veterans Affairs (VA) hospitals. We fit a hierarchical logistic regression model to evaluate the association of the patient's primary diagnosis, baseline low-density lipoprotein cholesterol (LDL-C) levels, socioeconomic indicators, and the Department of Veterans Affairs medical center enrollment with PCSK9i initiation. RESULTS: Of 519,566 patients with atherosclerotic vascular disease, 337,766 (65%), 79,926 (15%) and 101,874 (20%) had CAD, PAD, and CeVD, respectively. Among 2115/519,566 (0.4%) initiated on PCSK9i therapy, 84.3% had CAD, while only 7.2% and 8.5% had PAD and CeVD, respectively. Compared with CAD patients, PAD {odds ratio [OR] 0.50 (0.36-0.70)} and CeVD [OR 0.24 (0.15-0.37)] patients were less likely to receive PCSK9i. Relative to under $40K per year, PCSK9i initiation was higher if earning $40,000-$80,000 [OR 1.13 (1.01-1.27)] or > $80,000 [OR 1.41 (1.14-1.75)]. Even moderate community deprivation [OR 0.87 (0.77-0.97)] was associated with lower PCSK9i therapy. CONCLUSIONS: Adjusted for LDL-C levels, PAD and CeVD patients are much less likely to receive PCSK9i therapy. Despite low co-pay, PCSK9i initiation rates among US veterans, nationwide, is low, with household income and community deprivation appearing to predict PCSK9i use.

Healthcare providers experiences with shared medical appointments for heart failure.

Shared medical appointments (SMAs) offer a means for providing knowledge and skills needed for chronic disease management to patients. However, SMAs require a time and attention investment from health care providers, who must understand the goals and potential benefits of SMAs from the perspective of patients and providers. To better understand how to gain provider engagement and inform future SMA implementation, qualitative inquiry of provider experience based on a knowledge-attitude-practice model was explored. Semi-structured interviews were conducted with 24 health care providers leading SMAs for heart failure at three Veterans Administration Medical Centers. Rapid matrix analysis process techniques including team-based qualitative inquiry followed by stakeholder validation was employed. The interview guide followed a knowledge-attitude-practice model with a priori domains of knowledge of SMA structure and content (understanding of how SMAs were structured), SMA attitude/beliefs (general expectations about SMA use), attitudes regarding how leading SMAs affected patients, and providers. Data regarding the patient referral process (organizational processes for referring patients to SMAs) and suggested improvements were collected to further inform the development of SMA implementation best practices. Providers from all three sites reported similar knowledge, attitude and beliefs of SMAs. In general, providers reported that the multi-disciplinary structure of SMAs was an effective strategy towards improving clinical outcomes for patients. Emergent themes regarding experiences with SMAs included improved self-efficacy gained from real-time collaboration with providers from multiple disciplines, perceived decrease in patient re-hospitalizations, and promotion of self-management skills for patients with HF. Most providers reported that the SMA-setting facilitated patient learning by providing opportunities for the sharing of experiences and knowledge. This was associated with the perception of increased comradery and support among patients. Future research is needed to test suggested improvements and to develop best practices for training additional sites to implement HF SMA.

Group medical visits after heart failure hospitalization: Study protocol for a randomized-controlled trial.

A primary goal of this research project is to better understand how shared medical appointments (SMAs) can improve the health status and decrease hospitalization and death for patients recently discharged with heart failure (HF) by providing education, disease state monitoring, medication titration, and social support to patients and their caregivers. We propose a 3-site randomized-controlled efficacy trial with mixed methods to test a SMA intervention, versus usual care. Patients within 12 weeks of a HF hospitalization will be randomized to receive either HF-SMA (intervention arm) with optional co-participation with their caregivers, versus usual care (control arm). The HF-SMA will be provided by a non-physician team composed of a nurse, a nutritionist, a health psychologist, a nurse practitioner and/or a clinical pharmacist and will consist of four sessions of 2-h duration that occur every other week for 8 weeks. Each session will start with an assessment of patient needs followed by theme-based disease self-management education, followed by patient-initiated disease management discussion, and conclude with break-out sessions of individualized disease monitoring and medication case management. The study duration will be 180 days for all patients from the day of randomization. The primary study hypothesis is that, compared with usual care, patients randomized to HF-SMA will experience better cardiac health status at 90 and 180 days follow-up. The secondary hypotheses are that, compared to usual care, patients randomized to HF-SMA will experience better overall health status, a combined endpoint of hospitalization and death, better HF self-care behavior, and lower B-type natriuretic peptide levels.