Readmissions Among Patients With Surgically Managed Drug Use Associated-Infective Endocarditis Before and After the Implementation of an Addiction Consult Team: A Retrospective, Observational Analysis.

BACKGROUND: Patients who undergo cardiac surgery for drug use-associated infective endocarditis (DUA-IE) have high rates of readmissions for recurrent endocarditis, substance use disorder (SUD), and septicemia. Our primary objective was to assess whether exposure to an addiction consult team (ACT) was associated with reduced readmissions in this population. METHODS: This single-center retrospective analysis identified patients who underwent cardiac surgery for DUA-IE between 1/2012-9/2022 using the Society for Thoracic Surgeons database, and compared the cumulative incidence of readmissions at 1, 3, 6, and 12 months among those cared for before and after the implementation of an ACT in 9/2017, accounting for competing risk of mortality and adjusted for measured confounders using inverse probability of treatment weighting. RESULTS: The 58 patients (35 pre-ACT and 23 post-ACT) were young (36.4 +/- 7.7 years) and predominantly White (53.4%) and male (70.7%). The post-ACT cohort had a significantly lower risk of readmission at 1 month (adjusted risk difference [RD] -23.8% [95% CI -94.4%, -8.3%], P = 0.005) and 3 months (RD -34.1% [-55.1%, -13.1%], P = 0.005), but not at 6 or 12 months. In a sensitivity analysis, the post-ACT cohort also had significantly lower risk of readmissions for SUD complications at 3 months. DISCUSSION AND CONCLUSION: ACT exposure was associated with a lower risk of short-term readmission among patients with surgically managed DUA-IE, possibly due to a reduction in SUD-related complications. Additional studies are needed to replicate these findings and to identify ways to sustain the potential benefits of ACTs over the longer term.

Extracorporeal cardiopulmonary resuscitation (ECPR) survival: A quaternary center analysis.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue strategy for nonresponders to conventional CPR (CCPR) in cardiac arrest. Definitive guidelines for ECPR deployment do not exist. Prior studies suggest that arrest rhythm and cardiac origin of arrest may be variables used to assess candidacy for ECPR. AIM: To describe a single-center experience with ECPR and to assess associations between survival and physician-adjudicated origin of arrest and arrest rhythm. METHODS: A retrospective review of all patients who underwent ECPR at a quaternary care center over a 7-year period was performed. Demographic and clinical characteristics were extracted from the medical record and used to adjudicate the origin of cardiac arrest, etiology, rhythm, survival, and outcomes. Univariate analysis was performed to determine the association of patient and arrest characteristics with survival. RESULTS: Between 2010 and 2017, 47 cardiac arrest patients were initiated on extracorporeal membrane oxygenation (ECMO) at the time of active CPR. ECPR patient survival to hospital discharge was 25.5% (n = 12). Twenty-six patients died on ECMO (55.3%) while nine patients (19.1%) survived decannulation but died before discharge. Neither physician-adjudicated arrest rhythm nor underlying origin were significantly associated with survival to discharge, either alone or in combination. Younger age was significantly associated with survival. Nearly all survivors experienced myocardial recovery and left the hospital with a good neurological status. CONCLUSIONS: Arrest rhythm and etiology may be insufficient predictors of survival in ECPR utilization. Further multiinstitutional studies are needed to determine evidenced-based criteria for ECPR deployment.

Accuracy of race, ethnicity, and language preference in an electronic health record.

BACKGROUND: Collection of data on race, ethnicity, and language preference is required as part of the "meaningful use" of electronic health records (EHRs). These data serve as a foundation for interventions to reduce health disparities. OBJECTIVE: Our aim was to compare the accuracy of EHR-recorded data on race, ethnicity, and language preference to that reported directly by patients. DESIGN/SUBJECTS/MAIN MEASURES: Data collected as part of a tobacco cessation intervention for minority and low-income smokers across a network of 13 primary care clinics (n = 569). KEY RESULTS: Patients were more likely to self-report Hispanic ethnicity (19.6 % vs. 16.6 %, p < 0.001) and African American race (27.0 % vs. 20.4 %, p < 0.001) than was reported in the EHR. Conversely, patients were less likely to complete the survey in Spanish than the language preference noted in the EHR suggested (5.1 % vs. 6.3 %, p < 0.001). Thirty percent of whites self-reported identification with at least one other racial or ethnic group, as did 37.0 % of Hispanics, and 41.0 % of African Americans. Over one-third of EHR-documented Spanish speakers elected to take the survey in English. One-fifth of individuals who took the survey in Spanish were recorded in the EHR as English-speaking. CONCLUSION: We demonstrate important inaccuracies and the need for better processes to document race/ ethnicity and language preference in EHRs.

Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial.

IMPORTANCE: Widening socioeconomic disparities in mortality in the United States are largely explained by slower declines in tobacco use among smokers of low socioeconomic status (SES) than among those of higher SES, which points to the need for targeted tobacco cessation interventions. Documentation of smoking status in electronic health records (EHRs) provides the tools for health systems to proactively offer tobacco treatment to socioeconomically disadvantaged smokers. OBJECTIVE: To evaluate a proactive tobacco cessation strategy that addresses sociocontextual mediators of tobacco use for low-SES smokers. DESIGN, SETTING, AND PARTICIPANTS: This prospective, randomized clinical trial included low-SES adult smokers who described their race and/or ethnicity as black, Hispanic, or white and received primary care at 1 of 13 practices in the greater Boston area (intervention group, n = 399; control group, n = 308). INTERVENTIONS: We analyzed EHRs to identify potentially eligible participants and then used interactive voice response (IVR) techniques to reach out to them. Consenting patients were randomized to either receive usual care from their own health care team or enter an intervention program that included (1) telephone-based motivational counseling, (2) free nicotine replacement therapy (NRT) for 6 weeks, (3) access to community-based referrals to address sociocontextual mediators of tobacco use, and (4) integration of all these components into their normal health care through the EHR system. MAIN OUTCOMES AND MEASURES: Self-reported past-7-day tobacco abstinence 9 months after randomization ("quitting"), assessed by automated caller or blinded study staff. RESULTS: The intervention group had a higher quit rate than the usual care group (17.8% vs 8.1%; odds ratio, 2.5; 95% CI, 1.5-4.0; number needed to treat, 10). We examined whether use of intervention components was associated with quitting among individuals in the intervention group: individuals who participated in the telephone counseling were more likely to quit than those who did not (21.2% vs 10.4%; P < .001). There was no difference in quitting by use of NRT. Quitting did not differ by a request for a community referral, but individuals who used their referral were more likely to quit than those who did not (43.6% vs 15.3%; P < .001). CONCLUSIONS AND RELEVANCE: Proactive, IVR-facilitated outreach enables engagement with low-SES smokers. Providing counseling, NRT, and access to community-based resources to address sociocontextual mediators among smokers reached in this setting is effective. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01156610.