Implementing Heart Plus: Design and Early Results of a Novel Comanagement Clinic for Patients With Stimulant-associated Cardiomyopathy.

We describe the methodology, design, and early results of a novel multidisciplinary co management clinic model with Addiction Medicine and Cardiology providers using contingency management to engage patients with stimulant-associated cardiomyopathy (SA-CMP). Stimulant use, including methamphetamine and cocaine, is increasing in prevalence nationally and is associated with cardiovascular complications. People with SA-CMP have higher rates of mortality and acute care use (eg, emergency department visits, hospital admissions) and lower rates of outpatient care engagement than individuals with non-SA-CMP. This population also has disproportionately elevated rates of mental health and other medical comorbidities, challenges with social determinants of health, including housing and food insecurity, and representation from communities of color. This multidisciplinary comanagement care delivery model, called Heart Plus, was developed and funded as a quality improvement project. It led to a 5-fold increase in outpatient care engagement with a concomitant 53% decrease in acute care use. All participants reported a decrease in stimulant use. With increased clinical stability, patients were able to better engage with outpatient resources for social determinants of health, such as case management, social work, and housing and food service programs. Patients were also empowered to take control over their health while knowing that health care providers cared about their well-being.

Socioeconomic status and in-hospital outcomes for patients undergoing heart transplantation or ventricular assist device implantation.

INTRODUCTION: Although lower socioeconomic status (SES) has been associated with worse in-hospital outcomes among patients with heart failure, the in-hospital outcomes for patients undergoing durable Left Ventricular Assist Device (LVAD) implantation or Heart Transplantation (HT) based on SES have not been well characterized. METHODS: We analyzed data from the National Inpatient Sample of hospitalizations between January 2016 and December 2020 of patients aged 18 and over who underwent a HT or newly implanted LVAD. Quartile classification of the median household income of the patient's residential zip code was used to estimate SES. Multivariable analyses with logistic and linear regression were used to evaluate the effects of SES on inpatient outcomes including inpatient mortality, length of stay, and key inpatient complications. RESULTS: A total of 16,265 weighted hospitalizations for new LVAD implantation and 14,320 weighted hospitalizations for HT were identified. In multivariable analysis, among patients undergoing HT or LVAD implantation respectively, there were no significant differences between the lowest and highest SES quartiles among important in-hospital outcomes including length of stay (adj B-coeff .56, (-3.59)-(4.71), p = .79 and adj B-coeff 2.40, (-.21)-(5.02), p = .07) and mortality (aOR 1.02, .61-1.70, p = .94 and aOR 1.08, .72-1.62, p = .73). There were also no differences based on SES quartile in important inpatient complications including stroke and cardiac arrest. CONCLUSION: In this analysis from the National Inpatient Sample, we demonstrate that SES, evaluated by median zip code income, was not associated with important in-hospital metrics including mortality and length of stay among patients undergoing LVAD or HT.

Association Between Coronary Assessment in Heart Failure and Clinical Outcomes Within a Safety-Net Setting Using a Target Trial Emulation Observational Design.

BACKGROUND: Ischemic cardiomyopathy is the leading cause of heart failure (HF). Most patients do not undergo coronary assessment after HF diagnosis. There are no randomized clinical trials of coronary assessment after HF diagnosis. METHODS: Using an electronic health record cohort of all individuals with HF within the San Francisco Health Network from 2001 to 2019, we identified factors associated with coronary assessment. Then, we studied the association of coronary assessment within 30 days of HF diagnosis with all-cause mortality and a composite of mortality and emergent angiography using a target trial emulation observational comparative-effectiveness approach. Target trial emulation is an approach to causal inference based on creating a hypothetical randomized clinical trial protocol and using observational data to emulate the protocol. We used propensity scores for covariate adjustment. We used national death records to improve the ascertainment of mortality and included falsification end points for the cause of death. RESULTS: Among 14 829 individuals with HF (median, 62 years old; 5855 [40%] women), 3987 (26.9%) ever completed coronary assessment, with 2467/13 301 (18.5%) with unknown coronary artery disease status at HF diagnosis assessed. Women, older individuals, and people without stable housing were less likely to complete coronary assessment. Among 5972 eligible persons of whom 627 underwent early elective coronary assessment, coronary assessment was associated with lower mortality (hazard ratio, 0.84 [95% CI, 0.72-0.97]; P=0.025), reduced risk of the composite outcome (hazard ratio, 0.86 [95% CI, 0.73-1.00]), higher rates of revascularization (odds ratio, 7.6 [95% CI, 5.4-10.6]), and higher use of medical therapy (odds ratio, 2.5 [95% CI, 1.7-3.6]), but not the falsification end points. CONCLUSIONS: In a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by coronary artery disease risk factors. Early coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and guideline-directed medical therapy but with low certainty that this finding is not attributable to unmeasured confounding.

Coronary Assessment in Heart Failure within a Safety-Net Setting: Disparities and Outcomes.

Background: Though ischemic cardiomyopathy is the leading cause of heart failure (HF), most patients do not undergo coronary assessment after heart failure diagnosis. In a safety-net population, referral patterns have not been studied, and it is unknown whether coronary assessment is associated with improved HF outcomes. Methods: Using an electronic health record cohort of all individuals with HF within San Francisco Health Network from 2001-2019, we identified factors associated with completion of coronary assessment (invasive coronary angiography, nuclear stress, or coronary computed tomographic angiography). Then we emulated a randomized clinical trial of elective coronary assessment with outcomes of all-cause mortality and a composite outcome of mortality and emergent angiography. We used propensity scores to account for differences between groups. We used national death records to improve ascertainment of mortality. Results: Among 14,829 individuals with HF (median 62 years old, 5,855 [40%] women), 3,987 (26.9%) ever completed coronary assessment, with 2,467 (18.5%) assessed out of 13,301 with unknown CAD status at HF diagnosis. Women and older individuals were less likely to complete coronary assessment, with differences by race/ethnicity, medical history, substance use, housing, and echocardiographic findings. Among 5,972 eligible for inclusion in the "target trial," 627 underwent early elective coronary assessment and 5,345 did not. Coronary assessment was associated with lower mortality (HR 0.84; 95% CI 0.72-0.97; p=0.025), reduced risk of the composite outcome, higher rates of revascularization, and higher use of medical therapy. Conclusions: In a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by CAD risk factors. Our target trial emulation suggests coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and GDMT use, but with low certainty that this is finding is not attributable to unmeasured confounding.

Bridge the Gap: Reducing Inequity in Hospital Readmissions for African American Patients with Heart Failure Through Quality Improvement Initiatives.

Purpose: Heart failure (HF) disproportionately impacts African Americans. We evaluated existing quality improvement (QI) initiatives and patient and provider perceptions of barriers to HF care to develop equity-centered QI recommendations. Methods: We performed a literature review, interviewed providers and patients (N=11), and conducted a root cause analysis at a safety net hospital in San Francisco, California. Results: We have identified four elements to foster a more equitable HF care model: screening for social determinants of health, technological innovation, optimization of space, and implicit bias training. Conclusion: QI initiatives for HF should integrate health equity elements in their design and implementation.

All-Payer Analysis of Heart Failure Hospitalization 30-Day Readmission: Comorbidities Matter.

BACKGROUND: Thirty-day readmission following heart failure hospitalization impacts hospital performance measures and reimbursement. We investigated readmission characteristics and the magnitude of 30-day hospital readmissions after hospital discharge for heart failure using the Healthcare Cost and Utilization Project State Inpatient Databases (SID). METHODS: Adults aged ≥ 40 years hospitalized with a primary discharge diagnosis of heart failure from 2007-2011 were identified in the California, New York, and Florida SIDs. Characteristics of patients with and without 7-, 8 to 30-, and 30-day readmission, and primary readmission diagnoses and risk factors for readmission were examined. RESULTS: We identified 547,068 patients with mean age 74.7 years; 50.7% were female, and 65.4% were White. Of 117,123 patients (21.4%) readmitted within 30 days (median 12 days), 69.7% had a non-heart failure primary readmission diagnosis. Patients with 30-day readmissions more frequently had a history of previous admission with heart failure as a secondary diagnosis, fluid and electrolyte disorders, and chronic deficiency anemia. There were no significant clinical differences at baseline between those patients whose first readmission was in the first 7 days after discharge vs in the next 23 days. The most common primary diagnoses for 30-day non-heart failure readmissions were other cardiovascular conditions (14.9%), pulmonary disease (8.5%), and infections (7.7%). CONCLUSIONS: In this large all-payer cohort, ∼70% of 30-day readmissions were for non-heart failure causes, and the median time to readmission was 12 days. Future interventions to reduce readmissions should focus on common comorbid conditions that contribute to readmission burden.

Progressive degradation and subsequent refinement of acoustic representations in the adult auditory cortex.

Correlated neuronal activity is believed to play an important role in refining and maintaining cortical circuitry during early development. Here we provide evidence that globally and locally correlated activity mediate different forms of adult plasticity. Pulses of broad-spectrum noise were used to activate time-locked responses across large areas of the rat auditory cortex, globally synchronizing cortical activity. Brief tone pips were used to activate relatively small groups of neurons, generating locally correlated activity. Pairing pulsed noises with nucleus basalis (NB) stimulation in awake rats for 4 weeks broadened spectral tuning, disrupted tonotopic maps, and reduced spontaneous discharge correlation in the primary auditory cortex (AI), as examined under anesthesia. Those effects caused AI neurons to appear qualitatively similar to neurons in nonprimary auditory fields of naive animals. Subsequent pairing of tone pips with NB stimulation for a period of 4 weeks completely reversed these effects induced by previous noise-NB pairing. These findings further demonstrate that the adult auditory cortex retains a substantial capacity for receptive field plasticity and tonotopic map reorganization and that locally correlated activity plays an important role in plasticity in the adult, as in the developing cortex.

Adenosine A2A analogue reduces long-term neurologic injury after blunt spinal trauma.

BACKGROUND: ATL-146e is an adenosine A(2A) agonist that has recently been demonstrated to improve neurological outcome in spinal cord injury in animals. In the current study, we extended the treatment paradigm and tested neurobehavioral functioning out to 1 week after injury to assess if early neurological improvement is sustained long term by an adenosine analogue. MATERIALS AND METHODS: New Zealand White rabbits (3.0-3.5 kg) sustained mid-thoracic blunt spinal cord injury using a weight-drop model (10 g weight dropped from 6 cm directly onto dura). Animals received either (1) 3 h iv infusion of saline carrier (Trauma, N = 21); (2) 3 h iv infusion of 0.06 microg/kg/min ATL-146e followed by intraperitoneal bolus of 10.8 microg/kg ATL-146e at 3 h postinjury (ATL, N = 14); or (3) 3 h iv infusion of 0.06 microg/kg/min ATL-146e followed by intraperitoneal bolus injection of 10.8 microg/kg ATL-146e at 3, 12, and 24 h postinjury (ATL-PLUS, N = 11). Fourteen animals underwent sham injury. Hemodynamic parameters were monitored and hind limb motor functioning was assessed by Tarlov scores (0 = paralyzed to 5 = normal hop) for 7 days after injury. RESULTS: ATL-146e significantly improved Tarlov scores of ATL-146e groups compared with saline-treated controls (P < 0.01 12, 24, 36, and 48 h). Control animals, severely neurologically impaired at 48 h (Tarlov 1.61 +/- 0.35), were euthanized early due to ethical concerns, thus not permitting later statistical comparisons. Early neurological improvements in both ATL-146e-treated groups were sustained longer term (7 day mean Tarlov, SHAM 4.9 +/- 0.30, ATL 5.0 +/- 0, ATL-PLUS 4.25 +/- 0.31). CONCLUSIONS: ATL-146e given immediately after blunt spinal cord trauma significantly improves neurological outcome, which is sustained through 7 days. Early adenosine A2A receptor agonism may be critical since additional IP administration afforded no further neurological improvement. The current data further support the potential clinical utility of adenosine A(2A) agonists in the treatment of spinal cord injury.