Evaluation of video visit appropriateness for common symptoms seen in primary care: A retrospective cohort study.

INTRODUCTION: Little is known about which conditions seen in primary care are appropriate for video visits. This study evaluated video visits compared to office visits for six conditions: abdominal pain, joint pain, back pain, headache, chest pain, and dizziness. METHODS: Six hundred charts of adult patients from our institution's same-day outpatient clinic were reviewed in this study. Charts for video visits evaluating the aforementioned chief complaints that occurred between August and October 2020 were reviewed and compared with charts for office visits that occurred from August to September 2019. Frequencies of 3-week follow-up visits, Emergency Room visits, imaging, and referrals for office and video visits were measured. Reasons for in-person evaluation for patients seen by video were determined by review of clinician notes. RESULTS: Three-week in-person follow-up was more frequent for patients presenting with chest pain (52% vs 18%, p = 0.0007) and joint pain (24% vs 8%, p = 0.05) after video evaluation, relative to an office evaluation. Three-week in-person follow-up was also more frequent for patients presenting with dizziness (38% vs 28%) and low back pain (24% vs 14%); however, this difference was not statistically significant. Patients presenting with headache and abdominal pain did not have a higher rate of follow-up. DISCUSSION: Based on the frequency of in-person follow-up, this study suggests that video visits are generally adequate for evaluating headache and abdominal pain. Patients with dizziness and chest pain have the highest frequency of in-person and Emergency Room follow-up within 3 weeks when first seen by video compared to other conditions evaluated and may be less suitable for an initial video visit. Institutions can consider these findings when scheduling and providing guidance to patients on what type of visit is most appropriate for their symptoms.

An initiative to promote value-based stress test selection in primary care and cardiology clinics: A mixed methods evaluation.

OBJECTIVES: Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics. METHODS: Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2. RESULTS: Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001). CONCLUSIONS: This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.

Association of Neighborhood Income with Clinical Outcomes Among Pregnant Patients with Cardiac Disease.

Cardiovascular disease is the leading cause of pregnancy mortality. Socioeconomic and racial disparities in pregnancy are well established. Despite this, little is known about the impact of social determinants of health in pregnant patients with heart disease. This study aims to determine whether pregnant patients with heart disease living in lower income neighborhoods and managed at cardio-obstetrics programs have higher rates of cardiac events or preterm deliveries compared with those living in higher income neighborhoods. This is a retrospective cohort study of 206 patients between 2010 and 2020 at a quaternary care hospital in Northern California. The exposure was household income level based on neighborhood defined by the US Census data. Patients in lower income neighborhoods (N = 103) were 45% Hispanic, 34% White, and 14% Asian versus upper income neighborhoods (N = 103), which were 48% White, 31% Asian, and 12% Hispanic (p < 0.001). There was no significant difference in the rates of intrapartum cardiac events (10% vs. 4%; p = 0.16), postpartum cardiac events (14% vs. 17%; p = 0.7), and preterm delivery (24% vs. 17%; p = 0.23). The rates of antepartum hospitalization were higher for lower income neighborhoods (42% vs 22%; p = 0.004). While there is no significant difference in cardiac events and preterm delivery rates between patients from low versus high income neighborhoods, patients from lower income neighborhoods have higher antepartum hospitalization rates. Earlier identification of clinical deterioration provided by a cardio-obstetrics team may contribute to increased hospitalizations, which might mitigate socioeconomic disparities in outcomes for these pregnant patients with heart disease.

Bicuspid Aortic Valve and Ascending Aortic Aneurysm in a Twin Pregnancy.

Bicuspid aortic valve with ascending aortic aneurysm is a common condition encountered in pregnancy. There are limited data on how to manage these patients. To our knowledge, we report the only case of a bicuspid aortic valve and aortic aneurysm with twin gestations. (Level of Difficulty: Intermediate.).

Psychological Distress Among Female Cardiac Patients Presenting to a Women's Heart Health Clinic.

Female cardiac patients are at greater risk for mental health disorders than their male counterparts, and these mental health disorders have been associated with increased cardiac morbidity and mortality. However, few studies have closely examined the mental health disorders found among the female cardiac population. The primary aim of this study was to examine the prevalence of psychological distress in a sample of female cardiac outpatients at an academic medical center. A secondary aim was to determine whether different demographic variables, cardiac risk factors, or cardiac diagnoses were associated with different levels of emotional distress. A survey, including demographic information, medical status, and standardized symptom measures was completed by 117 female patients scheduled for medical visits at an outpatient women's heart health clinic over a 4-month period. Using standardized self-report questionnaires, 38% scored in the moderate-to-severe range for at least 1 mental disorder and 50% endorsed current insomnia. Symptoms of clinical depression (20%) and anxiety (42)% were endorsed at higher rates than predominantly male or mixed comparison samples. Although there was no apparent relation between the severity of cardiac problems and the degree of psychological distress, women with diagnoses of hyperlipidemia, prediabetes, and diabetes reported greater psychological distress than those without these problems. Women with lower income also reported more psychological distress. In conclusion, our findings suggest an unmet need for integrated mental health services for female cardiac patients.

Breastfeeding Duration and the Risk of Coronary Artery Disease.

BACKGROUND: Previous studies have suggested that prolonged breastfeeding has beneficial effects on the health of the mother including the reduction of long-term risk of coronary artery disease (CAD). The mechanism of this association remains unclear. METHODS: We surveyed 643 women aged 40-65 years receiving outpatient care at Stanford University Hospital on their reproductive/lactation history, including 137 women (cases) with clinically confirmed CAD. Survey data were supplemented with traditional risk factor data for CAD obtained from the participant's medical record. We then conducted logistic regression analyses to assess the relationship between breastfeeding duration and case-control status for each of the two separate definitions of duration. The first was based on the participant's single longest duration of breastfeeding considering all live births reported and the second was based on a participant's total duration of breastfeeding summed over all live births. For each of these two definitions, we ran three sequential models each with a different reference group-(1) nulliparous women, (2) parous women that never breastfed, and (3) parous women with a short duration of breastfeeding-successively excluding women in the reference group of the previous model(s). RESULTS: Just over one-half (51.6%) of the women surveyed reported a history of breastfeeding. We found nominally significant associations (p = 0.04-0.12) for our multivariate analyses that modeled maximum duration of breastfeeding. When compared with nulliparous women, parous women who either never breastfed or always breastfed for <5 months had approximately double the risk of CAD. Among parous women, women who breastfeed for ≥5 months at least once in their lifetime had a ∼30% decrease risk of CAD compared with those who did not initiate breastfeeding. Among parous women who breastfed ≥1 month, women who breastfed ≥5 months had ∼50% decreased risk of CAD. We found similar point estimates of effect for analogous analyses modeling maximum breastfeeding duration but p-values for these analyses were not significant. Unadjusted analyses demonstrated higher valued odds ratios and lower p-values suggesting the presence of some confounding by traditional risk factors. CONCLUSIONS: Parous women who breastfeed ≥5 months in at least one pregnancy seem to be at decreased risk of CAD later in their life, whereas parous women who either never breastfed or discontinued breastfeeding early seem to be at increased risk. More research is needed to more reliably quantify and determine the nature of the relationship between parity, breastfeeding duration, and risk of CAD.

Association of triglyceride to HDL cholesterol ratio with cardiometabolic outcomes.

Electronic medical records (EMRs) offer a potential opportunity to identify patients at high risk for cardiometabolic disease, which encompasses type 2 diabetes and cardiovascular disease (CVD). The objective of this retrospective cohort study is to use information gathered from EMR to investigate the association between triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C) and cardiometabolic outcomes in a general population of subjects over 50 years of age during a follow-up period of 8-9 years. TG/HDL-C was recorded for each of 1428 subjects in 2008, and diagnoses of type 2 diabetes and CVD were recorded through chart review until 2017. Cox proportional hazards models controlling for demographic characteristics and other risk factors demonstrated that high TG/HDL-C (>2.5 in women or >3.5 in men) was significantly associated with increased incidence of type 2 diabetes (HR 1.66; 95% CI 1.07 to 2.57; p=0.0230). There was also a suggested association between high TG/HDL-C and incidence of CVD (HR 1.51; 95% CI 0.98 to 2.35; p=0.0628). These findings suggest that using TG/HDL-C, which can be easily calculated from data in an EMR, should be another tool used in identifying patients at high cardiometabolic risk.

Impact of a Genetic Risk Score for Coronary Artery Disease on Reducing Cardiovascular Risk: A Pilot Randomized Controlled Study.

PURPOSE: We tested whether providing a genetic risk score (GRS) for coronary artery disease (CAD) would serve as a motivator to improve adherence to risk-reducing strategies. METHODS: We randomized 94 participants with at least moderate risk of CAD to receive standard-of-care with (N = 49) or without (N = 45) their GRS at a subsequent 3-month follow-up visit. Our primary outcome was change in low density lipoprotein cholesterol (LDL-C) between the 3- and 6-month follow-up visits (ΔLDL-C). Secondary outcomes included other CAD risk factors, weight loss, diet, physical activity, risk perceptions, and psychological outcomes. In pre-specified analyses, we examined whether there was a greater motivational effect in participants with a higher GRS. RESULTS: Sixty-five participants completed the protocol including 30 participants in the GRS arm. We found no change in the primary outcome between participants receiving their GRS and standard-of-care participants (ΔLDL-C: -13 vs. -9 mg/dl). Among participants with a higher GRS, we observed modest effects on weight loss and physical activity. All other secondary outcomes were not significantly different, including anxiety and worry. CONCLUSION: Adding GRS to standard-of-care did not change lipids, adherence, or psychological outcomes. Potential modest benefits in weight loss and physical activity for participants with high GRS need to be validated in larger trials.

Association of the Cardiometabolic Staging System with Individual Engagement and Quality of Life in the US Adult Population.

OBJECTIVE: The aim of this study was to examine the relationships of Cardiometabolic Disease Staging (CMDS), a validated five-stage system for assessing risk for diabetes, cardiovascular mortality, and all-cause mortality, with measures of individual engagement and health-related quality of life (HRQOL) in the US adult population. METHODS: Data from the 2011-2014 National Health and Nutrition Examination Survey were used to derive the CMDS stages, five participant engagement measures, and four HRQOL measures among adult participants ≥ 40 years of age. Analyses accounted for the complex sampling design and sample weights. RESULTS: Higher CMDS was associated with greater participant awareness of cardiometabolic risk, but after adjusting for covariates, only Stage 4 remained significant (odds ratio: 5.08; 95% CI: 3.25, 7.94). Higher CMDS was associated with receiving recommendations to engage in a healthy lifestyle, not meeting 2008 physical activity guidelines, and fewer leisure time moderate activities after controlling for covariates. For HRQOL measures, Stage 4 was associated with a higher likelihood of perceiving health as fair or poor (odds ratio: 4.85; 95% CI: 2.42, 9.73). CONCLUSIONS: Higher CMDS was associated with greater individual awareness of risk, less leisure time physical activity, and worse self-rated health. CMDS is a clinically practical method for identifying individuals for targeted preventive strategies.

Hypertensive Disorders of Pregnancy.

PURPOSE OF REVIEW: Although pregnancy-related deaths are rare in the USA, they are on the rise and have more than doubled in the last 20 years. A substantial portion of these deaths are related to cardiovascular disease, specifically hypertensive disorders of pregnancy (HDP). In this review, we will discuss the definitions and proposed pathophysiology of HDP as well as its potential role in cardiovascular morbidity and mortality. RECENT FINDINGS: Placental hypoperfusion may lead to an imbalance in proangiogenic and antiangiogenic factors, notably an increase in soluble fms-like tyrosine kinsase-1 (sFlt-1), thereby leading to endothelial dysfunction. Progress has been made in terms of determining the factors which lead to preeclampsia. Potential novel biomarkers for predicting preeclampsia risk have been identified through this research. Preeclampsia not only has important implications for the health during pregnancy but also for future cardiovascular risk. However, the exact mechanism by which it increases cardiovascular risk and the degree of risk it portends are yet to be elucidated.

Gender Differences in Weight-Related Attitudes and Behaviors Among Overweight and Obese Adults in the United States.

Few studies have used nationally representative data to focus specifically on gender differences in weight-related outcomes. This article examines gender differences in weight-related outcomes across the body mass index (BMI) spectrum in overweight and obese adults. Data from the National Health and Nutrition Examination Survey 2009-2010 was analyzed. Weight-related outcomes were accurate weight perception, weight dissatisfaction, attempted weight loss, successful weight loss, and weight loss strategies. Compared with women, overweight and obese men were less likely to have accurate weight perception (odds ratio [OR] = 0.36; 95% confidence interval [CI] = 0.30-0.44), weight dissatisfaction (OR = 0.39; 95% CI = 0.32-0.47), and attempted weight loss (OR = 0.55; 95% CI = 0.48-0.63). The modifying effect of gender on these associations decreased as BMI increased. By BMI 35, the mean probability of women and men to have accurate weight perception and weight dissatisfaction was 90%; attempted weight loss was 60% (women) and 50% (men). At lower BMIs, men had up to 40% less probability than women for these weight loss outcomes. Men who attempted weight loss were more likely than women to lose and maintain ≥10 lb over 1 year (OR = 1.41; 95% CI = 1.20-1.65) and increase exercise and eat less fat as weight loss strategies; women were more likely to join weight loss programs, take prescription diet pills, and follow special diets. A need exists for male-specific interventions to improve overweight and obese men's likelihood for accurate weight perception, attempted weight loss, and ultimately, successful weight loss.

Trends in menopausal hormone therapy use of US office-based physicians, 2000-2009.

OBJECTIVE: The aim of this study was to evaluate recent trends and the adoption of practice recommendations for menopausal hormone therapy (MHT) use from 2001 to 2009 by formulation, dose, woman's age, and characteristics of physicians reporting MHT visits. METHODS: The IMS Health (Plymouth Meeting PA) National Disease and Therapeutic Index physician survey data from 2001 to 2009 were analyzed for visits in which MHT use was reported by US office-based physicians. Estimated national volume of visits for which MHT use was reported. RESULTS: MHT use declined each year since 2002. Systemic MHT use fell from 16.3 million (M) visits in 2001 to 6.1 M visits in 2009. Declines were greatest for women 60 years or older (64%) but were also substantial for women younger than 50 years (59%) and women 50 to 59 years old (60%). Women 60 years or older accounted for 37% of MHT use. Lower dose product use increased modestly, from 0.7 M (2001) to 1.3 M (2009), as did vaginal MHT use, from 1.8 M (2001) to 2.4 M (2009). Declines in continuing systemic MHT use (65%) were greater than for newly initiated MHT use (51%). Compared with other physicians, obstetrician/gynecologists changed their practices less, thereby increasing their overall share of total MHT visits from 72% (2001) to 82% (2009). CONCLUSIONS: Total MHT use has steadily declined. Increased use of lower dose and vaginal products reflects clinical recommendations. Uptake of these products, however, has been modest, and substantial use of MHT continues in older women.