Clinical Impact of Routine Assessment of Patient-Reported Health Status in Heart Failure Clinic: The PRO-HF Trial.

BACKGROUND: The impact of routine clinic use of patient-reported outcome (PRO) measures on clinical outcomes in patients with heart failure (HF) has not been well-characterized. We tested if clinic-based use of a disease-specific PRO improves patient-reported quality of life at 1 year. METHODS: The PRO-HF trial (Patient-Reported Outcome Measurement in Heart Failure Clinic) was an open-label, parallel, patient-level randomized clinical trial of routine PRO assessment or usual care at an academic HF clinic between August 30, 2021, and June 30, 2022, with 1 year of follow-up. In the PRO assessment arm, participants completed the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) at each HF clinic visit, and results were shared with their treating clinician. The usual care arm completed the KCCQ-12 at randomization and 1 year later, which was not shared with the treating clinician. The primary outcome was the KCCQ-12 overall summary score (OSS) between 12 and 15 months after randomization. Secondary outcomes included domains of the KCCQ-12, hospitalization and emergency department visit rates, HF medication therapy, clinic visit frequency, and testing rates. RESULTS: Across 17 clinicians, 1248 participants were enrolled and randomized to PRO assessment (n=624) or usual care (n=624). The median age was 63.9 years (interquartile range [IQR], 51.8-72.8), 38.9% were women, and the median baseline KCCQ-12 OSS was 82.3 (IQR, 58.3-94.8). Final KCCQ-12 (available in 87.9% of the PRO arm and 85.1% in usual care; P=0.16) median OSS were 87.5 (IQR, 68.8-96.9) in the PRO arm and 87.6 (IQR, 69.7-96.9) in the usual care arm with a baseline-adjusted mean difference of 0.2 ([95% CI, -1.7 to 2.0]; P=0.85). The results were consistent across prespecified subgroups. A post hoc analysis demonstrated a significant interaction with greater benefit among participants with a baseline KCCQ-12 OSS of 60 to 80 but not in less or more symptomatic participants. No significant differences were found in 1-year mortality, hospitalizations, emergency department visits, medication therapy, clinic follow-up, or testing rates between arms. CONCLUSIONS: Routine PRO assessment in HF clinic visits did not impact patient-reported quality of life or other clinical outcomes. Alternate strategies and settings for embedding PROs into routine clinical care should be tested. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04164004.

Uptake of Sodium-Glucose Cotransporter-2 Inhibitors in Hospitalized Patients With Heart Failure: Insights From the Veterans Affairs Healthcare System.

BACKGROUND: The use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in Veterans Affairs (VA) patients hospitalized with heart failure (HF) has not been reported previously. METHODS: VA electronic health record data were used to identify patients hospitalized for HF (primary or secondary diagnosis) from 01/2019-11/2022. Patients with SGLT2i allergy, advanced/end-stage chronic kidney disease (CKD) or advanced HF therapies were excluded. We identified factors associated with discharge SGLT2i prescriptions for patients hospitalized due to HF in 2022. We also compared SGLT2i and angiotensin receptor-neprilysin inhibitor (ARNI) prescription rates. Hospital-level variations in SGLT2i prescriptions were assessed via the median odds ratio. RESULTS: A total of 69,680 patients were hospitalized due to HF; 10.3% were prescribed SGLT2i at discharge (4.4% newly prescribed, 5.9% continued preadmission therapy). SGLT2i prescription increased over time and was higher in patients with HFrEF and primary HF. Among 15,762 patients hospitalized in 2022, SGLT2i prescription was more likely in patients with diabetes (adjusted odds ratio [aOR] 2.27; 95% confidence interval [CI]: 2.09-2.47) and ischemic heart disease (aOR 1.14; 95% CI: 1.03-1.26). Patients with increased age (aOR 0.77 per 10 years; 95% CI: 0.73-0.80) and lower systolic blood pressure (aOR 0.94 per 10 mmHg; 95% CI: 0.92-0.96) were less likely to be prescribed SGLT2i, and SGLT2i prescription was not more likely in patients with CKD (aOR 1.07; 95% CI 0.98-1.16). The adjusted median odds ratio suggested a 1.8-fold variation in the likelihood that similar patients at 2 random VA sites were prescribed SGLT2i (range 0-21.0%). In patients with EF ≤ 40%, 30.9% were prescribed SGLT2i while 26.9% were prescribed ARNI (P < 0.01). CONCLUSION: One-tenth of VA patients hospitalized for HF were prescribed SGLT2i at discharge. Opportunities exist to reduce variation in SGLT2i prescription rates across hospitals and to promote its use in patients with CKD and older age.

Common brain regions with distinct patterns of neural responses during mentalizing about groups and individuals.

An individual has a mind; a group does not. Yet humans routinely endow groups with mental states irreducible to any of their members (e.g., "scientists hope to understand every aspect of nature"). But are these mental states categorically similar to those we attribute to individuals? In two fMRI experiments, we tested this question against a set of brain regions that are consistently associated with social cognition--medial pFC, anterior temporal lobe, TPJ, and medial parietal cortex. Participants alternately answered questions about the mental states and physical attributes of individual people and groups. Regions previously associated with mentalizing about individuals were also robustly responsive to judgments of groups, suggesting that perceivers deploy the same social-cognitive processes when thinking about the mind of an individual and the "mind" of a group. However, multivariate searchlight analysis revealed that several of these regions showed distinct multivoxel patterns of response to groups and individual people, suggesting that perceivers maintain distinct representations of groups and individuals during mental state inferences. These findings suggest that perceivers mentalize about groups in a manner qualitatively similar to mentalizing about individual people, but that the brain nevertheless maintains important distinctions between the representations of such entities.

Social influence modulates the neural computation of value.

Social influence--individuals' tendency to conform to the beliefs and attitudes of others--has interested psychologists for decades. However, it has traditionally been difficult to distinguish true modification of attitudes from mere public compliance with social norms; this study addressed this challenge using functional neuroimaging. Participants rated the attractiveness of faces and subsequently learned how their peers ostensibly rated each face. Participants were then scanned using functional MRI while they rated each face a second time. The second ratings were influenced by social norms: Participants changed their ratings to conform to those of their peers. This social influence was accompanied by modulated engagement of two brain regions associated with coding subjective value--the nucleus accumbens and orbitofrontal cortex--a finding suggesting that exposure to social norms affected participants' neural representations of value assigned to stimuli. These findings document the utility of neuroimaging to demonstrate the private acceptance of social norms.

Medial prefrontal cortex predicts intertemporal choice.

People often make shortsighted decisions to receive small benefits in the present rather than large benefits in the future, that is, to favor their current selves over their future selves. In two studies using fMRI, we demonstrated that people make such decisions in part because they fail to engage in the same degree of self-referential processing when thinking about their future selves. When participants predicted how much they would enjoy an event in the future, they showed less activity in brain regions associated with introspective self-reference--such as the ventromedial pFC (vMPFC)--than when they predicted how much they would enjoy events in the present. Moreover, the magnitude of vMPFC reduction predicted the extent to which participants made shortsighted monetary decisions several weeks later. In light of recent findings that the vMPFC contributes to the ability to simulate future events from a first-person perspective, these data suggest that shortsighted decisions result in part from a failure to fully imagine the subjective experience of one's future self.