The Preimplantation Psychosocial Evaluation and Prediction of Clinical Outcomes During Mechanical Circulatory Support: What Information Is Most Prognostic?

BACKGROUND: Psychosocial evaluations are required for long-term mechanical circulatory support (MCS) candidates, no matter whether MCS will be destination therapy (DT) or a bridge to heart transplantation. Although guidelines specify psychosocial contraindications to MCS, there is no comprehensive examination of which psychosocial evaluation domains are most prognostic for clinical outcomes. We evaluated whether overall psychosocial risk, determined across all psychosocial domains, predicted outcomes, and which specific domains appeared responsible for any effects. METHODS: A single-site retrospective analysis was performed for adults receiving MCS between April 2004 and December 2017. Using an established rating system, we coded psychosocial evaluations to identify patients at low, moderate, or high overall risk. We similarly determined risk within each of 10 individual psychosocial domains. Multivariable analyses evaluated whether psychosocial risk predicted clinical decisions about MCS use (DT versus bridge), and postimplantation mortality, transplantation, rehospitalization, MCS pump exchange, and standardly defined adverse medical events (AEs). RESULTS: In 241 MCS recipients, greater overall psychosocial risk increased the likelihood of a DT decision (odds ratio, 1.76; P = 0.017); and postimplantation pump exchange and occurrence of AEs (hazard ratios [HRs] ≥ 1.25; P ≤ 0.042). The individual AEs most strongly predicted were cardiac arrhythmias and device malfunctions (HRs ≥ 1.39; P ≤ 0.032). The specific psychosocial domains predicting at least 1 study outcome were mental health problem severity, poorer medical adherence, and substance use (odds ratios and HRs ≥ 1.32; P ≤ 0.010). CONCLUSIONS: The psychosocial evaluation predicts not only clinical decisions about MCS use (DT versus bridge) but important postimplantation outcomes. Strategies to address psychosocial risk factors before or soon after implantation may help to reduce postimplantation clinical risks.

Remote monitoring for heart failure: Assessing the risks of readmission and mortality.

Study objective: Remote monitoring (RM) can help patients with heart failure (HF) remain free of hospitalization. Our objective was to implement a patient-centered RM program that ensured timely clinical response, which would be associated with reduced mortality. Design: This was a retrospective, observational, propensity-matched study. Setting: A large regional health system between 9/1/2016-1/31/2018. Participants: Patients admitted with acute HF exacerbation were matched on key variables. Up to two comparison patients were selected for each RM user. Interventions: We used an algorithmic approach to assess daily physiologic data, assess symptoms, provide patient education, encourage patient self-management, and triage medical problems. Main outcome measures: We assessed all-cause mortality using Kaplan-Meier and log rank analysis. We used Cox proportional hazards to compare risk of death. Results: Our cohort of 680 RM users and 1198 comparisons were similar across baseline characteristics except age (74.7 years versus 76.6 years, p < 0.001, respectively). Having one or more admissions in the preceding 120 days was more prevalent in the RM group (35.9% versus 29.8%, p = 0.013). The 30- and 90-day all-cause readmission rates were each higher among the RM users compared with the comparison patients (p = 0.013 and p < 0.001 for 30 and 90 days, respectively). Mortality was lower in the RM group at 30 and 90 days post-discharge (p < 0.001). Conclusions: RM that responds to biometric data and encourages patient self-management can be used in a large hospital system and is associated with decreased all-cause mortality. Our findings underscore RM technology as a method to improve HF care.