Six Months of Remote Patient Monitoring Is Associated with Blood Pressure Reduction in Hypertensive Patients: An Uncontrolled Observational Study.

Background: Remote physiological monitoring (RPM) is a form of telehealth that measures vital signs at home and automatically reports the results to providers, thereby possibly improving chronic disease management. Medicare payment for RPM began in 2019. Two potential obstacles to RPM growth are the paucity of published clinical outcomes data and the Medicare requirement that monitoring be done at least 16 days per month to bill for the service. To help address these issues, we report the following uncontrolled observational study. Methods: A total of 1,102 consecutive patients enrolled in RPM were divided into four groups based on initial average mean arterial pressure (MAP) and into six groups based on the number of days per month MAP was measured. We report changes in MAP after 6 months of RPM as a function of initial MAP, and number of days per month MAP was monitored. Results: After 6 months of RPM, average MAP dropped from 97 to 93 (p < 0.01). This drop was greatest in the 50% of patients initially hypertensive. These patients saw average MAP reductions from 106 to 97 (p < 0.001) and became normotensive. Although MAP reduction was greatest the more frequently patients measured, significant reduction occurred in the hypertensive patients whether they measured more or less than 16 days per month (p < 0.001). No minimum threshold of measurements was found that predicted failure of RPM to lower MAP. Conclusions: RPM is associated with clinically and statistically significant reductions in average MAP in patients who were initially hypertensive. This benefit occurred irrespective of the number of days per month patients measured MAP.

Early Initiation of non-invasive ventilation at home improves survival and reduces healthcare costs in COPD patients with chronic hypercapnic respiratory failure: A retrospective cohort study.

BACKGROUND: While non-invasive ventilation at home (NIVH) is gaining wider acceptance as a treatment option for chronic obstructive pulmonary disease with chronic respiratory failure (COPD-CRF), uncertainty remains about the optimal time to begin NIVH, whether a specific phenotype of COPD-CRF predicts improved outcomes, and how NIVH affects healthcare costs. MATERIALS AND METHODS: Using 100% research identifiable fee-for-service Medicare claims from 2016 through 2020, we designed an observational, retrospective, cohort study to determine how NIVH use in COPD-CRF patients stratified by CRF phenotype and by timing of initiation affected mortality, healthcare utilization, and total healthcare costs compared to a matched control group. RESULTS: In hypercapnic COPD-CRF patients starting NIVH within the first week following diagnosis, risk of death was reduced by 43% (HR, 0.57; 95% CI 0.51-0.63, p < .0001), those starting 8-15 days following diagnosis had mortality reduction of 31% (HR, 0.69; 95% CI 0.62-0.77, p < .0001), and those starting 16-30 days following diagnosis showed mortality reduction of 16% (HR 0.84, CI 0.073-0.096, p < .01) compared to controls. Medicare spending was also associated with timing of NIVH initiation in hypercapnic COPD-CRF. Those beginning treatment 0-7 days and 0-15 days following diagnosis had a $5484 and a $3412 reduction in Medicare expenditures respectively the next year. NIVH was not associated with improved clinical outcomes or decreased Medicare spending in COPD-CRF patients who were not hypercapnic. CONCLUSION: In this study, early initiation of NIVH for hypercapnic COPD-CRF patients was associated with reductions in the risk of death and in total Medicare spending.

Non-invasive ventilation at home improves survival and decreases healthcare utilization in medicare beneficiaries with Chronic Obstructive Pulmonary Disease with chronic respiratory failure.

BACKGROUND: Patients with Chronic Obstructive Pulmonary Disease with chronic respiratory failure (COPD-CRF) experience high mortality and healthcare utilization. Non-invasive home ventilation (NIVH) is increasingly used in such patients. We examined the associations between NIVH and survival, hospitalizations, and emergency room (ER) use in COPD-CRF Medicare beneficiaries. MATERIALS AND METHODS: Retrospective cohort study using the Medicare Limited Data Set (2012-2018). Patients receiving NIVH within two months of CRF diagnosis (treatment group) were matched on demographic and clinical characteristics to patients never receiving NIVH (control group). CRF diagnosis was identified using ICD-9-CM/ICD-10-CM codes. Time to death, first hospitalization, and first ER visit were estimated using Cox regressions. RESULTS: After matching, 517 patients receiving NIVH and 511 controls (mean age: 70.6 years, 44% male) were compared. NIVH significantly reduced risk of death (aHR: 0.50; 95%CI: 0.36-0.65), hospitalization (aHR: 0.72; 95%CI: 0.52-0.93), and ER visit (aHR: 0.48; 95%CI: 0.38-0.58) at diagnosis. The NIVH risk reduction became smaller over time for mortality and ER visits, but continued to accrue for hospitalizations. One-year post-diagnosis, 28% of treated patients died versus 46% controls. For hospitalizations and ER visits, 55% and 72% treated patients experienced an event, respectively, versus 67% and 92% controls. The relative risk reduction was 39% for mortality, 17% for hospitalizations, and 22% for ER visits. Number needed to treat were 5.5, 9, and 5 to prevent a death, hospitalization, or ER visit one-year post-diagnosis, respectively. CONCLUSION: NIVH treatment is associated with reduced risk of death, hospitalizations, and ER visits among COPD-CRF Medicare beneficiaries.

Office-based laryngeal laser surgery: a review of 443 cases using three wavelengths.

BACKGROUND: Unsedated office-based laser surgery (UOLS) of the larynx and trachea has significantly improved the treatment options for patients with laryngotracheal pathology including recurrent respiratory papillomas, granulomas, leukoplakia, and polypoid degeneration. UOLS delivered by flexible endoscopes has dramatically impacted office-based surgery by reducing the time, costs, and morbidity of surgery. OBJECTIVES: To review our experience with 443 laryngotracheal cases treated by UOLS. METHODS: The laser logbooks at the Center for Voice and Swallowing Disorders were reviewed for UOLS, and the medical and laryngological histories were detailed, as were the treatment modalities, frequencies, and complications. RESULTS: Of the 443 cases, 406 were performed with the pulsed-dye laser, 10 with the carbon-dioxide laser, and 27 with the thulium: yttrium-aluminum-garnet laser. There were no significant complications in this series. A review of indications and wavelength selection criteria is presented. CONCLUSION: Unsedated, office-based, upper aerodigestive tract laser surgery appears to be a safe and effective treatment option for many patients with laryngotracheal pathology.

Age as an independent risk factor for severity of experimental choroidal neovascularization.

PURPOSE: For many vascular diseases, aging appears to be an independent risk factor for severity of vascular complications, and blood vessels of aged individuals often demonstrate exaggerated repair responses to injury. This study was undertaken to determine the influence of aging on the severity of neovascularization in a mouse model of laser-induced choroidal neovascularization (CNV). METHODS: CNV was induced in young (2-month-old) and aged (16-month-old) C57BL/6 mice by making four separate choroidal burns in each eye with a diode red laser (650 nm). At 1, 2, and 4 weeks, the left eyes were removed for histopathology, and the right eyes were removed for flatmount analysis of CNV surface area, vascularity, and cellularity. RESULTS: Aged mice demonstrated a much larger area of CNV than did young mice (3.81 +/- 1.28 vs. 1.36 +/- 0.99 disc areas, P < 0.001) at 2 weeks, when the lesions showed maximum growth. Aged mice also demonstrated higher ratios for vascularity and cellularity of the CNV (1.34 +/- 0.06 vs. 1.03 +/- 0.11, P < 0.0001 and 4.06 +/- 1.19 vs. 1.91 +/- 0.81, P < 0.002 at 2 weeks, respectively). Histopathology revealed that CNV in older eyes was larger, thicker, and more cellular than in young eyes. CONCLUSIONS: In mice, age is associated with more severe CNV, defined as larger surface area, greater vascularity, and greater cellularity. Age-related systemic susceptibility factors, independent of local changes in the retina, may contribute to the greater severity of CNV in older than in younger individuals.