Association between visit frequency, continuity of care, and pharmacy fill adherence in heart failure patients.

BACKGROUND: Despite advances in medical therapy for heart failure with reduced ejection fraction (HFrEF), major gaps in medication adherence to guideline-directed medical therapies (GDMT) remain. Greater continuity of care may impact medication adherence and reduced hospitalizations. METHODS: We conducted a cross-sectional study of adults with a diagnosis of HF and EF ≤40% with ≥2 outpatient encounters between January 1, 2017 and January 10, 2021, prescribed ≥1 of the following GDMT: 1) Beta Blocker, 2) Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker/Angiotensin Receptor Neprilysin Inhibitor, 3) Mineralocorticoid Receptor Antagonist, 4) Sodium Glucose Cotransporter-2 Inhibitor. Continuity of care was calculated using the Bice-Boxerman Continuity of Care Index (COC) and the Usual Provider of Care (UPC) index, categorized by quantile. The primary outcome was adherence to GDMT, defined as average proportion of days covered ≥80% over 1 year. Secondary outcomes included all-cause and HF hospitalization at 1-year. We performed multivariable logistic regression analyses adjusted for demographics, insurance status, comorbidity index, number of visits and neighborhood SES index. RESULTS: Overall, 3,971 individuals were included (mean age 72 years (SD 14), 71% male, 66% White race). In adjusted analyses, compared to individuals in the highest COC quartile, individuals in the third COC quartile had higher odds of GDMT adherence (OR 1.26, 95% CI 1.03-1.53, P = .024). UPC tertile was not associated with adherence (all P > .05). Compared to the highest quantiles, the lowest UPC and COC quantiles had higher odds of all-cause (UPC: OR 1.53, 95%CI 1.23-1.91; COC: OR 2.54, 95%CI 1.94-3.34) and HF (UPC: OR 1.81, 95%CI 1.23-2.67; COC: OR 1.77, 95%CI 1.09-2.95) hospitalizations. CONCLUSIONS: Continuity of care was not associated with GDMT adherence among patients with HFrEF but lower continuity of care was associated with increased all-cause and HF-hospitalizations.

Prospective Bidirectional Relationship Between Sleep Duration and Posttraumatic Stress Disorder Symptoms After Suspected Acute Coronary Syndrome.

OBJECTIVE: Sleep disturbance is a "hallmark" symptom of posttraumatic stress disorder (PTSD). Poor sleep (including short sleep) after combat-related trauma can also predict subsequent PTSD. Less is known about the association between sleep duration and PTSD symptoms when PTSD is induced by acute coronary syndrome (ACS). We examined the bidirectional relationship between sleep duration and PTSD symptoms over the year after hospital evaluation for ACS. METHODS: Participants were enrolled in this observational study after emergency department evaluation for ACS. Sleep duration ("During the past month, how many hours of actual sleep did you get at night?") and cardiac event or hospitalization-induced PTSD symptoms (PTSD Checklist) were assessed at 1, 6, and 12 months after hospital discharge. Cross-lagged path analysis was used to model the effects of sleep duration and PTSD symptoms on each other. Covariates included age, sex, race/ethnicity, cardiac severity, baseline depression symptoms, and early acute stress disorder symptoms. RESULTS: The sample included 1145 participants; 16% screened positive for probable PTSD (PTSD Checklist score ≥33). Mean sleep duration across time points was 6.1 hours. Higher PTSD symptoms predicted shorter sleep duration at the next time point (i.e., 1-6 and 6-12 months; B = -0.14 hours/10-point difference, SE = 0.03, p < .001). Shorter sleep duration was associated with higher PTSD symptoms at the next time point (B = -0.25 points/hour, SE = 0.12, p = .04). CONCLUSIONS: Short sleep duration and PTSD symptoms are mutually reinforcing across the first year after ACS evaluation. Findings suggest that sleep, PTSD symptoms, and their relationship should be considered in the post-ACS period.

Antihypertensive medication nonadherence and target organ damage in children with chronic kidney disease.

BACKGROUND: Nonadherence is common in children with chronic kidney disease (CKD). This may contribute to inadequate blood pressure control and adverse outcomes. This study examined associations between antihypertensive medication nonadherence, ambulatory blood pressure monitoring (ABPM) parameters, kidney function, and cardiac structure among children with CKD. METHODS: We performed secondary analyses of data from the CKD in Children (CKiD) study, including participants with treated hypertension who underwent ABPM, laboratory testing, and echocardiography biannually. Nonadherence was defined by self-report of any missed antihypertensive medication 7 days prior to the study visit. Linear regression and mixed-effects models were used to assess the association of nonadherence with baseline and time-updated ABPM profiles, estimated glomerular filtration rate (eGFR), urine protein to creatinine ratio (UPCR), and left ventricular mass index (LVMI). RESULTS: Five-hundred and eight participants met inclusion criteria, followed for a median of 2.9 years; 212 (42%) were female, with median age 13 years (IQR 10-16), median baseline eGFR 49 (33-64) ml/min/1.73 m2 and median UPCR 0.4 (0.1-1.0) g/g. Nonadherence occurred in 71 (14%) participants. Baseline nonadherence was not significantly associated with baseline 24-h ABPM parameters (for example, mean 24-h SBP [ß - 0.1, 95% CI - 2.7, 2.5]), eGFR (ß 1.0, 95% CI - 0.9, 1.2), UCPR (ß 1.1, 95% CI - 0.8, 1.5), or LVMI (ß 0.6, 95% CI - 1.6, 2.9). Similarly, there were no associations between baseline nonadherence and time-updated outcome measures. CONCLUSIONS: Self-reported antihypertensive medication nonadherence occurred in 1 in 7 children with CKD. We found no associations between nonadherence and kidney function or cardiac structure over time. A higher resolution version of the Graphical abstract is available as Supplementary information.

Impact of Native Language, English Proficiency, and Language Concordance on Interpersonal Care During Evaluation of Acute Coronary Syndrome.

BACKGROUND: High-quality interpersonal interactions between clinicians and patients can improve communication and reduce health disparities among patients with novice English proficiency (NEP). Yet, little is known about the impact of native language, NEP, and native language concordance on patient on perceptions of interpersonal care in the emergency department (ED). OBJECTIVE: To determine the associations of native language, NEP, and native language concordance with patient perceptions of interpersonal care among patients undergoing evaluation for suspected acute coronary syndrome (ACS) in the ED. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included 1000 patients undergoing evaluation for suspected ACS at an urban ED from 2013 to 2016. MAIN MEASURES: English- and Spanish-speaking patients were surveyed to identify native language, English proficiency (classified as advanced, intermediate, or novice), and perceived language of the treating ED clinician. Patient perceptions of interpersonal care were assessed using the Interpersonal Processes of Care (IPC) survey, a validated 18-item tool for assessing social-psychological domains of patient-clinician interactions. IPC scores ≤ 4 were categorized as sub-optimal (range, 1-5). The associations between native language, English proficiency, and native language concordance with sub-optimal communication were assessed using hierarchical logistic regression adjusted for all three language variables, sociodemographic characteristics, and depression. KEY RESULTS: Nine hundred thirty-three patients (48.0% native non-English-speaking, 55.7% Hispanic) completed the IPC; 522 (57.4%) perceived native language concordance. In unadjusted analyses, non-English native language (OR 1.38, 95% CI 1.04-1.82) and NEP (OR 1.45, 95% CI 1.06-1.98) were associated with sub-optimal communication, whereas language concordance was protective (OR 0.61, 95% CI 0.46-0.81). In fully adjusted analyses, only language concordance remained significantly associated with sub-optimal communication (AOR 0.62, 95% CI 0.42-0.93). CONCLUSIONS: This study suggests that perceived native language concordance acts as a protective factor for patient-clinician interpersonal care in the acute setting, regardless of native language or English proficiency.

Analysis of N-of-1 trials using Bayesian distributed lag model with autocorrelated errors.

An N-of-1 trial is a multi-period crossover trial performed in a single individual, with a primary goal to estimate treatment effect on the individual instead of population-level mean responses. As in a conventional crossover trial, it is critical to understand carryover effects of the treatment in an N-of-1 trial, especially when no washout periods between treatment periods are instituted to reduce trial duration. To deal with this issue in situations where a high volume of measurements are made during the study, we introduce a novel Bayesian distributed lag model that facilitates the estimation of carryover effects, while accounting for temporal correlations using an autoregressive model. Specifically, we propose a prior variance-covariance structure on the lag coefficients to address collinearity caused by the fact that treatment exposures are typically identical on successive days. A connection between the proposed Bayesian model and penalized regression is noted. Simulation results demonstrate that the proposed model substantially reduces the root mean squared error in the estimation of carryover effects and immediate effects when compared to other existing methods, while being comparable in the estimation of the total effects. We also apply the proposed method to assess the extent of carryover effects of light therapies in relieving depressive symptoms in cancer survivors.

Anhedonic Depression Is Not Associated With Risk of Recurrent Major Adverse Cardiac Events and All-Cause Mortality in Acute Coronary Syndrome Patients.

BACKGROUND: Depression after acute coronary syndrome (ACS) is common and increases risks of adverse outcomes, but it remains unclear which depression features are most associated with major adverse cardiac events (MACE) and all-cause mortality (ACM). PURPOSE: To examine whether a subtype of depression characterized by anhedonia and major depressive disorder (MDD) predicts 1-year MACE/ACM occurrence in ACS patients compared to no MDD history. We also consider other depression features in the literature as predictors. METHODS: Patients (N = 1,087) presenting to a hospital with ACS completed a self-report measure of current depressive symptoms in-hospital and a diagnostic interview assessing MDD within 1 week post-hospitalization. MACE/ACM events were assessed at 1-, 6-, and 12-month follow-ups. Cox regression models were used to examine the association of the anhedonic depression subtype and MDD without anhedonia with time to MACE/ACM, adjusting for sociodemographic and clinical covariates. RESULTS: There were 142 MACE/ACM events over the 12-month follow-up. The 1-year MACE/ACM in patients with anhedonic depression, compared to those with no MDD, was somewhat higher in an age-adjusted model (hazard ratio [HR] = 1.63, p = .08), but was not significant after further covariate adjustment (HR = 1.24, p = .47). Of the additional depression features, moderate-to-severe self-reported depressive symptoms significantly predicted the risk of MACE/ACM, even in covariate-adjusted models (HR = 1.72, p = .04), but the continuous measure of self-reported depressive symptoms did not. CONCLUSION: The anhedonic depression subtype did not uniquely predict MACE/ACM as hypothesized. Moderate-to-severe levels of total self-reported depressive symptoms, however, may be associated with increased MACE/ACM risk, even after accounting for potential sociodemographic and clinical confounders.

Skin Conductance Reactivity as a Predictor of Stroke-induced Posttraumatic Stress Disorder Symptoms: A Dimensional Approach.

Background: Posttraumatic stress disorder (PTSD) symptoms can develop following acute, life-threatening medical events. This study explores a potential biomarker of PTSD risk that is novel to a medical trauma population: a noninvasive, mobile skin conductance (SC) measurement. Methods: Participants (N=64) were enrolled in-hospital following a stroke or transient ischemic attack (TIA). Mobile measurement of SC reactivity to recalling the stroke/TIA traumatic event was conducted at hospital bedside in the days following the stroke/TIA. PTSD symptoms that developed in response to the stroke/TIA were measured at 1-month follow-up. We tested the association between SC reactivity and total 1-month PTSD symptoms, as well as PTSD symptom dimensions of fear and dysphoria. Results: In unadjusted analyses, there were significant positive associations between in-hospital SC reactivity to recalling the stroke/TIA traumatic event and higher-order fear-related symptoms (r=.30, p=.016), as well as lower-order fear-related symptoms of anxious arousal (r=.27, p=.035) and avoidance (r=.25, p=.043) at 1 month. Associations between SC reactivity and the fear, anxious arousal, and avoidance symptom dimensions remained significant in multivariable regression models that adjusted for relevant covariates including age, gender, stroke severity, medical comorbidity, and psychosocial factors. Although there was a positive association observed between SC reactivity to recalling the stroke/TIA event and total PTSD symptom severity at 1-month follow-up, it did not reach the level of statistical significance (r=.23, p=.070). Further, no significant association was detected for dysphoria-related symptoms (r=.11, p=.393). Conclusions: This is the first study to test the prospective association of SC reactivity with PTSD symptom development following a medical trauma. The findings indicate that mobile measures of SC reactivity may be useful for in-hospital identification of individuals at risk for fear-related PTSD symptom development following a medical event and highlight the potential mechanisms involved in the development of these symptoms following a medical event.

Telehealth After Stroke Care Pilot Randomized Trial of Home Blood Pressure Telemonitoring in an Underserved Setting.

BACKGROUND: Hypertension is the most important modifiable stroke risk factor, but blood pressure (BP) remains poorly controlled after stroke, especially among Black and Hispanic patients. We tested the feasibility of TASC (Telehealth After Stroke Care), a post-acute stroke care model integrating nurse-supported home BP telemonitoring, tailored infographics, and multidisciplinary team video visits. METHODS: Acute stroke patients with hypertension were randomized at discharge to usual care or usual care with TASC. Usual care patients received video visits with primary care and stroke. TASC included a tablet and monitor to wirelessly transmit BP data to the electronic health record, with telenursing support, tailored infographics to explain BP readings, and pharmacist visits. Outcomes assessment was blinded. Feasibility outcomes included recruitment, randomization, adherence, and retention. Systolic BP from baseline to 3 months after discharge was evaluated using generalized linear modeling. RESULTS: Fifty patients (64±14 years; 36% women' 44% Hispanic, 32% Black, 54% ≤high school education, 30% private insurance), and 75% of all eligible were enrolled over 6.3 months. Baseline systolic BP was similar in both (TASC n=25, 140±19 mm Hg; usual care n=25, 142±19 mm Hg). At 3 months, adherence to video visits (91% versus 75%, P=0.14) and retention (84% versus 64%, P=0.11) were higher with TASC. Home systolic BP declined by 16±19 mm Hg from baseline in TASC and increased by 3±24 mm Hg in usual care (P=0.01). Among Black patients, systolic BP control (<130 mm Hg) improved from 40% to 100% with TASC versus 14% to 29%, and among Hispanic patients, from 23% to 62% with TASC, versus 33% to 17% in usual care. CONCLUSIONS: Enhancing post-acute stroke care with home BP telemonitoring is feasible to improve hypertension in an underserved setting and should be tested in a definitive randomized clinical trial. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT04640519.

Factors associated with antihypertensive monotherapy among US adults with treated hypertension and uncontrolled blood pressure overall and by race/ethnicity, National Health and Nutrition Examination Survey 2013-2018.

BACKGROUND: Treating hypertension with antihypertensive medications combinations, rather than one medication (ie, monotherapy), is underused in the United States, particularly in certain race/ethnic groups. Identifying factors associated with monotherapy use despite uncontrolled blood pressure (BP) overall and within race/ethnic groups may elucidate intervention targets in under-treated populations. METHODS: Cross-sectional analysis of National Health and Nutrition Examination Surveys (NHANES; 2013-2014 through 2017-2018). We included participants age ≥20 years with hypertension, taking at least one antihypertensive medication, and uncontrolled BP (systolic BP [SBP] ≥ 140 mmHg or diastolic BP [DBP] ≥ 90 mmHg). Demographic, clinical, and healthcare-access factors associated with antihypertensive monotherapy were determined using multivariable-adjusted Poisson regression. RESULTS: Among 1,597 participants with hypertension and uncontrolled BP, age- and sex- adjusted prevalence of monotherapy was 42.6% overall, 45.4% among non-Hispanic White, 31.9% among non-Hispanic Black, 39.6% among Hispanic, and 50.9% among non-Hispanic Asian adults. Overall, higher SBP was associated with higher monotherapy use, while older age, having a healthcare visit in the previous year, higher body mass index, and having heart failure were associated with lower monotherapy use. CONCLUSION: Clinical and healthcare-access factors, including a healthcare visit within the previous year and co-morbid conditions were associated with a higher likelihood of combination antihypertensive therapy.

Association of Perceived Stress With Incident Heart Failure.

BACKGROUND: The relationship between psychological stress and heart failure (HF) has not been well studied. We sought to assess the relationship between perceived stress and incident HF. METHODS: We used data from the national REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a large prospective biracial cohort study that enrolled community-dwellers aged 45 years and older between 2003 and 2007, with follow-up. We included participants free of suspected prevalent HF who completed the Cohen 4-item Perceived Stress Scale (PSS-4). Our outcome variables were incident HF event, HF with reduced ejection fraction events, and HF with preserved ejection fraction events. We estimated Cox proportional hazard models to determine if PSS-4 quartiles were independently associated with incident HF events, adjusting for sociodemographics, social support, unhealthy behaviors, comorbid conditions, and physiologic parameters. We also tested interactions by baseline statin use, given its anti-inflammatory properties. RESULTS: Among 25,785 participants with a mean age of 64 ± 9.3 years, 55% were female and 40% were Black. Over a median follow-up of 10.1 years, 1109 ± 4.3% experienced an incident HF event. In fully adjusted models, the PSS-4 was not associated with HF or HF with reduced ejection fraction. However, PSS-4 quartiles 2-4 (compared with the lowest quartile) were associated with incident HF with preserved ejection fraction (Q2 hazard ratio 1.37, 95% confidence interval 1.00-1.88; Q3 hazard ratio 1.42, 95% confidence interval 1.03-1.95; Q4 hazard ratio 1.41, 95% confidence interval 1.04-1.92). Notably, this association was attenuated among participants who took a statin at baseline (P for interaction = .07). CONCLUSIONS: Elevated perceived stress was associated with incident HF with preserved ejection fraction but not HF with reduced ejection fraction.

N-of-1 trials to facilitate evidence-based deprescribing: Rationale and case study.

Deprescribing has emerged as an important aspect of patient-centred medication management but is vastly underutilized in clinical practice. The current narrative review will describe an innovative patient-centred approach to deprescribing-N-of-1 trials. N-of-1 trials involve multiple-period crossover design experiments conducted within individual patients. They enable patients to compare the effects of two or more treatments or, in the case of deprescribing N-of-1 trials, continuation with a current treatment versus no treatment or placebo. N-of-1 trials are distinct from traditional between-patient studies such as parallel-group or crossover designs which provide an average effect across a group of patients and obscure differences between individuals. By generating data on the effect of an intervention for the individual rather than the population, N-of-1 trials can promote therapeutic precision. N-of-1 trials are a particularly appealing strategy to inform deprescribing because they can generate individual-level evidence for deprescribing when evidence is uncertain, and can thus allay patient and physician concerns about discontinuing medications. To illustrate the use of deprescribing N-of-1 trials, we share a case example of an ongoing series of N-of-1 trials that compare maintenance versus deprescribing of beta-blockers in patients with heart failure with preserved ejection fraction. By providing quantifiable data on patient-reported outcomes, promoting personalized pharmacotherapy, and facilitating shared decision making, N-of-1 trials represent a potentially transformative strategy to address polypharmacy.

Psychological Distress After Sudden Cardiac Arrest and Its Impact on Recovery.

PURPOSE OF REVIEW: To summarize the prevalence, correlates, and health consequences of poor mental health in the increasingly sizable population of survivors of Sudden cardiac arrest (CA) and to describe current intervention research in this area. RECENT FINDINGS: After CA many patients report high psychological distress, including depression, generalized anxiety, and posttraumatic stress. Emerging evidence suggests that distressed patients' attention may narrow such that anxious awareness of afferent cardiac signals e.g., changes in heart rate or blood pressure, becomes predominant and a cause for concerned, constant monitoring. This cardiac-specific anxiety followed by behavioral avoidance and physiological hyperreactivity may increase patients' already high risk of secondary cardiovascular disease and undermine their health-related quality of life (HRQoL). Unlike other cardiovascular diseases, no clinical practice guidelines exist for assessing or treating psychological sequelae of CA. Future research should identify modifiable psychological targets to reduce secondary cardiovascular disease risk and improve HRQoL.

Associations between emergency department crowding and perceptions of interpersonal care in patients presenting with suspected acute coronary syndrome.

BACKGROUND: Emergency department (ED) crowding is associated with numerous healthcare issues, but little is known about its effect on psychosocial aspects of patient-provider interactions or interpersonal care. We examined whether ED crowding was associated with perceptions of interpersonal care in patients evaluated for acute coronary syndrome (ACS). METHODS: Patients presenting to a quaternary academic medical centre ED in New York City for evaluation of suspected ACS were enrolled between November 2013 and December 2016. ED crowding was measured using the ED Work Index (EDWIN), which incorporates patient volume, triage category, physician staffing and bed availability. Patients completed the 18-item Interpersonal Processes of Care (IPC) survey, which assesses communication, patient-centred decision-making and interpersonal style. Regression analyses examined associations between EDWIN and IPC scores, adjusting for demographics, comorbidities and depression. RESULTS: Among 933 included patients, 11% experienced ED overcrowding (EDWIN score >2) at admission, 11% experienced ED overcrowding throughout the ED stay and 30% reported suboptimal interpersonal care (defined as per-item IPC score <5). Higher admission EDWIN score was associated with modestly lower IPC score in both unadjusted (ß=-1.70, 95% CI -3.15 to -0.24, p=0.02) and adjusted models (ß = -1.77, 95% CI -3.31 to -0.24, p=0.02). EDWIN score averaged over the entire ED stay was not significantly associated with IPC score (unadjusted ß=-1.30, 95% CI -3.19 to 0.59, p=0.18; adjusted ß=-1.24, 95% CI -3.21 to 0.74, p=0.22). CONCLUSION: Increased crowding at the time of ED admission was associated with poorer perceptions of interpersonal care among patients with suspected ACS.

Medications as Traumatic Reminders in Patients With Stroke/Transient Ischemic Attack-Induced Posttraumatic Stress Disorder.

BACKGROUND AND PURPOSE: Posttraumatic stress disorder (PTSD) symptoms are common after stroke/transient ischemic attack (TIA) and have been associated with medication nonadherence, potentially because medications serve as traumatic reminders of the prior stroke/TIA. This study examined associations between stroke/TIA-induced PTSD and aversive cognitions toward preventive medications. METHODS: We enrolled a cohort of patients presenting to the emergency department with suspected stroke/TIA. One month posthospitalization, we assessed PTSD symptoms specific to the index stroke/TIA using the PTSD checklist specific and asked patients how often (1) did thinking about your stroke medication make you feel nervous or anxious?; (2) did thinking about your stroke medication make you think about your risk for future strokes?; and (3) did you skip or avoid taking your stroke medication so you would not have to think about your stroke? Logistic regression models tested the association between PTSD symptoms and each aversive cognition, adjusting for age, sex, ethnicity, and depression. RESULTS: Among 408 included patients, 11.0% had elevated PTSD symptoms. These patients were more likely to report that thinking about their stroke medication made them feel nervous or anxious (37.8% versus 9.9%, P<0.001) that thinking about their stroke medication made them think about their risk for future stroke/TIA (60.0% versus 24.0%, P<0.001), and that they skipped or avoided their stroke medication to not think about their prior stroke/TIA (11.1% versus 2.2%, P=0.009). In adjusted analyses, higher PTSD checklist specific scores were associated with increased nervousness/anxiety (odds ratio, 1.33 [95% CI, 1.18-1.50], P<0.001) and thoughts of future stroke (odds ratio, 1.27 [95% CI, 1.14-1.41], P<0.001), with a trend toward significance for skipping medications to avoid reminders of stroke (odds ratio, 1.20 [95% CI, 0.99-1.44], P=0.06). CONCLUSIONS: Medications may serve as traumatic reminders after stroke/TIA-induced PTSD, potentially leading to medication nonadherence.

Hospital Readmissions After Implementation of a Discharge Care Program for Patients with COVID-19 Illness.

BACKGROUND: The surge of coronavirus 2019 (COVID-19) hospitalizations in New York City required rapid discharges to maintain hospital capacity. OBJECTIVE: To determine whether lenient provisional discharge guidelines with remote monitoring after discharge resulted in safe discharges home for patients hospitalized with COVID-19 illness. DESIGN: Retrospective case series SETTING: Tertiary care medical center PATIENTS: Consecutive adult patients hospitalized with COVID-19 illness between March 26, 2020, and April 8, 2020, with a subset discharged home INTERVENTIONS: COVID-19 Discharge Care Program consisting of lenient provisional inpatient discharge criteria and option for daily telephone monitoring for up to 14 days after discharge MEASUREMENTS: Fourteen-day emergency department (ED) visits and hospital readmissions RESULTS: Among 812 patients with COVID-19 illness hospitalized during the study time period, 15.5% died prior to discharge, 24.1% remained hospitalized, 10.0% were discharged to another facility, and 50.4% were discharged home. Characteristics of the 409 patients discharged home were mean (SD) age 57.3 (16.6) years; 245 (59.9%) male; 27 (6.6%) with temperature ≥ 100.4 °F; and 154 (37.7%) with oxygen saturation < 95% on day of discharge. Over 14 days of follow-up, 45 patients (11.0%) returned to the ED, of whom 31 patients (7.6%) were readmitted. Compared to patients not referred, patients referred for remote monitoring had fewer ED visits (8.3% vs 14.1%; OR 0.60, 95% CI 0.31-1.15, p = 0.12) and readmissions (6.9% vs 8.3%; OR 1.15, 95% CI 0.52-2.52, p = 0.73). LIMITATIONS: Single-center study; assignment to remote monitoring was not randomized. CONCLUSIONS: During the COVID-19 surge in New York City, lenient discharge criteria in conjunction with remote monitoring after discharge were associated with a rate of early readmissions after COVID-related hospitalizations that was comparable to the rate of readmissions after other reasons for hospitalization before the COVID pandemic.

Short Sleep Duration After Hospital Evaluation for Acute Coronary Syndrome Is Associated With Increased Risk of 6-Month Readmission.

OBJECTIVE: Hospital readmission after acute coronary syndrome (ACS) is associated with worsened patient outcomes and financial burden. Short sleep duration is a risk factor for cardiovascular events and may therefore represent a behavioral factor that increases risk of adverse posthospitalization outcomes. This study examined whether short sleep duration in the month after hospital evaluation for ACS is associated with 6-month all-cause emergency department (ED) and hospital readmission. METHODS: The current analyses entail a secondary analysis of a larger prospective observational cohort study. Sleep duration during the month after hospital evaluation for ACS was assessed subjectively and dichotomized as short (<6 hours) or not short (≥6 hours). A Cox proportional hazards model was used to assess the association between short sleep duration during the month after ACS hospital evaluation and 6-month all-cause ED/hospital readmission. RESULTS: A total of 576 participants with complete data were included in analyses. Approximately 34% of participants reported short sleep duration during the month after ACS evaluation. Short sleep duration was significantly associated with 6-month all-cause ED/hospital readmission (hazard ratio = 2.03; 95% confidence interval = 1.12-3.66) in the model adjusted for age, sex, race/ethnicity, clinical severity, cardiac and renal markers, depression, acute stress, and including a sleep duration by ACS status interaction. CONCLUSIONS: Short sleep duration after ACS hospital evaluation is prevalent and is associated with increased risk of all-cause readmission within 6 months of discharge. Current findings suggest that short sleep duration is an important modifiable behavioral factor to consider after hospital evaluation for ACS.

Partner presence in the emergency department and adherence to daily cardiovascular medications in patients evaluated for acute coronary syndrome.

Stressful health situations may compromise spouses'/partners' ability to provide patients with support. We tested whether partner status/partner presence in the emergency department (ED) were associated with patients' adherence to daily cardiovascular medications and whether effects differed by age/gender. Participants were 189 patients evaluated for acute coronary syndrome at an urban academic ED (MAge = 62.18; 57.1% male; 58.7% Hispanic). Participants self-reported partner status/partner presence. Medication adherence was measured using an electronic pillcap. For male patients, having a partner was associated with increased adherence in the first month post-discharge, OR 1.94, p < .001, but having a partner present in the ED was associated with lower adherence, OR 0.33, p < .001. The opposite effect was evident for female patients. Partner status/partner presence in the ED are associated with medication adherence during the first month post discharge, with opposing effects for male and female patients.

Are patients afraid to go home? Disposition preferences after transient ischaemic attack and minor stroke.

BACKGROUND: Recent evidence suggests clinical equipoise for managing transient ischaemic attack and minor stroke (TIAMS) either via discharge from the emergency department (ED) with rapid outpatient follow-up or inpatient admission. Understanding patient preferences may guide decision-making around disposition after TIAMS that can lead to higher patient satisfaction and adherence. Psychological distress, particularly a sense of vulnerability (eg, 'threat perception') is associated with adverse psychological outcomes following TIAMS and may influence patient disposition preference. We hypothesised patients with higher threat perceptions in the ED would prefer inpatient admission versus early discharge with rapid outpatient follow-up. METHODS: This was a planned secondary analysis of a prospective observational cohort study of ED patients with suspected TIAMS (defined as National Institutes of Health Stroke Scale (NIHSS) score of ≤5). Patients reported disposition preferences and completed a validated scale of threat perception while in the ED (score range: 1-4). RESULTS: 147 TIAMS patients were evaluated (mean age: 59.7±15.4, 45.6% female, 39.5% Hispanic, median NIHSS=1, IQR: 0, 3). A majority of patients (98, 66.7%) preferred inpatient admission compared with discharge from the ED. Overall threat scores were median 1.0 (IQR: 0.43, 1.68). Those preferring admission had similar threat scores compared with those who preferred early disposition (median: 1.00, IQR: 0.43, 1.57) versus 1.00, (IQR: 0.49, 1.68); p=0.40). In a model adjusted for demographic characteristics, threat perceptions remained unassociated with disposition preference. CONCLUSION: Overall, two-thirds of TIAMS patients preferred inpatient admission over discharge. Disposition preference was not associated with higher threat perception in the ED. Further research examining potential drivers of patient disposition preferences may inform patient discussions and optimise patient satisfaction.

Increasing the Precision of Hypertension Treatment Through Personalized Trials: a Pilot Study.

BACKGROUND: There are substantial differences in the effects of blood pressure (BP) medications in individual patients. Yet, the current standard approach to prescribing BP medications is not personalized. OBJECTIVE: To determine the feasibility of individualizing the selection of BP medications through pragmatic personalized (i.e., N-of-1) trials. DESIGN: Series of N-of-1 trials. SETTING: Outpatient. PATIENTS: Hypertensive adults prescribed none or one BP medication. INTERVENTION: Participation in a flexible, open-label personalized trial of two to three BP medications (NCT02744456). MEASUREMENTS: BP was measured twice per day with a validated home BP device. Frequency and severity of side effects were assessed at the end of the day via an electronic questionnaire. Patients' BP medication preference was assessed after reviewing BP lowering and side effect results with a study clinician. Feasibility was assessed by determining the proportion of patients who adhered to self-assessments. Benefit was assessed by asking patients to rate the helpfulness of participation and whether they would recommend personalized trials to other hypertensive patients. KEY RESULTS: Of ten patients enrolled, two dropped out prior to initiation, one discovered white coat hypertension through ambulatory BP monitoring, and seven (mean age 58 years, 71% of women) completed personalized trials. All seven were compliant with home BP monitoring and side effect tracking. All seven recommended personalized trials of BP medications to others. Thiazides were preferred by three patients, renin-angiotensin system-blocking agents by two patients, a combination of thiazide and beta-blocker by one patient, and any of three classes by one patient. CONCLUSIONS: Personalized trials of BP medications were feasible and led to improved treatment precision. Heterogeneity of patient preferences and of therapeutic BP response for first-line BP medications can be determined through a personalized trial approach.