Informational Postcards Increase Engagement with Remote Monitoring Among Veterans with Pacemakers and Implantable Cardioverter-Defibrillators: a Stepped-Wedge Randomized Controlled Trial.

BACKGROUND: Remote monitoring (RM) of pacemakers and implantable cardioverter-defibrillators (ICDs) reduces morbidity and mortality. However, many patients are not adherent to RM. OBJECTIVE: To test the effect of informational postcards on RM adherence. DESIGN/PATIENTS: Stepped-wedge randomized controlled trial among Veterans with pacemakers and ICDs. INTERVENTION: In wave 1, Veterans who had sent at least 1 transmission within the past 2 years but had become non-adherent were randomly assigned to receive a postcard or no postcard. Those receiving postcards were randomized to 1 of 2 messages: (1) a"warning" postcard describing risks of non-adherence or (2) an "encouraging" postcard describing benefits of adherence. In wave 2, Veterans who had either not received a postcard in wave 1 or had since become non-adherent were mailed a postcard (again, randomized to 1 of 2 messages). Patients who did not send an RM transmission within 1 month were mailed a second, identical postcard. MAIN MEASURES: Transmission within 70 days. KEY RESULTS: Overall, 6351 Veterans were included. In waves 1 and 2, postcards were mailed to 5657 Veterans (2821 "warning" messages and 2836 "encouraging" messages). Wave 1 included 2178 Veterans as controls (i.e., not mailed a postcard), some of whom received a postcard in wave 2 if they remained non-adherent. In wave 2, 3473 postcards were sent. Of the 5657 patients mailed a postcard, 2756 (48.7%) sent an RM transmission within 70 days, compared to 530 (24.3%) of 2178 controls (absolute difference 24.4%, 95% confidence interval [CI] 22.2%, 26.6%). Of those who sent a transmission, 71.8% did so after the first postcard. Transmission rates at 70 days did not significantly differ between "warning" and "encouraging" messages (odds ratio 1.04, 95% CI 0.92, 1.18). CONCLUSIONS: Informational postcards led to a 24.4% absolute increase in adherence at 70 days among Veterans with pacemakers and ICDs who were non-adherent to RM.

Informational letters or postcards to initiate remote monitoring among veterans with pacemakers and implantable cardioverter-defibrillators: A randomized, controlled trial.

BACKGROUND: Remote monitoring (RM) of pacemakers and implantable cardioverter-defibrillators (ICDs) is a Class 1, Level of Evidence A recommendation because of its multitude of clinical benefits. However, RM adherence rates are suboptimal, precluding patients from achieving these benefits. There is a need for direct-to-patient efforts to improve adherence. METHODS: In this national randomized, controlled trial conducted in the Veterans Health Administration (VHA), 2120 patients with a pacemaker or ICD who had not sent an RM transmission for ≥1 year (and usually ≥3 years) while under VHA care for their device were randomly assigned to be mailed a postcard (n = 1076) or a detailed letter (n = 1044). The postcard described what RM does and its key benefits (reduced mortality and fewer in-person visits). The letter provided a similar message but included more details about RM benefits and the process. The primary outcome was an RM transmission sent within 90 days of mailing, and a secondary outcome was an RM transmission sent within 365 days. RESULTS: The primary outcome was achieved in 121 (11.3%) in the postcard and 96 patients (9.2%) in the letter group (p = .12). The secondary outcome was achieved in 266 (24.7%) and 239 (22.9%), respectively (p = .32). CONCLUSIONS: This randomized trial showed no significant difference in the proportion of chronically non-adherent patients who sent an RM transmission after receiving a low-cost postcard or a detailed, higher-cost letter encouraging their participation in RM. However, as only a minority of patients responded to either, further work is needed to engage patients in the life-saving benefits of RM.

Genetics professionals are key to the integration of genetic testing within the practice of frontline clinicians.

PURPOSE: Genetic tests have become widely available. We sought to understand the use of genetic tests in the practice of frontline clinicians within the United States Department of Veterans Affairs (VA). METHODS: We administered a web-based survey to clinicians at 20 VA facilities. Physicians, nurse practitioners, physician assistants, and pharmacists were eligible. We excluded genetics providers and clinicians not seeing patients. We used multiple logistic regression to evaluate the associations between clinician characteristics and experience with genetics. RESULTS: The response rate was 11.3% (1207/10,680) and of these, 909 respondents were eligible. Only 20.8% of the respondents reported feeling prepared to use genetic tests and 13.0% of the respondents were currently ordering genetic tests; although, it was usually only 1 or 2 a year. Delivery of genetic tests without involving genetics providers was preferred by only 7.9% of the respondents. Characteristics positively associated with currently ordering genetic tests included practice in clinical and research settings, believing improving genetics knowledge could alter their practice, feeling prepared to use genetic tests, and referral of at least 1 patient to genetics in the past year. CONCLUSION: Most VA clinicians don't feel prepared to use genetic tests. Those with genetic testing experience are more likely to consult genetics providers. The demand for genetics providers should increase as frontline clinicians use genetic tests in their practice.

Travel Burden as a Measure of Healthcare Access and the Impact of Telehealth within the Veterans Health Administration.

BACKGROUND: Travel is a major barrier to healthcare access for Veteran Affairs (VA) patients, and disproportionately affects rural Veterans (approximately one quarter of Veterans). The CHOICE/MISSION acts' intent is to increase timeliness of care and decrease travel, although not clearly demonstrated. The impact on outcomes remains unclear. Increased community care increases VA costs and increases care fragmentation. Retaining Veterans within the VA is a high priority, and reduction of travel burdens will help achieve this goal. Sleep medicine is presented as a use case to quantify travel related barriers. OBJECTIVE: The Observed and Excess Travel Distances are proposed as two measures of healthcare access, allowing for quantification of healthcare delivery related to travel burden. A telehealth initiative that reduced travel burden is presented. DESIGN: Retrospective, observational, utilizing administrative data. SUBJECTS: VA patients with sleep related care between 2017 and 2021. In-person encounters: Office visits and polysomnograms; telehealth encounters: virtual visits and home sleep apnea tests (HSAT). MAIN MEASURES: Observed distance: distance between Veteran's home and treating VA facility. Excess distance: difference between where Veteran received care and nearest VA facility offering the service of interest. Avoided distance: distance between Veteran's home and nearest VA facility offering in-person equivalent of telehealth service. KEY RESULTS: In-person encounters peaked between 2018 and 2019, and have down trended since, while telehealth encounters have increased. During the 5-year period, Veterans traveled an excess 14.1 million miles, while 10.9 million miles of travel were avoided due to telehealth encounters, and 48.4 million miles were avoided due to HSAT devices. CONCLUSIONS: Veterans often experience a substantial travel burden when seeking medical care. Observed and excess travel distances are valuable measures to quantify this major healthcare access barrier. These measures allow for assessment of novel healthcare approaches to improve Veteran healthcare access and identify specific regions that may benefit from additional resources.

Effects of a patient-centered digital health intervention in patients referred to cardiac rehabilitation: the Smart HEART clinical trial.

BACKGROUND: Cardiac rehabilitation (CR) improves outcomes in heart disease yet remains vastly underutilized. Remote CR enhanced with a digital health intervention (DHI) may offer higher access and improved patient-centered outcomes over non-technology approaches. We sought to pragmatically determine whether offering a DHI improves CR access, cardiac risk profile, and patient-reported outcome measures. METHODS: Adults referred to CR at a tertiary VA medical center between October 2017 and December 2021 were offered enrollment into a DHI alongside other CR modalities using shared decision-making. The DHI consisted of remote CR with a structured, 3-month home exercise program enhanced with multi-component coaching, a commercial smartphone app, and wearable activity tracker. We measured completion rates among DHI participants and evaluated changes in 6-min walk distance, cardiovascular risk factors, and patient-reported outcomes from pre- to post-intervention. RESULTS: Among 1,643 patients referred to CR, 258 (16%) consented to the DHI where the mean age was 60 ± 9 years, 93% were male, and 48% were black. A majority (90%) of the DHI group completed the program. Over 3-months, significant improvements were seen in 6MWT (mean difference [MD] -29 m; 95% CI, 10 to 49; P < 0.01) and low-density lipoprotein cholesterol (MD -11 mg/dL; 95% CI, -17 to -5; P < 0.01), and the absolute proportion of patients who reported smoking decreased (10% vs 15%; MD, -5%; 95% CI, -8% to -2%; P < 0.01) among DHI participants with available data. No adverse events were reported. CONCLUSIONS: The addition of a DHI-enhanced remote CR program was delivered in 16% of referred veterans and associated with improved CR access, markers of cardiovascular risk, and healthy behaviors in this real-world study. These findings support the continued implementation of DHIs for remote CR in real-world clinical settings. TRIAL REGISTRATION: This trial was registered on ClinicalTrials.gov: NCT02791685 (07/06/2016).

Agent Orange Exposure and Risk of Idiopathic Pulmonary Fibrosis among U.S. Veterans.

Rationale: There is limited literature exploring the relationship between military exposures and idiopathic pulmonary fibrosis (IPF). Objectives: To evaluate whether exposure to Agent Orange is associated with an increased risk of IPF among veterans. Methods: We used Veterans Health Administration data to identify patients diagnosed with IPF between 2010 and 2019. We restricted the cohort to male Vietnam veterans and performed multivariate logistic regression to examine the association between presumptive Agent Orange exposure and IPF. We conducted sensitivity analyses restricting the cohort to army veterans (highest theoretical burden of exposure, surrogate for dose response) and a more specific case definition of IPF. Fine-Gray competing risk models were used to evaluate age to IPF diagnosis. Measurements and Main Results: Among 3.6 million male Vietnam veterans, 948,103 (26%) had presumptive Agent Orange exposure. IPF occurred in 2.2% of veterans with Agent Orange exposure versus 1.9% without exposure (odds ratio, 1.14; 95% confidence interval [CI], 1.12-1.16; P < 0.001). The relationship persisted after adjusting for known IPF risk factors (odds ratio, 1.08; 95% CI, 1.06-1.10; P < 0.001). The attributable risk among exposed veterans was 7% (95% CI, 5.3-8.7%; P < 0.001). Numerically greater risk was observed when restricting the cohort to 1) Vietnam veterans who served in the army and 2) a more specific definition of IPF. After accounting for the competing risk of death, veterans with Agent Orange exposure were still more likely to develop IPF. Conclusions: Presumptive Agent Orange exposure is associated with greater risk of IPF. Future research should validate this association and investigate the biological mechanisms involved.

The association of post-traumatic stress disorder with glomerular filtration rate decline.

While major depression is known to be associated with glomerular filtration rate (GFR) decline, there is a lack of data on the association of other mental illnesses like posttraumatic stress disorder (PTSD) with kidney disease. In 640 adult participants of the Heart and Soul Study (mean baseline age of 66.2 years) with a high prevalence cardiovascular disease, hypertension and diabetes, we examined the association of PTSD with GFR decline over a 5-year follow-up. We observed a significantly greater estimated (e) GFR decline over time in those with PTSD compared to those without (2.97 vs. 2.11 ml/min/1.73 m2 /year; p = .022). PTSD was associated with 91% (95% CI 12%-225%) higher odds of 'rapid' versus 'mild' (>3.0 vs. <3.0 ml/min/1.73 m2 /per year) eGFR decline. These associations remained consistent despite controlling for demographics, medical comorbidities, other mental disorders and psychiatric medications. In conclusion, our study provides evidence that PTSD is independently associated with GFR decline in middle-aged adults with a high comorbidity burden. This association needs to be examined in larger cohorts with longer follow-ups.

Hospital Readmissions Among Veterans Within 90 Days of Discharge Following Initial Hospitalization for COVID-19.

INTRODUCTION: Some patients experience ongoing sequelae after discharge, including rehospitalization; therefore, outcomes following COVID-19 hospitalization are of continued interest. We examined readmissions within 90 days of hospital discharge for veterans hospitalized with COVID-19 during the first 10 months of the pandemic in the US. METHODS: Veterans hospitalized with COVID-19 at a Veterans Health Administration (VA) hospital from March 1, 2020, through December 31, 2020 were followed for 90 days after discharge to determine readmission rates. RESULTS: Of 20,414 veterans hospitalized with COVID-19 during this time period, 13% (n = 2,643) died in the hospital. Among survivors (n = 17,771), 16% (n = 2,764) were readmitted within 90 days of discharge, with a mean time to readmission of 21.6 days (SD = 21.1). Characteristics of the initial COVID-19 hospitalization associated with readmission included length of stay, mechanical ventilator use, higher comorbidity index score, current smoking, urban residence, discharged against medical advice, and hospitalized from September through December 2020 versus March through August 2020 (all P values <.02). Veterans readmitted from September through December 2020 were more often White, lived in a rural or highly rural area, and had shorter initial hospitalizations than veterans hospitalized earlier in the year. CONCLUSION: Approximately 1 of 6 veterans discharged alive following a COVID-19 hospitalization from March 1 through December 31, 2020, were readmitted within 90 days. The longer the hospital stay, the greater the likelihood of readmission. Readmissions also were more likely when the initial admission required mechanical ventilation, or when the veteran had multiple comorbidities, smoked, or lived in an urban area. COVID-19 hospitalizations were shorter from September through December 2020, suggesting that hospital over-capacity may have resulted in earlier discharges and increased readmissions. Efforts to monitor and provide support for patients discharged in high bed-capacity situations may help avoid readmissions.

Adenoma Detection Rate (ADR) Irrespective of Indication Is Comparable to Screening ADR: Implications for Quality Monitoring.

BACKGROUND & AIMS: Adenoma detection rate (ADR) is a key measure of colonoscopy quality. However, efficient measurement of ADR can be challenging because many colonoscopies are performed for non-screening purposes. Measuring ADR without being restricted to screening indication may likely facilitate more widespread implementation of quality monitoring. We hypothesized that the ADR for all colonoscopies, irrespective of the indication, would be equivalent to the ADR for screening colonoscopies. METHODS: We reviewed consecutive colonoscopies at two Veterans Affairs centers performed by 21 endoscopists over 6 months in 2015. We calculated the ADR for screening exams, non-screening (surveillance and diagnostic) exams, and all exams (irrespective of indication), correcting for within-endoscopist correlation. We then performed simulation modeling to calculate the ADRs under 16 hypothetical scenarios of various indication distributions. We simulated 100,000 trials with 3,000 participants, randomly assigned indication (screening, surveillance, diagnostic, and FIT+) from a multinomial distribution, randomly drew adenoma using the observed ADRs per indication, and calculated 95% confidence intervals of the mean differences in ADR of screening and non-screening indications. RESULTS: Among 2628 colonoscopies performed by 21 gastroenterologists, the indication was screening in 28.9%, surveillance in 48.2% and diagnostic in 22.9%. There was no significant difference in the ADR, 50% (95%CI: 45-56%) for all colonoscopies vs 49% (95%CI: 43-56%) for screening exams (p=.55). ADRs were 56% for surveillance and 38% for diagnostic exams. In our simulation modeling, only one out of 16 scenarios (screening 10%, surveillance 70%, diagnostic 10% and FIT+ 10%) resulted in a significant difference between the calculated ADRs for screening and non-screening indications. CONCLUSIONS: In our study, the overall ADR computed from all colonoscopies was not significantly different than the conventional ADR based on screening colonoscopies. Assessing ADR for colonoscopy irrespective of indication may be adequate for quality monitoring, and could facilitate the implementation of quality measurement and reporting. Future prospective studies should evaluate the validity of using overall ADR for quality reporting in other jurisdictions before adopting this method in clinical practice.

Preoperative Medical Testing and Falls in Medicare Beneficiaries Awaiting Cataract Surgery.

PURPOSE: Delaying cataract surgery is associated with an increased risk of falls, but whether routine preoperative testing delays cataract surgery long enough to cause clinical harm is unknown. We sought to determine whether the use of routine preoperative testing leads to harm in the form of delayed surgery and falls in Medicare beneficiaries awaiting cataract surgery. DESIGN: Retrospective, observational cohort study using 2006-2014 Medicare claims. PARTICIPANTS: Medicare beneficiaries 66+ years of age with a Current Procedural Terminology claim for ocular biometry. METHODS: We measured the mean and median number of days between biometry and cataract surgery, calculated the proportion of patients waiting ≥ 30 days or ≥ 90 days for surgery, and determined the odds of sustaining a fall within 90 days of biometry among patients of high-testing physicians (testing performed in ≥ 75% of their patients) compared with patients of low-testing physicians. We also estimated the number of days of delay attributable to high-testing physicians. MAIN OUTCOME MEASURES: Incidence of falls occurring between biometry and surgery, odds of falling within 90 days of biometry, and estimated delay associated with physician testing behavior. RESULTS: Of 248 345 beneficiaries, 16.4% were patients of high-testing physicians. More patients of high-testing physicians waited ≥ 30 days and ≥ 90 days to undergo surgery (31.4% and 8.2% vs. 25.0% and 5.5%, respectively; P < 0.0001 for both). Falls before surgery in patients of high-testing physicians increased by 43% within the 90 days after ocular biometry (1.0% vs. 0.7%; P < 0.0001). The adjusted odds ratio of falling within 90 days of biometry in patients of high-testing physicians versus low-testing physicians was 1.10 (95% confidence interval [CI], 1.03-1.19; P = 0.008). After adjusting for surgical wait time, the odds ratio decreased to 1.07 (95% CI, 1.00-1.15; P = 0.06). The delay associated with having a high-testing physician was approximately 8 days (estimate, 7.97 days; 95% CI, 6.40-9.55 days; P < 0.0001). Other factors associated with delayed surgery included patient race (non-White), Northeast region, ophthalmologist ≤ 40 years of age, and low surgical volume. CONCLUSIONS: Overuse of routine preoperative medical testing by high-testing physicians is associated with delayed surgery and increased falls in cataract patients awaiting surgery.

Does Community Outsourcing Improve Timeliness of Care for Veterans With Obstructive Sleep Apnea?

BACKGROUND: Providing timely access to care has been a long-standing priority for the Veterans Affairs Healthcare System. Recent strategies to reduce long wait times have focused on purchasing community care by a fee-for-service model. Whether outsourcing Veterans Affairs (VA) specialty care to the community improves access is unclear. OBJECTIVES: We compared time from referral to treatment among Veterans whose care was provided by VA versus community care purchased by the VA, using obstructive sleep apnea as an example condition. METHODS: This was a retrospective cohort study of Northern California Veterans seeking sleep apnea care through the San Francisco VA Healthcare System between 2012 and 2018. We used multivariable linear regression with propensity score matching to investigate the relationship between time to care delivery and care setting (VA provided vs. VA-purchased community care). A total of 1347 Northern California Veterans who completed sleep apnea testing within the VA and 88 Veterans who completed sleep apnea testing in the community had complete data for analysis. RESULTS: Among Northern California Veterans with obstructive sleep apnea, outsourcing of care to the community was associated with longer time from referral to therapy (mean±SD, 129.6±82.8 d with VA care vs. 252.0±158.8 d with community care, P<0.001) and greater loss to follow-up. CONCLUSIONS: These findings suggest that purchasing community care may lead to care fragmentation and not improve wait times nor improve access to subspecialty care for Veterans.

Implementation Strategies for Frontline Healthcare Professionals: People, Process Mapping, and Problem Solving.

Implementation science is focused on developing and evaluating methods to reduce gaps between research and practice. As healthcare organizations become increasingly accountable for equity, quality, and value, attention has been directed to identifying specific implementation strategies that can accelerate the adoption of evidence-based therapies into clinical practice. In this perspective, we offer three simple, practical strategies that can be used by frontline healthcare providers who are involved in on-the-ground implementation: people (stakeholder) engagement, process mapping, and problem solving. As a use case example, we describe the iterative application of these strategies to the implementation of a new home sleep apnea testing program for patients in the Veterans Health Administration (VA) healthcare system.

Impact of Longitudinal Virtual Primary Care on Diabetes Quality of Care.

BACKGROUND: Lack of healthcare access to due to physician shortages is a significant driver of telemedicine expansion in rural areas. Telemedicine is effective for management of chronic conditions such as diabetes but its effectiveness in primary care settings is unknown. OBJECTIVE: To evaluate differences in diabetes care before and after implementation of a longitudinal virtual primary care program. DESIGN: Propensity score-matched cohort study utilizing difference-in-differences analysis. PARTICIPANTS: Patients with diabetes who received care at VA primary care clinics between January 2018 and December 2019 where the Virtual Integrated Multisite Patient Aligned Care Teams (V-IMPACT) program was implemented. EXPOSURE: Patient participation in at least one V-IMPACT visit while usual care patients did not participate in V-IMPACT. MAIN MEASURES: The primary outcome was change in hemoglobin A1C (HbA1C) and secondary outcomes included change in the proportion of patients meeting diabetes quality indicators: blood pressure control, statin use, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACEi/ARB) use, and annual microalbuminuria testing. KEY RESULTS: Our propensity-matched cohort included 9010 patients split evenly between those who participated in V-IMPACT and those who remained in usual in-person care. Among individuals with diabetes who participated in V-IMPACT, the change in mean HbA1C was - 0.055% (95% CI - 0.088 to - 0.022%) while those in usual care had a - 0.047% (95% CI - 0.080 to - 0.014%) change before and after program implementation. We observed a 5.1% (95% CI 2.4 to 7.7%) absolute increase in the proportion prescribed statins in the V-IMPACT group, a 5.3% (95% CI 2.5 to 8.2%) increase prescribed ACE/ARBs, and a 4.6% (95% 1.7 to 7.5%) increase in completed yearly microalbuminuria testing. V-IMPACT was not associated with a significant difference in the proportion with controlled blood pressure at < 140/90 or < 130/90 mmHg thresholds. CONCLUSIONS: Quality of diabetes care delivered by a longitudinal virtual primary care model was similar if not better than traditional in-person care.

Simplifying Measurement of Adenoma Detection Rates for Colonoscopy.

BACKGROUND: Adenoma detection rate (ADR) is the colonoscopy quality metric with the strongest association to interval or "missed" cancer. Accurate measurement of ADR can be laborious and costly. AIMS: Our aim was to determine if administrative procedure codes for colonoscopy and text searches of pathology results for adenoma mentions could estimate ADR. METHODS: We identified US Veterans with a colonoscopy using Current Procedure Terminology (CPT) codes between January 2013 and December 2016 at ten Veterans Affairs sites. We applied simple text searches using Microsoft SQL Server full-text searches to query all pathology notes for "adenoma(s)" or "adenomatous" text mentions to calculate ADRs. To validate our identification of colonoscopy procedures, endoscopists of record, and adenoma detection from the electronic health record, we manually reviewed a random sample of 2000 procedure and pathology notes from the 10 sites. RESULTS: Structured data fields were accurate in identification of colonoscopies being performed (PPV = 0.99; 95% CI 0.99-1.00) and identifying the endoscopist of record (PPV of 0.95; 95% CI 0.94-0.96) for ADR measurement. Simple text searches of pathology notes for adenoma mentions had excellent performance statistics as follows: sensitivity 0.99 (95% CI 0.98-1.00), specificity 0.93 (95% CI 0.92-0.95), NPV 0.99 (95% CI 0.98-1.00), and PPV 0.93 (0.91-0.94) for measurement of ADR. There was no clinically significant difference in the estimates of overall ADR vs. screening ADR (p > 0.05). CONCLUSIONS: Measuring ADR using administrative codes and text searches from pathology results is an efficient method to broadly survey colonoscopy quality.

Leveraging Telehealth to improve access to care: a qualitative evaluation of Veterans' experience with the VA TeleSleep program.

BACKGROUND: Obstructive sleep apnea is common among rural Veterans, however, access to diagnostic sleep testing, sleep specialists, and treatment devices is limited. To improve access to sleep care, the Veterans Health Administration (VA) implemented a national sleep telemedicine program. The TeleSleep program components included: 1) virtual clinical encounters; 2) home sleep apnea testing; and 3) web application for Veterans and providers to remotely monitor symptoms, sleep quality and use of positive airway pressure (PAP) therapy. This study aimed to identify factors impacting Veteran's participation, satisfaction and experience with the TeleSleep program as part of a quality improvement initiative. METHODS: Semi-structured interview questions elicited patient perspectives and preferences regarding accessing and engaging with TeleSleep care. Rapid qualitative and matrix analysis methods for health services research were used to organize and describe the qualitative data. RESULTS: Thirty Veterans with obstructive sleep apnea (OSA) recruited from 6 VA telehealth "hubs" participated in interviews. Veterans reported positive experiences with sleep telemedicine, including improvements in sleep quality, other health conditions, and quality of life. Access to care improved as a result of decreased travel burden and ability of both clinicians and Veterans to remotely monitor and track personal sleep data. Overall experiences with telehealth technology were positive. Veterans indicated a strong preference for VA over non-VA community-based sleep care. Patient recommendations for change included improving scheduling, continuity and timeliness of communication, and the equipment refill process. CONCLUSIONS: The VA TeleSleep program improved patient experiences across multiple aspects of care including a reduction in travel burden, increased access to clinicians and remote monitoring, and patient-reported health and quality of life outcomes, though some communication and continuity challenges remain. Implementing telehealth services may also improve the experiences of patients served by other subspecialties or healthcare systems.

Cardiac Rehabilitation: Under-Utilized Globally.

PURPOSE OF REVIEW: Cardiac rehabilitation (CR) is grossly under-utilized. This review summarizes current knowledge about degree of CR utilization, reasons for under-utilization, and strategies to increase use. RECENT FINDINGS: ICCPR's global CR audit quantified for the first time the number of additional CR spots needed per year to treat indicated patients, so there are programs they may use. The first randomized trial of automatic/systematic CR referral has shown it results in significantly greater patient completion. Moreover, the recent update of the Cochrane review on interventions to increase use has provided unequivocal evidence on the significant impact of clinician CR encouragement at the bedside; a course is now available to train clinicians. The USA is leading the way in implementing automatic referral with inpatient-clinician CR discussions. Suggestions to triage patients based on risk to less resource-intensive, unsupervised program models could simultaneously expand capacity and support patient adherence.

Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology.

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Association of Longitudinal Change in High-Sensitivity Troponin with All-Cause Mortality in Coronary Artery Disease: The Heart and Soul Study.

BACKGROUND: Serial increases in high-sensitivity cardiac troponin (hs-cTnT) have been associated with death in community-dwelling adults, but the association remains uninvestigated in those with coronary artery disease (CAD). METHODS: We measured hs-cTnT at baseline and after 5 years in 635 ambulatory Heart and Soul Study patients with CAD. We also performed echocardiography at rest and after treadmill exercise at baseline and after 5 years. Participants were subsequently followed for the outcome of death. We used a multivariable-adjusted Cox proportional hazards model to evaluate the association between 5-year change in hs-cTnT and subsequent all-cause mortality. RESULTS: Of the 635 subjects, there were 386 participants (61%) who had an increase in hs-cTnT levels between baseline and year 5 measurements (median increase 5.6 pg/mL, IQR 3.2-9.9 pg/mL). There were 182 deaths after a mean 4.2-year follow-up after the year 5 visit. After adjusting for clinical variables, a >50% increase in hs-cTnT between baseline and year 5 was associated with a nearly 2-fold increased risk of death from any cause (hazard ratio 1.7, 95% confidence interval 1.1-2.7). When addition of year 5 hs-cTnT was compared to a model including clinical variables and baseline hs-cTnT, there was a modest but statistically significant increase in C-statistic from 0.82 to 0.83 (p = 0.04). CONCLUSION: In ambulatory patients with CAD, serial increases in hs-cTnT over time are associated with an increased risk of death.

Vital Signs Data and Probability of Hospitalization, Transfer to Another Facility, or Emergency Department Death Among Adults Presenting for Medical Illnesses to the Emergency Department at a Large Urban Hospital in the United States.

BACKGROUND: Vital signs are routinely measured from patients presenting to the emergency department (ED), but how they predict clinical outcomes like hospitalization is unclear. OBJECTIVES: To evaluate how pulse, respiratory rate, temperature, and mean arterial pressure (MAP) at ED presentation predicted probability of hospitalization, transfer to another center, or death in the ED (as a composite outcome) vs. other ED dispositions (discharged, eloped, and sent to observation or labor and delivery), and to assess the performance of different modeling strategies, specifically, models including flexible forms of vital signs (as restricted cubic splines) vs. linear forms (untransformed numeric variables) vs. binary transformations (vital signs values categorized simply as normal or abnormal). METHODS: We analyzed the data of 12,660 adults presenting for medical illnesses to the ED at the University of California, San Francisco Medical Center, San Francisco, California, throughout 2014. We used flexible forms of vital signs data at presentation (pulse, temperature, respiratory rate, and MAP) to predict ED disposition (admitted, transferred, or died, vs. other ED dispositions) and to guide binary transformation of vital signs. We compared performance of models including vital signs as flexible terms, binary transformations, or linear terms. RESULTS: A model including flexible forms of vital signs and age to predict the outcome had good calibration and moderate discrimination (C-statistic = 71.2, 95% confidence interval [CI] 70.0-72.4). Binary transformation of vital signs had minimal impact on performance (C-statistic = 71.3, 95% CI 70.2-72.5). A model with linear forms was less calibrated and had slightly reduced discrimination (C-statistic = 70.3, 95% CI 69.1-71.5). CONCLUSIONS: Findings suggest that flexible modeling of vital signs may better reflect their association with clinical outcomes. Future studies to evaluate how vital signs could assist clinical decision-making in acute care settings are suggested.

Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: Opportunity for Improvement.

BACKGROUND: Cardiac rehabilitation is strongly recommended after myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery, but it is historically underused. We sought to evaluate variation in cardiac rehabilitation participation across the United States. METHODS: From administrative data from the Veterans Affairs (VA) healthcare system and a 5% Medicare sample, we used International Classification of Diseases, 9th Revision codes to identify patients hospitalized for myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery from 2007 to 2011. After excluding patients who died in ≤30 days of hospitalization, we calculated the percentage of patients who participated in ≥1 outpatient visits for cardiac rehabilitation during the 12 months after hospitalization. We estimated adjusted and standardized rates of participation in cardiac rehabilitation by state using hierarchical logistic regression models. RESULTS: Overall, participation in cardiac rehabilitation was 16.3% (23 403/143 756) in Medicare and 10.3% (9123/88 826) in VA. However, participation rates varied widely across states, ranging from 3.2% to 41.8% in Medicare and 1.2% to 47.6% in VA. Similar regional variation was observed in both populations. Patients in the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) had the highest participation, whereas those in the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) had the lowest participation in both Medicare (33.7% versus 10.6%) and VA (16.6% versus 5.1%) populations. Significant hospital-level variation was also present, with participation ranging from 3% to 75% in Medicare and 1% to 43% in VA. CONCLUSIONS: Cardiac rehabilitation participation remains low overall in both Medicare and VA populations. However, remarkably similar regional variation exists, with some regions and hospitals achieving high rates of participation in both populations. This provides an opportunity to identify best practices from higher performing hospitals and regions that could be used to improve cardiac rehabilitation participation in lower performing hospitals and regions.