BACKGROUND: Inability to resume employment after acute myocardial infarction (MI) has important implications for patients. We sought to assess the prevalence of and outcomes associated with adverse change in employment after MI in a national US cohort. METHODS AND RESULTS: The TRANSLATE-ACS study (Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome) assessed employment status at baseline and 1 year among 9319 patients with MI (mean age, 60.8 years; SD, 11.3; 27.3% women) enrolled at 233 US hospitals. We defined adverse change in employment as patients working at baseline but working less or not working at 1-year post-MI. In multivariable models, we assessed factors associated with adverse change in employment and its association with patient-reported depression, health status, persistence to evidence-based medications prescribed at discharge, and financial hardship affording medications. Half of the patients (51%; n=4730) were employed at the time of MI. By 1 year, 10% (n=492) of these reported an adverse change in employment, with 3% (n=143) working less and 7% (n=349) no longer working (only 27 of 349 reported retirement). Factors significantly associated with adverse change in employment included a number of unplanned readmissions, postdischarge bleeding complications, hypertension, and smoking. At 1 year, patients with an adverse change in employment were more likely to report depression (Patient Health Questionnaire 2 score >3: 27.4% versus 16.7%), lower health status (mean EuroQoL visual analogue scale: 73 [SD, 17.8] versus 78 [SD, 14.8]), and moderate-extreme financial hardship with medication costs (41.0% versus 28.4%; all P<0.001). There was no difference in persistence to evidence-based medications prescribed at discharge. CONCLUSIONS: Patients who experienced an adverse change in employment after MI reported lower quality of life, increased depression, and more difficulty affording medications. These results underscore the need for interventions to address this patient-centered outcome and its health impact. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01088503.
PURPOSE OF REVIEW: Dyslipidemia in patients with T2DM confers significant additional risk of adverse outcomes to patients with cardiovascular disease (CVD). These patients carry residual risk of adverse outcomes despite optimal management with conventional therapy such as lifestyle changes and statin therapy. The role of both nonstatin monotherapy in statin-intolerant patients and combination therapy with statins in patients with high risk of CVD events has been well studied. We sought to review the role of newer therapies in risk reduction in these patients. RECENT FINDINGS: Traditionally, non-statin options have included medications such as niacin, ezetimibe, fenofibrate, and n-3 fatty acids. Recently, drugs such as ezetimibe, inclisiran, and PCSK9 inhibitors have been studied with favorable results without an increased risk of developing new-onset diabetes. These medications hold the promise of increasing options to reduce cardiovascular risk in patients with T2DM. The role of newer non-statin therapies in patients with diabetic dyslipidemia in combination with statins needs to be further explored.
Health professionals within the medical community feel that the principles of humanism in medicine have not been a point of emphasis for information and computer technology in healthcare. There is concern that the electronic health record is eroding the patient-clinician relationship and distancing clinicians from their patients. New analytic technologies, on the contrary, by taking over repetitive and mundane tasks, can provide an avenue to make medical care more patient-centered by freeing clinicians' time, and the time of the whole clinical care team, to engage with patients. Technology such as advanced speech recognition that optimizes clinicians' workflow could revitalize the patient-clinician relationship and perhaps also improve clinician well-being. Digital phenotyping can gain invaluable additional data from patients using technology that is already used for personal reasons by the majority of patients. The digital transformation of healthcare has the potential to make healthcare more humane and personalized, however, several important steps are needed to avoid the pitfalls that have come with prior iterations of information technology in medicine such as a heightened emphasis on data security and transparency. Both patients and clinicians should be involved from the early stages of development of medical technologies to ensure that they are person-centric. Technologists and engineers developing healthcare technologies should have experiences with the delivery of healthcare and the lives of patients and clinicians. These steps are necessary to develop a common commitment to the design concept that technology and humane care are not mutually exclusive, and in fact, can be symbiotic.
BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) and cancer are among the leading causes of economic burden, morbidity, and mortality in the United States. We aimed to quantify the overall impact of cardiovascular modifiable risk factor (CRF) profile on healthcare expenditures among those with and without ASCVD and/or cancer. METHODS AND RESULTS: The 2012-2013 Medical Expenditure Panel Survey, a nationally representative adult sample (>/=40 years), was utilized for the study. Variables included ASCVD, CRF (hypertension, diabetes mellitus, hypercholesterolemia, smoking, physical activity and/or obesity), and cancer (all). Two-part econometric models analyzed cost data. Medical Expenditure Panel Survey participants (n=27 275, 59+/-9 years, 52% female) were studied and 14% had cancer, translating to 25.6 million US adults over 40 years of age. A higher prevalence of ASCVD was noted in those with versus without cancer (25% versus 14%). Absence of ASCVD and a more favorable CRF profile were associated with significantly lower expenditures across the spectrum of cancer diagnosis. Among cancer patients, the adjusted mean annual cost for those with and without ASCVD were $10 852 (95% confidence interval [8917, 12 788]) and $6436 (95% confidence interval [5531, 7342]). Among cancer patients without ASCVD, adjusted annual healthcare expenditures among those with optimal versus poor CRF profile were $4782 and $7256. CONCLUSIONS: In a nationally representative US adult population, absence of ASCVD and a favorable CRF profile were associated with significantly lower medical expenditure among cancer patients. This provides estimates to continue better cardiovascular management and prevention practices, while contextualizing the burden of cancer.
BACKGROUND: Evidence supporting nonstatin lipid-lowering therapy in atherosclerotic cardiovascular disease risk reduction is variable. We aim to examine nonstatin utilization and expenditures in the United States between 2002 and 2013. METHODS AND RESULTS: We used the Medical Expenditure Panel Survey database to estimate national trends in nonstatin use and cost (total and out-of-pocket, adjusted to 2013 US dollars using a gross domestic product deflator) among adults 40 years or older. Nonstatin users increased from 3 million (2.5%) in 2002-2003 (20.1 million prescriptions) to 8 million (5.6%) in 2012-2013 (45.8 million prescriptions). Among adults with atherosclerotic cardiovascular disease, nonstatin use increased from 7.5% in 2002-2003 to 13.9% in 2012-2013 after peaking at 20.3% in 2006-2007. In 2012-2013, 15.9% of high-intensity statin users also used nonstatins, versus 9.7% of low/moderate-intensity users and 3.6% of statin nonusers. Nonstatin use was significantly lower among women (odds ratio 0.80; 95% confidence interval 0.75-0.86), racial/ethnic minorities (odds ratio 0.41; 95% confidence interval 0.36-0.47), and the uninsured (odds ratio 0.47; 95% confidence interval 0.40-0.56). Total nonstatin expenditures increased from $1.7 billion (out-of-pocket cost, $0.7 billion) in 2002-2003 to $7.9 billion (out-of-pocket cost $1.6 billion) in 2012-2013, as per-user nonstatin expenditure increased from $550 to $992. Nonstatin expenditure as a proportion of all lipid-lowering therapy expenditure increased 4-fold from 8% to 32%. CONCLUSIONS: Between 2002 and 2013, nonstatin use increased by 124%, resulting in a 364% increase in nonstatin-associated expenditures.
BACKGROUND: Older hospitalized acute decompensated heart failure (HF) patients have persistently poor outcomes and delayed recovery regardless of ejection fraction (EF). We hypothesized that impairments in physical function, frailty, cognition, mood, and quality of life (QoL) potentially contributing to poor clinical outcomes would be similarly severe in acute decompensated HF patients >/=60 years of age with preserved versus reduced EF (HFpEF and HFrEF). METHODS AND RESULTS: In 202 consecutive older (>/=60 years) hospitalized acute decompensated HF patients in a multicenter trial, we prospectively performed at baseline: short physical performance battery, 6-minute walk distance, frailty assessment, Geriatric Depression Scale, Montreal Cognitive Assessment, and QoL assessments. Older acute decompensated HFpEF (EF >/=45%, n=96) and HFrEF (EF <45%, n=106) patients had similar impairments in all physical function measures (short physical performance battery [5.9+/-0.3 versus 6.2+/-0.2]; 6-minute walk distance [184+/-10 versus 186+/-9 m]; and gait speed [0.60+/-0.02 versus 0.61+/-0.02 m/s]) and rates of frailty (55% versus 52%; P=0.70) and cognitive impairment (77% versus 81%; P=0.56) when adjusted for differences in sex, body mass index, and comorbidities. However, depression and QoL were consistently worse in HFpEF versus HFrEF. Depression was usually unrecognized clinically with 38% having Geriatric Depression Scale >/=5 and no documented history of depression. CONCLUSIONS: Patients >/=60 years hospitalized with acute decompensated HF patients have broad, marked impairments in physical function and high rates of frailty and impaired cognition: these impairments are similar in HFpEF versus HFrEF. Further, depression was common and QoL was reduced, and both were worse in HFpEF than HFrEF. Depression was usually unrecognized clinically. These findings suggest opportunities for novel interventions to improve these important patient-centered outcomes. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02196038.
Heart failure (HF) is an increasingly prevalent condition with a very high symptom burden. To address challenges faced by palliative care clinicians, we assembled a team of experts to provide high-yield tips for the management of these patients. Prognosis is unpredictable in HF and many patients and physicians overestimate survival. Ejection fraction, notably, is not predictive of prognosis. It is important to have thorough discussions about implantable cardioverter defibrillators in terminally ill HF patients. Diuresis is the mainstay of managing volume overload and dyspnea in these patients and it is important to be aggressive and creative to achieve symptom relief. However, HF patients have a high burden of comorbidities and have many symptoms beyond dyspnea as well. Management in hospice remains challenging for these patients, with a significant risk for readmission to the hospital. Almost a quarter of HF patients discharged to hospice from the hospital die in less than three days.
BACKGROUND: Deaths from drug intoxication have increased in the United States but outcomes of recipients of orthotopic heart transplantation (OHT) from these donors are not well characterized. METHODS: We performed a retrospective analysis of the United Network for Organ Sharing's STAR database between January 2000 and March 2014 and assessed mortality and retransplantation using adjusted Cox models by mechanism of donor death. RESULTS: Of the 31,660 OHTs from 2000 to 2014, 1233 (3.9%) were from drug intoxication. These donors were more likely to be female, white, with greater tobacco use and higher BMI compared to donors who died of other mechanisms. Drug intoxication accounted for 1.1% of OHT donors in 2000 and 6.2% in March 2014. No significant difference was observed in 10-year mortality (adjusted hazard ratio [HR], 95% confidence interval [CI]: 0.99, 0.87-1.13), 10-year retransplantation (adjusted HR 0.84, 0.49-1.41) or 1-year and 3-year rehospitalization with other mechanisms of death compared to drug intoxication. CONCLUSION: There has been a large increase in OHT donors who die of drug intoxication in the United States. OHT outcomes from these donors are similar to those dying from other mechanisms. These data have important implications for donor selection in context of the ongoing opioid epidemic.
Importance: While 1 in 10 older patients hospitalized with heart failure (HF) die within 30 days, end-of-life care for this population is not well described. Objective: To assess rates of discharge to hospice, readmission after hospice, and survival in hospice in patients following hospital discharge. Design, Setting, and Participants: In this observational cohort analysis of patients in the multicenter American Heart Association Get With The Guidelines (GWTG)-HF registry linked to Medicare fee-for-service claims data, we analyzed patients 65 years and older discharged alive from the hospital between 2005 and 2014. We compared 4588 patients discharged to hospice with 4357 patients with advanced HF (ejection fraction /=45 mg/dL [to convert to micromoles per liter, multiply by 0.357], systolic blood pressure