Publications by Year: 2021

2021
Kamal AH, Warraich HJ. Advanced Analytics as an Accelerator for Palliative Care and Oncology Integration. JCO Oncol Pract. 2021 :OP2100596.
Maqsood MH, Khan MS, Warraich HJ. Association of Palliative Care Intervention With Health Care Use, Symptom Burden and Advance Care Planning in Adults With Heart Failure and Other Noncancer Chronic Illness. J Pain Symptom Manage. 2021;62 :828-835.Abstract
CONTEXT: Palliative care (PC) improves outcomes in noncancer illness. We hypothesized the benefit is driven by studies of heart failure (HF) patients exclusively versus studies of other noncancer illnesses. OBJECTIVES: To assess difference in outcomes in trials with HF patients exclusively vs studies of other noncancer chronic illness. METHODS: We performed a meta-analysis of studies that assessed association of PC with hospital admissions, emergency department (ED) visits and advance care planning in noncancer chronic illness and compared studies of HF patients versus those with other noncancer chronic illness. RESULTS: Our analysis included 10 HF studies (n=4,057) and 16 non-HF studies (11 mixed conditions, 3 dementia, 2 COPD, n=10,235). PC led to reduction in hospital admissions in HF studies (OR=0.67 [95% CI=0.48-0.95]) but not in other noncancer illness studies (OR=0.86 [95% CI=0.62-1.21]). PC intervention was nonsignificant for change in ED visits in either HF (OR=0.70 [95% CI=0.38-1.28]) or other noncancer studies (OR=0.86 [95% CI=0.69-1.07]). Increase in advance care planning was noted in both HF (OR=4.29 [95% CI=1.44-12.76]) and other studies (OR=2.67 [95% CI=1.29-5.52]). Nonsignificant reductions in symptom burden were noted for both HF-studies and non-HF studies, though overall there was a significant improvement in symptom burden (weighted mean difference -1.15 [95% CI=-1.65, -0.65]). Similar results were noted when studies of mixed populations were excluded from the non-HF studies. CONCLUSION: PC is particularly effective at reducing potentially unwanted hospital admissions for patients with HF compared to other noncancer illnesses. Our findings should further encourage efforts to increase PC access to HF patients.
Kaufman BG, Granger BB, Sun JL, Sanders G, Taylor, D. H. J, Mark DB, Warraich H, Fiuzat M, Steinhauser K, Tulsky JA, et al. The Cost-Effectiveness of Palliative Care: Insights from the PAL-HF Trial. J Card Fail. 2021;27 :662-669.Abstract
BACKGROUND: In a randomized control trial, Palliative Care in Heart Failure (PAL-HF) improved heart failure-related quality of life, though cost-effectiveness remains unknown. The aim of this study was to evaluate the cost-effectiveness of the PAL-HF trial, which provided outpatient palliative care to patients with advanced heart failure. METHODS AND RESULTS: Outcomes for usual care and PAL-HF strategies were compared using a Markov cohort model over 36 months from a payer perspective. The model parameters were informed by PAL-HF trial data and supplemented with meta-analyses and Medicare administrative data. Outcomes included hospitalization, place of death, Medicare expenditures, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Simulated mortality rates were the same for PAL-HF and usual care cohorts, at 89.7% at 36 months. In the base case analysis, the PAL-HF intervention resulted in an incremental gain of 0.03 QALYs and an incremental cost of $964 per patient for an incremental cost-effectiveness ratio of $29,041 per QALY. In 1-way sensitivity analyses, an intervention cost of up to $140 per month is cost effective at $50,000 per QALY. Of 1000 simulations, the PC intervention had a 66.1% probability of being cost effective at a $50,000 willingness-to-pay threshold assuming no decrease in hospitalization. In a scenario analysis, PAL-HF decreased payer spending through reductions in noncardiovascular hospitalizations. CONCLUSIONS: These results from this single-center trial are encouraging that palliative care for advanced heart failure is an economically attractive intervention. Confirmation of these findings in larger multicenter trials will be an important part of developing the evidence to support more widespread implementation of the PAL-HF palliative care intervention.
Kim JM, Kochar A, Warraich HJ. Palliative Care: A Vital Element in the Management of Cardiogenic Shock. J Card Fail. 2021;27 :616-617.
Kumar P, Yasmin F, Khan MS, Shahid I, Diwan MN, Leiter RE, Warraich HJ. Place of death in Parkinson's disease: trends in the USA. BMJ Support Palliat Care. 2021.Abstract
BACKGROUND: Parkinson's disease (PD) is a significant cause of mortality but little is known about the place of death for patients with PD in the USA, a key metric of end-of-life care. METHODOLOGY: A trend analysis was conducted for years 2003-2017 using aggregated death certificate data from the Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research) database, with individual-level mortality data from the Mortality Multiple Cause-of-Death Public Use Record available between 2013 and 2017. All natural deaths for which PD was identified as an underlying cause of death were identified. Place of death was categorised as hospital, decedent home, hospice facility, nursing home/long-term care and other. RESULTS: Between 2003 and 2017, 346141 deaths were attributed to PD (59% males, 93.7% White). Most deaths occurred in patients aged 75-84 years (43.9%), followed by those aged >/=85 years (40.9 %). Hospital and nursing home deaths decreased from 18% (n=3240) and 52.6% (n=9474) in 2003 to 9.2% (n=2949) and 42% (n=13 429) in 2017, respectively. Home deaths increased from 21.1% (n=3804) to 32.4% (n=10 347) and hospice facility deaths increased from 0.3% (n=47) in 2003 to 8.6% (n=2739) in 2017. Female sex, being married and college education were associated with increased odds of home deaths while Hispanic ethnicity and non-white race were associated with increased odds of hospital deaths. CONCLUSION: Home and hospice facility deaths are gradually increasing in patients with PD. Particular attention should be provided to vulnerable socioeconomic groups that continue to have higher rates of hospital deaths and decreased usage of hospice facilities.
Khan MS, Kumar P, Sreenivasan J, Khan SU, Michos ED, Yancy CW, Warraich HJ. Preventable Deaths From Heart Disease and Stroke Among Racial and Ethnic Minorities in the United States. Circ Cardiovasc Qual Outcomes. 2021;14 :e007835.
Khan MS, Kumar P, Sreenivasan J, Khan SU, Nasir K, Mehra MR, C DO', Warraich HJ. Rural-Urban Differences in Mortality From Ischemic Heart Disease, Heart Failure, and Stroke in the United States. Circ Cardiovasc Qual Outcomes. 2021;14 :e007341.
Cross SH, Warraich HJ. Rural-Urban Disparities in Mortality from Alzheimer's and Related Dementias in the United States, 1999-2018. J Am Geriatr Soc. 2021;69 :1095-1096.
Cross SH, Califf RM, Warraich HJ. Rural-Urban Disparity in Mortality in the US From 1999 to 2019. JAMA. 2021;325 :2312-2314.
Bhatia V, Huang Y, Tulsky JA, Cross SH, Kamal AH, Warraich HJ. Trends and Characteristics of Medicare Hospice Beneficiaries in the USA. J Gen Intern Med. 2021;36 :3246-3248.
Maqsood MH, Khan MS, Warraich HJ. Association of Palliative Care Intervention With Health Care Use, Symptom Burden and Advance Care Planning in Adults With Heart Failure and Other Noncancer Chronic Illness. J Pain Symptom Manage. 2021;62 :828-835.Abstract
CONTEXT: Palliative care (PC) improves outcomes in noncancer illness. We hypothesized the benefit is driven by studies of heart failure (HF) patients exclusively versus studies of other noncancer illnesses. OBJECTIVES: To assess difference in outcomes in trials with HF patients exclusively vs studies of other noncancer chronic illness. METHODS: We performed a meta-analysis of studies that assessed association of PC with hospital admissions, emergency department (ED) visits and advance care planning in noncancer chronic illness and compared studies of HF patients versus those with other noncancer chronic illness. RESULTS: Our analysis included 10 HF studies (n=4,057) and 16 non-HF studies (11 mixed conditions, 3 dementia, 2 COPD, n=10,235). PC led to reduction in hospital admissions in HF studies (OR=0.67 [95% CI=0.48-0.95]) but not in other noncancer illness studies (OR=0.86 [95% CI=0.62-1.21]). PC intervention was nonsignificant for change in ED visits in either HF (OR=0.70 [95% CI=0.38-1.28]) or other noncancer studies (OR=0.86 [95% CI=0.69-1.07]). Increase in advance care planning was noted in both HF (OR=4.29 [95% CI=1.44-12.76]) and other studies (OR=2.67 [95% CI=1.29-5.52]). Nonsignificant reductions in symptom burden were noted for both HF-studies and non-HF studies, though overall there was a significant improvement in symptom burden (weighted mean difference -1.15 [95% CI=-1.65, -0.65]). Similar results were noted when studies of mixed populations were excluded from the non-HF studies. CONCLUSION: PC is particularly effective at reducing potentially unwanted hospital admissions for patients with HF compared to other noncancer illnesses. Our findings should further encourage efforts to increase PC access to HF patients.
Valero-Elizondo J, Chouairi F, Khera R, Grandhi GR, Saxena A, Warraich HJ, Virani SS, Desai NR, Sasangohar F, Krumholz HM, et al. Atherosclerotic Cardiovascular Disease, Cancer, and Financial Toxicity Among Adults in the United States. JACC CardioOncol. 2021;3 :236-246.Abstract
Background: Financial toxicity (FT) is a well-established side-effect of the high costs associated with cancer care. In recent years, studies have suggested that a significant proportion of those with atherosclerotic cardiovascular disease (ASCVD) experience FT and its consequences. Objectives: This study aimed to compare FT for individuals with neither ASCVD nor cancer, ASCVD only, cancer only, and both ASCVD and cancer. Methods: From the National Health Interview Survey, we identified adults with self-reported ASCVD and/or cancer between 2013 and 2018, stratifying results by nonelderly (age <65 years) and elderly (age >/=65 years). We defined FT if any of the following were present: any difficulty paying medical bills, high financial distress, cost-related medication nonadherence, food insecurity, and/or foregone/delayed care due to cost. Results: The prevalence of FT was higher among those with ASCVD when compared with cancer (54% vs. 41%; p < 0.001). When studying the individual components of FT, in adjusted analyses, those with ASCVD had higher odds of any difficulty paying medical bills (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.09 to 1.36), inability to pay bills (OR: 1.25; 95% CI: 1.04 to 1.50), cost-related medication nonadherence (OR: 1.28; 95% CI: 1.08 to 1.51), food insecurity (OR: 1.39; 95% CI: 1.17 to 1.64), and foregone/delayed care due to cost (OR: 1.17; 95% CI: 1.01 to 1.36). The presence of >/=3 of these factors was significantly higher among those with ASCVD and those with both ASCVD and cancer when compared with those with cancer (23% vs. 30% vs. 13%, respectively; p < 0.001). These results remained similar in the elderly population. Conclusions: Our study highlights that FT is greater among patients with ASCVD compared with those with cancer, with the highest burden among those with both conditions.
Orlovic M, Warraich H, Wolf D, Mossialos E. End-of-Life Planning Depends on Socio-Economic and Racial Background: Evidence from the US Health and Retirement Study (HRS). J Pain Symptom Manage. 2021;62 :1198-1206.Abstract
CONTEXT: Americans express a strong preference for participating in decisions regarding their medical care, yet they are often unable to participate in decision-making regarding their end-of-life care. OBJECTIVE: To examine determinants of end-of-life planning; including, the effect of an individual's ageing and dying process, health status and socio-economic and racial/ethnic background. METHODS: US observational cohort study, using data from the Health and Retirement Study (1992 - 2014) including 37,494 individuals. Random-effects logistic regression analysis was used to examine the relationship between the presence of a living will and a range of individual time-varying characteristics, including time to death, and several time-invariant characteristics. RESULTS: End-of-life planning depends on several patient characteristics and circumstances, with socio-economic and racial/ethnic background having the largest effects. The probability of having a living will rises sharply late in life, as we would expect, and is further modified by the patient's proximity to death. The dying process, exerts a stronger influence on end-of-life planning than does the aging. CONCLUSIONS: Understanding differences that increase end-of-life planning is important to incentivize patients' participation. Advance planning should be encouraged and accessible to people of all ages as it is inevitable for the provision of patient-centered and cost-effective care.
Slavin SD, Khera R, Zafar SY, Nasir K, Warraich HJ. Financial burden, distress, and toxicity in cardiovascular disease. Am Heart J. 2021;238 :75-84.Abstract
Cardiovascular disease (CVD) is a major source of financial burden and distress, which has 3 main domains: (1) psychological distress; (2) cost-related care non-adherence or medical care deferral, and (3) tradeoffs with basic non-medical needs. We propose 4 ways to reduce financial distress in CVD: (1) policymakers can expand insurance coverage and curtail underinsurance; (2) health systems can limit expenditure on low-benefit, high-cost treatments while developing services for high-risk individuals; (3) physicians can engage in shared-decision-making for high-cost interventions, and (4) community-based initiatives can support patients with system navigation and financial coping. Avenues for research include (1) analysis of how healthcare policies affect financial burden; (2) comparative effectiveness studies examining high and low-cost strategies for CVD management; and (3) studying interventions to reduce financial burden, financial coaching, and community health worker integration.
Thomas A, Valero-Elizondo J, Khera R, Warraich HJ, Reinhardt SW, Ali HJ, Nasir K, Desai NR. Forgone Medical Care Associated With Increased Health Care Costs Among the U.S. Heart Failure Population. JACC Heart Fail. 2021;9 :710-719.Abstract
OBJECTIVES: The objective of this study was to describe the prevalence of patients with forgone/delayed care for heart failure (HF) and examine the associated demographic characteristics, health care utilization, and costs. BACKGROUND: HF is a leading cause of morbidity and mortality, with health care expenditures projected to increase 3-fold from 2012 to 2030. The proportion of HF patients with forgone/delayed medical care and the association with health care expenditures and utilization remain unknown. METHODS: Data on patients with HF were obtained from the Medical Expenditure Panel Survey to assess expenditures and health care utilization in the United States from 2004 to 2015. Patients with HF who reported forgone/delayed care, any missed or delayed medical treatment, were compared with those without care lapses. RESULTS: Overall, 16% of patients with HF reported forgone/delayed care, including 10% among the elderly (aged >/=65 years) and 27% among the nonelderly (aged <65 years). Patients with HF who reported forgone/delayed care had annual health care expenses $8,027 (95% CI: $1,181-$14,872) higher than those who did not. Among the elderly, those reporting forgone/delayed care had more emergency department visits (43% vs 58%; P < 0.05), and had higher annual inpatient costs (+$7,548; 95% CI: $1,109-$13,988) and total health care costs (+$10,581; 95% CI: $1,754-$19,409). Sixty percent of nonelderly and 46% of elderly patients with HF reported deferring care due to financial barriers. CONCLUSIONS: Nearly 1 in 6 patients with HF in the United States reported forgone/delayed medical care, with one-half attributing it to financial reasons, and this was associated with higher overall health care spending.
Kim JM, Kochar A, Warraich HJ. Palliative Care: A Vital Element in the Management of Cardiogenic Shock. J Card Fail. 2021;27 :616-617.
Wan L, Samsky MD, O'Connor CM, Stebbins A, Alhanti B, Warraich HJ, Johnson KS, Anstrom KJ, Fiuzat M, Granger BB, et al. Patterns of Change in Individual Domains of the Kansas City Cardiomyopathy Questionnaire With a Palliative Care Intervention for Patients With Advanced Heart Failure: Insights from PAL-HF. J Card Fail. 2021;27 :1476-1478.
Kumar P, Yasmin F, Khan MS, Shahid I, Diwan MN, Leiter RE, Warraich HJ. Place of death in Parkinson's disease: trends in the USA. BMJ Support Palliat Care. 2021.Abstract
BACKGROUND: Parkinson's disease (PD) is a significant cause of mortality but little is known about the place of death for patients with PD in the USA, a key metric of end-of-life care. METHODOLOGY: A trend analysis was conducted for years 2003-2017 using aggregated death certificate data from the Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research) database, with individual-level mortality data from the Mortality Multiple Cause-of-Death Public Use Record available between 2013 and 2017. All natural deaths for which PD was identified as an underlying cause of death were identified. Place of death was categorised as hospital, decedent home, hospice facility, nursing home/long-term care and other. RESULTS: Between 2003 and 2017, 346141 deaths were attributed to PD (59% males, 93.7% White). Most deaths occurred in patients aged 75-84 years (43.9%), followed by those aged >/=85 years (40.9 %). Hospital and nursing home deaths decreased from 18% (n=3240) and 52.6% (n=9474) in 2003 to 9.2% (n=2949) and 42% (n=13 429) in 2017, respectively. Home deaths increased from 21.1% (n=3804) to 32.4% (n=10 347) and hospice facility deaths increased from 0.3% (n=47) in 2003 to 8.6% (n=2739) in 2017. Female sex, being married and college education were associated with increased odds of home deaths while Hispanic ethnicity and non-white race were associated with increased odds of hospital deaths. CONCLUSION: Home and hospice facility deaths are gradually increasing in patients with PD. Particular attention should be provided to vulnerable socioeconomic groups that continue to have higher rates of hospital deaths and decreased usage of hospice facilities.
Vaduganathan M, Li D, Van Meijgaard J, Warraich HJ. Prescription Filling Patterns of Evidence-Based Medical Therapies for Heart Failure During the COVID-19 Pandemic in the United States. J Card Fail. 2021;27 :1280-1284.Abstract
BACKGROUND: Maintaining a steady medication supply during a public health crisis is a major health priority. We leveraged a large U.S. pharmacy-claims database to understand the use of evidence-based therapies in heart failure (HF) care during the coronavirus disease-2019 (COVID-19) pandemic. METHODS: We analyzed 27,027,650 individual claims from an all-payer pharmacy-claims database across 56,155 chain, independent and mail-order pharmacies in 14,164 zip codes in 50 states. Prescriptions dispensed (in 2-week intervals) of evidence-based HF therapies in 2020 were indexed to comparable timeframes in 2019. We normalized these year-to-year changes in HF medical therapies relative to those observed with a stable basket of drugs. RESULTS: Fills of losartan, lisinopril, carvedilol, and metoprolol all peaked in the weeks of March 2020 and demonstrated trajectories thereafter that were relatively consistent with the reference set of drugs. Fills of spironolactone (+4%) and eplerenone (+18%) showed modest trends toward increased relative use during 2020. Fills of empagliflozin (+75%), dapagliflozin (+65%) and sacubitril/valsartan (+61%) showed striking longitudinal increases throughout 2020 that deviated substantially from year-to-year trends of the overall basket of drugs. For all 3 therapies, fills of all quantity sizes increased relatively throughout 2020. For both generic and brand-name therapies, prescription fill patterns from mail-order pharmacies increased substantially over expected trends beginning in March 2020 CONCLUSION: Prescription fills of most established generic therapies used in HF care were maintained, whereas those of sacubitril/valsartan and the sodium-glucose cotransporter-2 inhibitors steeply increased during the COVID-19 pandemic. These nationwide pharmacy claims data provide reassurance about therapeutic access, during a public health crisis, to evidence-based medications used in HF care.
Tobin RS, Samsky MD, Kuchibhatla M, O'Connor CM, Fiuzat M, Warraich HJ, Anstrom KJ, Granger BB, Mark DB, Tulsky JA, et al. Race Differences in Quality of Life following a Palliative Care Intervention in Patients with Advanced Heart Failure: Insights from the Palliative Care in Heart Failure Trial. J Palliat Med. 2021.Abstract
Introduction: Black patients have a higher incidence of heart failure (HF) and worse outcomes than white patients. Guidelines recommend palliative care for patients with advanced HF, but no studies have examined outcomes in a black patient cohort. Methods: This is a post hoc analysis of the Palliative Care in Heart Failure trial, which randomized patients to usual care plus a palliative care intervention (UC+PAL) or usual care (UC). Quality of life (QoL) was measured using Kansas City Cardiomyopathy Questionnaire (KCCQ) and Functional Assessment of Chronic Illness Therapy-Palliative Care scale (FACIT-Pal). Results: Black patients represented 41% of the 148 patients. At six months, QoL improved more in UC+PAL than UC for both racial subgroups. The difference was greater for black than white patients (difference: KCCQ 10.8 vs. 2.5; FACIT-Pal: 14.8 vs. 3.9). However, the findings were not statistically significant. Conclusions: Larger studies are needed to assess the benefits of palliative care for black patients with HF. ClinicalTrials.gov Identifier: NCT01589601.

Pages