Publications

2019
Cross SH, Kaufman BG, Warraich HJ. Trends in Location of Death for Individuals With Cerebrovascular Disease in the United States. JAMA Neurol. 2019.
Cross SH, Kaufman BG, Mentz RJ, Kamal AH, Taylor, D. H. J, Warraich HJ. Trends in Place of Death for Individuals With Cardiovascular Disease in the United States. J Am Coll Cardiol. 2019;74 :1943-1946.
Okunrintemi V, Khera R, Spatz ES, Salami JA, Valero-Elizondo J, Warraich HJ, Virani SS, Blankstein R, Blaha MJ, Pawlik TM, et al. Association of Income Disparities with Patient-Reported Healthcare Experience. J Gen Intern Med. 2019;34 :884-892.Abstract
BACKGROUND: Disparities in health outcome exist among patients according to socioeconomic status. However, little is known regarding the differences in healthcare experiences across the various levels of income of patients. In a nationally representative US adult population, we evaluate the differences in healthcare experiences based on patient level of income. OBJECTIVES: To evaluate the differences in patient healthcare experiences based on level of income. PATIENTS AND METHODS: We identified 68,447 individuals (mean age, 48 +/- 18 years; 55% female) representing 176.8 million US adults, who had an established healthcare provider in the 2010-2013 Medical Expenditure Panel Survey cohort. This retrospective study examined the differences in all five patient-reported healthcare experience measures (access to care, provider responsiveness, patient-provider communication, shared decision-making, and patient satisfaction) under the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We examined the relationship between patient income and their healthcare experience. RESULTS: Overall, 32% of the study participants were high-income earners while 23% had very-low income. Lower income was consistently associated with poor patient report on healthcare experience. Compared with those with high income, very-low-income-earning participants had 1.63 times greater odds (OR 1.63, 95% CI 1.45-1.82) of experiencing difficulty accessing care, had 1.34 times higher odds (OR 1.34, 95% CI 1.25-1.45) of experiencing poor communication, had higher odds (OR 1.68, 95% CI 1.46-1.92) of experiencing delays in healthcare delivery, and were more likely to report poor provider satisfaction (OR 1.48, 95% CI 1.37-1.61). CONCLUSION: Lower income-earning patients have poorer healthcare experience in all aspects of access and quality of care. Targeted policies focusing on improving communication, engagement, and satisfaction are needed to enhance patient healthcare experience for this vulnerable population.
Warraich HJ, O'Connor CM, Yang H, Granger BB, Johnson KS, Mark DB, Anstrom KJ, Patel CB, Steinhauser KE, Tulsky JA, et al. African Americans With Advanced Heart Failure Are More Likely to Die in a Health Care Facility Than at Home or in Hospice: An Analysis From the PAL-HF Trial. J Card Fail. 2019.
Carbone J, Sethi-Brown A, Rosenberg B, Warraich H. Aid in Dying in North Carolina. N C Med J. 2019;80 :128.
Warraich HJ, Wolf SP, Mentz RJ, Rogers JG, Samsa G, Kamal AH. Characteristics and Trends Among Patients With Cardiovascular Disease Referred to Palliative Care. JAMA Netw Open. 2019;2 :e192375.Abstract
Importance: Use of palliative care (PC) for patients with cardiovascular disease (CVD) has increased recently. However, it is unknown if patients are receiving earlier referrals to PC. Objective: To assess characteristics and trends of patients with CVD referred to PC. Design, Setting, and Participants: Cohort study in which analysis of data from the multicenter Quality Data Collection Tool for Palliative Care registry from January 2, 2015, through December 29, 2017, included patients with CVD 18 years or older referred to initial PC consultation who had a documented palliative performance score (PPS) . Exposures: Patients with CVD who presented for an initial PC visit. Main Outcomes and Measures: The primary outcome was PPS. Secondary outcomes included symptoms and end-of-life documentation. Results: Among 1801 patients (mean [SD] age, 77.7 [13.7] years) from 16 sites in the analysis, 875 (48.6%) were women and 1339 (74.3%) were white. A low PPS score (0%-30%), consistent with bedbound status, was recorded for 521 patients (28.9%), with no change through time. The most common moderate to severe symptoms were poor well-being, tiredness, anorexia, and dyspnea. Year of encounter was associated with improved symptoms of pain (odds ratio, 1.25; 95% CI, 1.05-1.50) and with constipation (odds ratio, 1.32; 95% CI, 1.03-1.69). No change through time was noted in other symptoms or end-of-life documentation. Although the proportion of referrals from general medicine increased from 43.2% (167 of 387) in 2015 to 52.9% (410 of 775) in 2017, the proportion of referrals from cardiologists decreased from 16.5% (64 of 387) in 2015 to 10.5% (81 of 775) in 2017. The proportion of patients referred to PC who were black decreased from 11.9% (46 of 387) in 2015 to 6.3% (49 of 775) in 2017. While 69.5% of all patients with CVD (1252 of 1801) had a primary diagnosis of heart failure, the proportion of non-heart failure CVD diagnoses, such as coronary artery disease and valvular heart disease, increased from 25.6% (99 of 387) in 2015 to 30.1% (233 of 775) in 2017. Conclusions and Relevance: Patients with CVD demonstrated significant symptom burden, and there was no evidence in the registry of change in the PPSs of patients with CVD referred to PC through time. Cardiologists provided comparatively fewer referrals to PC for patients with CVD, and this proportion decreased through time. The proportion of racial and ethnic minorities referred to PC was small and decreased through time. These findings reinforce the need for cardiologists to be more engaged with PC and consider referring appropriate patients with CVD sooner.
Warraich HJ, Allen LA, Blue LJ, Chaussee EL, Thompson JS, McIlvennan CK, Flint KM, Matlock DD, Patel CB. Comorbidities and the decision to undergo or forego destination therapy left ventricular assist device implantation: An analysis from the Trial of a Shared Decision Support Intervention for Patients and their Caregivers Offered Destination Therapy for End. Am Heart J. 2019;213 :91-96.Abstract
BACKGROUND: Patients considering destination therapy left ventricular assist devices (DT LVAD) often have high comorbid burden but the association between these comorbidities and post-decision outcomes is unknown. METHODS: We included subjects in DECIDE-LVAD (NCT02344576), a stepped-wedge multicenter trial of patients considering LVADs, recording comorbidities per INTERMACS protocol. We compared decisional conflict, regret, perceived stress, quality of life (EQ-VAS), depression (PHQ-2), struggle with- and acceptance of illness by comorbid burden and amongst the most common comorbidities. RESULTS: Of 239 patients, LVAD recipients (n=164) and non-recipients (n=75) had a similar proportion with >/=1 comorbidity (70% v. 80%, P=.09). Patients with comorbidities were younger regardless of LVAD implantation status. After adjusting for age, overall and amongst LVAD recipients, patients with >/=1 comorbidity had higher mean decision conflict at baseline (23.2+/-1.5 vs. 17.4+/-2.2), and at 6 months, higher stress (13.0+/-0.6 vs. 10.4+/-1.0) and struggle with illness (13.3+/-0.4 vs. 11.1+/-0.6) than those without comorbidities (P<.05). No difference was noted in decision regret, PHQ-2, EQ-VAS, acceptance of illness and survival overall and amongst LVAD recipients. Of the three most common comorbidities, while patients with pulmonary hypertension had worse decision regret, depression, stress and acceptance of illness at 6-month follow-up than those who did not have pulmonary hypertension, no difference was noted in patients with chronic renal disease or high body mass index. CONCLUSION: Patients considering LVAD implantation with comorbidities experience increased decision conflict, stress and struggle with illness. These findings provide insights in the role comorbidities play in patient decision-making and decisional outcomes.
Warraich HJ, Califf RM. Differences in Health Outcomes between Men and Women: Biological, Behavioral, and Societal Factors. Clin Chem. 2019;65 :19-23.
Warraich HJ, Yancy CW. Failure Is Not an Option: Optimizing Care for Heart Failure Patients at the End of Life. JACC Heart Fail. 2019;7 :558-560.
Warraich HJ, Taylor Dh J, Casarett DJ, Hasan M, Patel CB, Kamal AH, Harker M, Mentz RJ. Hospice Care for Heart Failure: Challenges Faced by Hospice Staff in a Predominantly Rural Setting. J Palliat Med. 2019;22 :7-8.
Cross SH, Kamal AH, Taylor, D. H. J, Warraich HJ. Hospice Use Among Patients with Heart Failure. Card Fail Rev. 2019;5 :93-98.Abstract
Despite its many benefits, hospice care is underused for patients with heart failure. This paper discusses the factors contributing to this underuse and offers recommendations to optimise use for patients with heart failure and proposes metrics to optimise quality of hospice care for this patient group.
Warraich HJ, Patel CB, Kochar A, Rogers JG, Patel MR. Incorporating Shared Decision Making and Palliative Care Into Cardiogenic Shock Pathways. J Am Coll Cardiol. 2019;74 :591-592.
Chuzi S, Allen LA, Dunlay SM, Warraich HJ. Palliative Inotrope Therapy: A Narrative Review. JAMA Cardiol. 2019.Abstract
Importance: The number of patients living with end-stage heart failure is steadily growing, and ambulatory intravenous inotropic support is increasingly offered as a palliative therapy. However, the optimal ways to initiate, manage, and discuss the risks and benefits of palliative inotropes in the current era of heart failure care are unclear. Observations: The initiation of palliative inotropes requires an understanding of clinical, psychosocial, and economic factors, as well as the changing risk-to-benefit calculus. While earlier studies suggested that outpatient inotrope therapy provided symptomatic benefit at the expense of reduced survival, recent data suggest that the survival of patients receiving chronic inotropes may be improving over time, perhaps owing to the use of implantable cardioverter defibrillators, concurrent guideline-directed medical therapy, or lower doses of inotropes. The use of heart failure therapies, such as beta-blockade, among patients receiving palliative inotropes is controversial but may be appropriate in select situations. Conclusions and Relevance: The role of palliative inotropes is changing in tandem with advances in chronic heart failure care. However, there remains a profound lack of data and guidance on the effect of palliative inotropes on quality of life and mortality and little consensus on how this therapy can be optimally used in contemporary practice. This review provides a framework for the prescription and management of palliative inotropes, including a discussion of potential risks and benefits and a roadmap for how to initiate, maintain, and wean them.
Warraich HJ, Meier DE. Serious-Illness Care 2.0 - Meeting the Needs of Patients with Heart Failure. N Engl J Med. 2019;380 :2492-2494.
Patel RB, Warraich HJ, Butler J, Vaduganathan M. Surprise, surprise: improving the referral pathway to palliative care interventions in advanced heart failure. Eur J Heart Fail. 2019;21 :235-237.
Warraich HJ, Maurer MS, Patel CB, Mentz RJ, Swetz KM. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Left Ventricular Assist Devices. J Palliat Med. 2019;22 :437-441.Abstract
Advanced heart failure (HF) is a common condition that leads to significant suffering for patients and their families. Left ventricular assist devices (LVADs) can improve both the quantity and quality of life for those suffering with advanced HF. Palliative care clinicians are being asked with increasing frequency to assist HF teams to manage patients with LVADs in the preimplantation, post-operative, and end-of-life settings, although not all palliative care providers feel comfortable with this technology. Written by specialists in HF, geriatric cardiology, and palliative care, this article seeks to improve palliative care providers' knowledge of LVADs and will prepare palliative care teams to counsel and support LVAD patients and their families from pre-implantation to the end of life.
2018
Warraich HJ, Rana JS. Diabetic Dyslipidemia: Epidemiology and Prevention of Cardiovascular Disease and Implications of Newer Therapies. Curr Cardiol Rep. 2018;20 :125.Abstract
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.
Salami JA, Warraich HJ, Valero-Elizondo J, Spatz ES, Desai NR, Rana JS, Virani SS, Blankstein R, Khera A, Blaha MJ, et al. National Trends in Nonstatin Use and Expenditures Among the US Adult Population From 2002 to 2013: Insights From Medical Expenditure Panel Survey. J Am Heart Assoc. 2018;7.Abstract
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.
Warraich HJ, Rogers JG, Dunlay SM, Hummel E, Mentz RJ. Top Ten Tips for Palliative Care Clinicians Caring for Heart Failure Patients. J Palliat Med. 2018;21 :1646-1650.Abstract
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.
Warraich HJ, Kaltenbach LA, Fonarow GC, Peterson ED, Wang TY. Adverse Change in Employment Status After Acute Myocardial Infarction: Analysis From the TRANSLATE-ACS Study. Circ Cardiovasc Qual Outcomes. 2018;11 :e004528.Abstract
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.

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