Prediction model for COVID-19 patient visits in the ambulatory setting.

Objective: Healthcare systems globally were shocked by coronavirus disease 2019 (COVID-19). Policies put in place to curb the tide of the pandemic resulted in a decrease of patient volumes throughout the ambulatory system. The future implications of COVID-19 in healthcare are still unknown, specifically the continued impact on the ambulatory landscape. The primary objective of this study is to accurately forecast the number of COVID-19 and non-COVID-19 weekly visits in primary care practices. Materials and Methods: This retrospective study was conducted in a single health system in Delaware. All patients' records were abstracted from our electronic health records system (EHR) from January 1, 2019 to July 25, 2020. Patient demographics and comorbidities were compared using t-tests, Chi square, and Mann Whitney U analyses as appropriate. ARIMA time series models were developed to provide an 8-week future forecast for two ambulatory practices (AmbP) and compare it to a naïve moving average approach. Results: Among the 271,530 patients considered during this study period, 4,195 patients (1.5%) were identified as COVID-19 patients. The best fitting ARIMA models for the two AmbP are as follows: AmbP1 COVID-19+ ARIMAX(4,0,1), AmbP1 nonCOVID-19 ARIMA(2,0,1), AmbP2 COVID-19+ ARIMAX(1,1,1), and AmbP2 nonCOVID-19 ARIMA(1,0,0). Discussion and Conclusion: Accurately predicting future patient volumes in the ambulatory setting is essential for resource planning and developing safety guidelines. Our findings show that a time series model that accounts for the number of positive COVID-19 patients delivers better performance than a moving average approach for predicting weekly ambulatory patient volumes in a short-term period.

The impact of care management information technology model on quality of care after Coronary Artery Bypass Surgery: "Bridging the Divides".

BACKGROUND: Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after Coronary Artery Bypass Surgery (CABG) and reduce readmissions. METHODS: CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). In addition there is an analytic engine to help evaluate and guide care, Neuron™ (Coldlight Solutions, LLC). RESULTS: The "Bridges" program enrolled a total of 716 CABG patients with 850 admissions from April 2013 through March 2015. The data of the program was compared with those of 1111 CABG patients with 1203 admissions in the 3years prior to the program. No impact was seen with respect to readmissions, Blood Pressure or LDL control. There was no significant improvement in patients' reported outcomes using either the CTM-3 or any of the SAQ-7 scores. Patient follow-up with physicians within 1week of discharge improved during the Bridges years. CONCLUSIONS: The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time.

The impact of care management information technology model on quality of care after percutaneous coronary intervention: "Bridging the Divides".

BACKGROUND: Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after percutaneous coronary intervention (PCI) and reduce readmissions. METHODS: CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). An additional analytic engine [Neuron™ (ColdLight Solutions, LLC)] helps, evaluates and guide care. RESULTS: The "Bridges" program enrolled a total of 2054 PCI patients with 2835 admission from April, 1st 2013 through March 1st, 2015. The data of the program was compared with those of 3691 PCI patients with 4414 admissions in the 3years prior to the program. No impact was seen with respect to inpatient and observation readmission, or emergency department visits. Similarly no change was noticed in LDL control. There was minimal improvement in BP control and only in the CTM-3 and SAQ-7 physical limitation scores in the patients' reported outcomes. Patient follow-up with physicians within 1week of discharge improved during the Bridges years. CONCLUSIONS: The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time. The Bridges program suggests that population health management must be a long-term goal, improving preventive care in the community.

Impact of a Multidisciplinary Team Approach Including an Intensivist on the Outcomes of Critically Ill Patients in the Cardiac Care Unit.

OBJECTIVE: To investigate the impact of integrating a medical intensivist into a cardiac care unit (CCU) multidisciplinary team on the outcomes of CCU patients. PATIENTS AND METHODS: We conducted a retrospective cohort study of 2239 CCU admissions between July 1, 2011, and July 1, 2013, which constituted patients admitted in the 12 months before and 12 months after the introduction of intensivists into the CCU multidisciplinary team. This team included a cardiologist, a medical intensivist, medical house staff, nurses, a pharmacist, a dietitian, and physical and respiratory therapists. The primary outcome was CCU mortality. Secondary outcomes included hospital mortality, CCU length of stay, hospital length of stay, and duration of mechanical ventilation. RESULTS: After the implementation of a multidisciplinary team approach, there was a significant decrease in both adjusted CCU mortality (3.5% vs 5.9%; P=.01) and hospital mortality (4.4% vs 11.1%; P<.01). A similar impact was observed on adjusted mean CCU length of stay (2.5±2.0 vs 2.9±2.0 days; P<.01), adjusted mean hospital length of stay (7.0±4.5 vs 7.5±4.5 days; P<.01), and adjusted mean ventilation duration (2.0±1.0 vs 4.3±2.5 days; P<.01). CONCLUSION: The implementation of a multidisciplinary team approach in which an intensivist and a cardiologist comanage the critical care of CCU patients is feasible and may result in better patient outcomes.

Anemia does not predict mortality in elderly patients with heart failure.

Recent studies suggest that anemia is an independent predictor of adverse outcomes in patients with heart failure (HF), but the importance of anemia in elderly HF patients is unclear. To investigate this relationship, the authors quantified the prognostic importance of anemia in elderly vs younger patients with HF was performed. A chart review of 359 patients hospitalized in 1999 with HF was performed. Patients were categorized based on their hemoglobin (Hgb) level (<11.5, 11.5-13.4, >13.4 g/dL), and the authors used time-to-event analyses to test the hypothesis that Hgb predicted mortality over a mean follow-up of 25 months. Lower Hgb predicted worse survival in patients younger than 75 years (n=204; P=.03), but there was no correlation between Hgb level and mortality in patients 75 or older (n=155; P not significant). The authors conclude that anemia is not an important predictor of long-term survival in very elderly patients hospitalized with HF.

Poor prognosis for patients with chronic kidney disease despite ICD therapy for the primary prevention of sudden death.

INTRODUCTION: Chronic kidney disease (CKD) has been independently associated with increased cardiovascular mortality. Little is known about the benefit of implantable cardioverter defibrillator (ICD) therapy for prevention of sudden death in this large, high-risk population. We sought to evaluate the impact of CKD on survival in patients who received an ICD for primary prevention of sudden death. METHODS AND RESULTS: In this retrospective study of patients who underwent ICD implantation for primary prevention of sudden death, patients were stratified by CKD, defined as serum creatinine > or = 2 mg/dL or dialysis use. Primary endpoint was mortality. CKD was identified in 35 of 229 patients (15.3%). There were 33 deaths during a follow-up period of 18.0 +/- 15.2 months: 17 of 35 CKD patients and 16 of 194 patients without CKD (48.6% vs 8.2%, P < 0.00001 by log-rank). One-year survival for patients with and without CKD was 61.2% and 96.3%, respectively. Cox regression analysis controlling for age, sex, comorbidities, ejection fraction, and medications proved CKD to be the strongest independent predictor of death (hazard ratio 10.5; 95% confidence interval 4.8-23.1; P = 0.0001). This risk was dependant on severity of CKD; a 10 mL/min reduction in creatinine clearance was associated with a 55% increase in hazard of death (P < 0.0001). CONCLUSIONS: In patients receiving an ICD for primary prevention of sudden death, CKD significantly reduced long-term survival. This poor prognosis may limit the impact of primary prevention ICD therapy in this patient population.

Radiofrequency ablation of atrioventricular nodal reentrant tachycardia using a novel magnetic guidance system compared with a conventional approach.

BACKGROUND: A novel magnetic guidance system has been developed that allows the operator to remotely navigate an electrophysiology mapping/ablation catheter to precise locations in the heart for treatment of tachyarrhythmias. To date, this new technology has not been directly compared with the conventional approach. OBJECTIVE: To compare the use of the magnetic guidance system to the conventional approach for ablation of atrioventricular nodal reentry tachycardia. METHODS: Between November 2002 and October 2004, 28 patients with atrioventricular nodal reentry tachycardia treated with the magnetic guidance system were retrospectively compared with 28 matched control patients. RESULTS: Patients treated using the magnetic guidance system had similar procedure durations and fluoroscopy times compared with the matched controls. The only statistically significant difference between the groups was a longer time between insertion of the ablation catheter and placement of the first radiofrequency lesion in the magnetic guidance system cohort (23.3 +/- 12.0 vs. 10.5 +/- 13.9, p=0.001), possibly due to the research protocol. However, there was a trend toward a shorter total time that radiofrequency energy was applied in the magnetic guidance system cohort (5.2 +/- 4.5 vs. 8.0 +/- 7.2, p=0.087). There were no major complications or recurrences after at least 3 months of follow-up among the patients treated with the magnetic guidance system. CONCLUSION: The magnetic guidance system appears to have similar, and possibly improved, clinical efficacy compared with conventional catheter navigation for the treatment of atrioventricular nodal reentrant tachycardia.

Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall.

PURPOSE: Patients at high risk for falls are presumed to be at increased risk for intracranial hemorrhage, and high risk for falls is cited as a contraindication to antithrombotic therapy. Data substantiating this concern are lacking. METHODS: Quality improvement organizations identified 1245 Medicare beneficiaries who were documented in the medical record to be at high risk of falls and 18261 other patients with atrial fibrillation. The patients were elderly (mean 80 years), and 48% were prescribed warfarin at hospital discharge. The primary endpoint was subsequent hospitalization for an intracranial hemorrhage, based on ICD-9 codes. RESULTS: Rates (95% confidence interval [CI]) of intracranial hemorrhage per 100 patient-years were 2.8 (1.9-4.1) in patients at high risk for falls and 1.1 (1.0-1.3) in other patients. Rates (95% CI) of traumatic intracranial hemorrhage were 2.0 (1.3-3.1) in patients at high risk for falls and 0.34 (0.27-0.45) in other patients. Hazard ratios (95% CI) of other independent risk factors for intracranial hemorrhage were 1.4 (1.0-3.1) for neuropsychiatric disease, 2.1 (1.6-2.7) for prior stroke, and 1.9 (1.4-2.4) for prior major bleeding. Warfarin prescription was associated with intracranial hemorrhage mortality but not with intracranial hemorrhage occurrence. Ischemic stroke rates per 100 patient-years were 13.7 in patients at high risk for falls and 6.9 in other patients. Warfarin prescription in patients prone to fall who had atrial fibrillation and multiple additional stroke risk factors appeared to protect against a composite endpoint of stroke, intracranial hemorrhage, myocardial infarction, and death. CONCLUSION: Patients at high risk for falls with atrial fibrillation are at substantially increased risk of intracranial hemorrhage, especially traumatic intracranial hemorrhage. However, because of their high stroke rate, they appear to benefit from anticoagulant therapy if they have multiple stroke risk factors.

Atrial fibrillation in the elderly / 老年心脏病学杂志（英文版）

Atrial fibrillation (AF) is an extremely common condition in the elderly, with increasing prevalence around the world as the population ages. AF may be associated with serious health consequences, including stroke, heart failure, and decreased quality of life, so that careful management of AF by geriatric health care providers is required. With careful attention to anticoagulation therapy, and prudent use of medications and invasive procedures to minimize symptoms, many of the adverse health consequences of AF can be prevented.

Predictors of mortality in younger and older patients with heart failure and preserved or reduced left ventricular ejection fraction.

BACKGROUND: Although half of elderly patients with heart failure have preserved left ventricular ejection fraction (LVEF), little is known about predictors of mortality in this group. METHODS: We reviewed the charts of 400 patients hospitalized at an academic medical center in 1999 with a principal discharge diagnosis of heart failure. Patients were divided into 4 groups on the basis of age > or =75 or <75 years and the presence of preserved or reduced LVEF. Vital status was ascertained as of October 2001. RESULTS: A total of 373 patients (mean age 69.1 years, 56.0% female, 47.5% nonwhite) underwent echocardiography to assess LVEF. Of these, 216 patients were <75 years of age (81 with preserved LVEF [group 1, 21.7%] and 135 with reduced LVEF [group 2, 36.2%]), and 157 were > or =75 years of age (81 with preserved LVEF [group 3, 21.7%] and 76 with reduced LVEF [group 4, 19.6%]). After a mean follow-up of 25 months, independent predictors of mortality among the 4 groups differed substantially: group 1, male sex, prescription of a calcium-channel blocker, and diuretic dose at discharge; group 2, blood urea nitrogen (BUN), lower hemoglobin level, and not being prescribed a beta-blocker at discharge; group 3, BUN; and group 4, older age, history of myocardial infarction, severity of reduced LVEF, and diuretic dose. CONCLUSION: In patients with heart failure, predictors of mortality vary by age and by the presence of preserved or reduced LVEF. Traditional predictors of mortality in patients with reduced LVEF may not apply to elderly patients with preserved LVEF.

Management of heart failure in the elderly.

Chronic heart failure is an epidemic disorder in the elderly population. The frequent coexistence of comorbid illnesses and psychosocial issues in older persons often makes diagnosis and management difficult. Physicians must be aware of the current diagnostic modalities and proven therapies as they apply to elderly patients in order to achieve optimal outcomes. This article reviews new approaches to the diagnosis of heart failure, and discusses the latest evidence for both pharmacologic and nonpharmacologic treatment for this condition. Multidisciplinary strategies for the management of heart failure and end-of-life care are also briefly discussed.