Overcoming gaps: regional collaborative to optimize capacity management and predict length of stay of patients admitted with COVID-19.

OBJECTIVE: Ensuring an efficient response to COVID-19 requires a degree of inter-system coordination and capacity management coupled with an accurate assessment of hospital utilization including length of stay (LOS). We aimed to establish optimal practices in inter-system data sharing and LOS modeling to support patient care and regional hospital operations. MATERIALS AND METHODS: We completed a retrospective observational study of patients admitted with COVID-19 followed by 12-week prospective validation, involving 36 hospitals covering the upper Midwest. We developed a method for sharing de-identified patient data across systems for analysis. From this, we compared 3 approaches, generalized linear model (GLM) and random forest (RF), and aggregated system level averages to identify features associated with LOS. We compared model performance by area under the ROC curve (AUROC). RESULTS: A total of 2068 patients were included and used for model derivation and 597 patients for validation. LOS overall had a median of 5.0 days and mean of 8.2 days. Consistent predictors of LOS included age, critical illness, oxygen requirement, weight loss, and nursing home admission. In the validation cohort, the RF model (AUROC 0.890) and GLM model (AUROC 0.864) achieved good to excellent prediction of LOS, but only marginally better than system averages in practice. CONCLUSION: Regional sharing of patient data allowed for effective prediction of LOS across systems; however, this only provided marginal improvement over hospital averages at the aggregate level. A federated approach of sharing aggregated system capacity and average LOS will likely allow for effective capacity management at the regional level.

The Cardiovascular Quality Improvement and Care Innovation Consortium: Inception of a Multicenter Collaborative to Improve Cardiovascular Care.

Despite decades of improvement in the quality and outcomes of cardiovascular care, significant gaps remain. Existing quality improvement strategies are often limited in scope to specific clinical conditions and episodic care. Health services and outcomes research is essential to inform gaps in care but rarely results in the development and implementation of care delivery solutions. Although individual health systems are engaged in projects to improve the quality of care delivery, these efforts often lack a robust study design or implementation evaluation that can inform generalizability and further dissemination. Aligning the work of health care systems and health services and outcomes researchers could serve as a strategy to overcome persisting gaps in cardiovascular quality and outcomes. We describe the inception of the Cardiovascular Quality Improvement and Care Innovation Consortium that seeks to rapidly improve cardiovascular care by (1) developing, implementing, and evaluating multicenter quality improvement projects using innovative care designs; (2) serving as a resource for quality improvement and care innovation partners; and (3) establishing a presence within existing quality improvement and care innovation structures. Success of the collaborative will be defined by projects that result in changes to care delivery with demonstrable impacts on the quality and outcomes of care across multiple health systems. Furthermore, insights gained from implementation of these projects across sites in Cardiovascular Quality Improvement and Care Innovation Consortium will inform and promote broad dissemination for greater impact.

CD34+ cell therapy significantly reduces adverse cardiac events, health care expenditures, and mortality in patients with refractory angina.

Patients with refractory angina who are suboptimal candidates for further revascularization have improved exercise time, decreased angina frequency, and reduced major adverse cardiac events with intramyocardial delivery of CD34+ cells. However, the effect of CD34+ cell therapy on health care expenditures before and after treatment is unknown. We determined the effect of CD34+ cell therapy on cardiac-related hospital visits and costs during the 12 months following stem cell injection compared with the 12 months prior to injection. Cardiac-related hospital admissions and procedures were retrospectively tabulated for patients enrolled at one site in one of three double-blinded, placebo-controlled CD34+ trials in the 12 months before and after intramyocardial injections of CD34+ cells vs placebo. Fifty-six patients were randomized to CD34+ cell therapy (n = 37) vs placebo (n = 19). Patients randomized to cell therapy experienced 1.57 ± 1.39 cardiac-related hospital visits 12 months before injection, compared with 0.78 ± 1.90 hospital visits 12 months after injection, which was associated with a 62% cost reduction translating to an average savings of $5500 per cell therapy patient. Patients in the placebo group also demonstrated a reduction in cardiac-related hospital events and costs, although to a lesser degree than the CD34+ group. Through 1 January 2019, 24% of CD34+ subjects died at an average of 6.5 ± 2.4 years after enrollment, whereas 47% of placebo patients died at an average of 3.7 ± 1.9 years after enrollment. In conclusion, CD34+ cell therapy for subjects with refractory angina is associated with improved mortality and a reduction in hospital visits and expenditures for cardiac procedures in the year following treatment.

Use of routinely captured echocardiographic data in the diagnosis of severe aortic stenosis.

OBJECTIVE: To determine the implications of applying guideline-recommended definitions of aortic stenosis to echocardiographic data captured in routine clinical care. METHODS: Retrospective observational study of 213 174 patients who underwent transthoracic echocardiographic imaging within Allina Health between January 2013 and October 2017. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of echocardiographic measures for severe aortic stenosis were determined relative to the documented interpretation of severe aortic stenosis. RESULTS: Among 77 067 patients with complete assessment of the aortic valve, 1219 (1.6%) patients were categorised as having severe aortic stenosis by the echocardiographic reader. Relative to the documented interpretation, aortic valve area (AVA) as a measure of severe aortic stenosis had the high sensitivity (94.1%) but a low positive predictive value (37.5%). Aortic valve peak velocity and mean gradient were specific (>99%), but less sensitive (<70%). A measure incorporating peak velocity, mean gradient and dimensionless index (either by velocity time integral or peak velocity ratio) achieved a balance of sensitivity (92%) and specificity (99%) with little detriment in accuracy relative to peak velocity and mean gradient alone (98.9% vs 99.3%). Using all available data, the proportion of patients whose echocardiogram could be assessed for aortic stenosis was 79.8% as compared with 52.7% by documented interpretation alone. CONCLUSION: A measure that used dimensionless index in place of AVA addressed discrepancies between quantitative echocardiographic data and the documented interpretation of severe aortic stenosis. These findings highlight the importance of understanding the limitations of clinical data as it relates to quality improvement efforts and pragmatic research design.

Resource utilization and outcome among patients with selective versus nonselective troponin testing.

OBJECTIVE: In patients with suspected acute coronary syndrome (ACS), troponin testing is effective for diagnosis and prognosis. Troponin testing has now expanded to include patients without suspected ACS. This nonselective troponin testing has unknown consequences for resource utilization and outcome. Therefore, we examined selective versus nonselective troponin testing with respect to patient characteristics, resource utilization, and outcome. METHODS: This retrospective 1-year study included all patients with troponin testing at a U.S. emergency department. Testing was classified as selective (ACS) or nonselective (non-ACS) based on admission ICD-9 codes. Troponin upper reference limit (URL) was ≥99th percentile. RESULTS: Among 47,053 patients, troponin was measured in 9109 (19%) of whom 5764 were hospitalized. Admission diagnosis was non-ACS in 4427 (77%) and ACS in 1337 (23%). Non-ACS patients were older, 71±17 versus 65±16 years, with longer hospital stay, 77 versus 32 h, and greater 1-year mortality 22% versus 6.7%; P<.001. In patients with troponin ≥URL, revascularization was performed in 64 (4.7%) of non-ACS versus 213 (48%) of ACS; P<.001. In patients with troponin 80% of the non-ACS population CONCLUSIONS: Contemporary troponin testing is frequently nonselective. The non-ACS and ACS populations differ significantly regarding clinical characteristics, revascularization rates, and outcomes. Troponin elevation is a powerful predictor of 1-year mortality in non-ACS, this association reveals an opportunity for risk stratification and targeted therapy. KEY QUESTIONS: In patients with suspected acute coronary syndrome (ACS), troponin testing is effective for diagnosis and prognosis. However, troponin testing has now expanded to include patients without suspected ACS. This nonselective troponin testing has unknown consequences for hospital resource utilization and patient outcome. Our findings demonstrate contemporary troponin testing is largely nonselective (77% of testing was performed in patients without acute coronary syndrome). In comparison to patients with acute coronary syndrome, those with non-acute coronary syndrome are older, with longer hospital stay, lower revascularization rates, and greater 1-year mortality. Troponin elevation identifies a high-risk population in both acute coronary syndrome and non-acute coronary syndrome populations, yet effective treatment for the latter is lacking.

Value-Based ST-Segment-Elevation Myocardial Infarction Care Using Risk-Guided Triage and Early Discharge.

BACKGROUND: Prior studies suggest that low-risk ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention can be considered for early discharge. We describe the implementation of an STEMI risk score to decrease cost while maintaining optimal patient outcomes. METHODS AND RESULTS: We determined the impact of risk-guided STEMI care on healthcare value through the retrospective application of the Zwolle Risk Score to 967 patients receiving primary percutaneous coronary intervention between 2009 and 2011. Of these patients, 540 (56%) were categorized as low risk, indicating they may be safely triaged directly to a telemetry unit rather than the intensive care unit and targeted for early discharge. We subsequently developed and implemented a modified Zwolle Risk Calculator into the electronic medical record to support application of the fast-track protocol for low-risk STEMI patients. Among 549 prospective patients with STEMI, 62% were low risk, and the fast-track protocol was followed in 75% of cases. Prospective results confirmed lower rates of complications (low risk 8.3% versus high risk 38.7%; P<0.001) and in-hospital mortality (low risk 0.4% versus High risk 12.5%; P<0.001) in the low-risk cohort. Low-risk patients had a shorter median length of stay (median and [25th, 75th percentiles]: low risk 2 [2, 3] versus high risk: 3 [2, 6]; P<0.001) and lower overall costs (low risk $6720 [$5280-$9030] versus high risk $11 783 [$7953-$25 359]; P<0.001). Low-risk patients treated on-protocol had shorter median length of stay (on-protocol 2 [1, 2] versus off-protocol 2 [2, 3]; P<0.001) and hospital costs (on-protocol $6090 [$4730, $7356] versus off-protocol $11 783 [$7953, $25 359]; P<0.001) than those treated off-protocol. On-protocol low-risk patients in the prospective cohort also had lower costs and shorter length of stay than low-risk patients in the retrospective cohort (P<0.001 for both). CONCLUSIONS: In our study, risk-guided triage and discharge after primary percutaneous coronary intervention for STEMI improved healthcare value by reducing costs of care without compromising quality of care or patient outcomes.

Value in cardiovascular care.

Healthcare value, defined as health outcomes achieved relative to the costs of care, has been proposed as a unifying approach to measure improvements in the quality and affordability of healthcare. Although value is of increasing interest to payers, many providers remain unfamiliar with how value differs from other approaches to the comparison of cost and outcomes (ie, cost-effectiveness analysis). While cost-effectiveness studies can be used by policy makers and payers to inform decisions about coverage and reimbursement for new therapies, the assessment of healthcare can guide improvements in the delivery of healthcare to achieve better outcomes at lower cost. Comparison on value allows for the identification of healthcare delivery organisations or care delivery settings where patient outcomes have been optimised at a lower cost. Gaps remain in the measurement of healthcare value, particularly as it relates to patient-reported health status (symptoms, functional status and health-related quality of life). The use of technology platforms that capture health status measures with minimal disruption to clinical workflow (ie, web portals, automated telephonic systems and tablets to facilitate capture outside of in-person clinical interaction) is facilitating use of health status measures to improve clinical care and optimise patient outcomes. Furthermore, the use of a value framework has catalysed quality improvement efforts and research to seek better patient outcomes at lower cost.

Design, Challenges, and Implications of Quality Improvement Projects Using the Electronic Medical Record: Case Study: A Protocol to Reduce the Burden of Postoperative Atrial Fibrillation.

Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery, which results in increased morbidity, mortality, length of stay, and hospital costs. We developed and followed a process map to implement a protocol to decrease POAF: (1) identify stakeholders and form a working committee, (2) formal literature and guideline review, (3) retrospective analysis of current institutional data, (4) data modeling to determine expected effects of change, (4) protocol development and implementation into the electronic medical record, and (5) ongoing review of data and protocol adjustment. Retrospective analysis demonstrated that POAF occurred in 29.8% of all cardiovascular surgery cases. Median length of stay was 2 days longer (P<0.001), and median total variable costs $2495 higher (P<0.001) in POAF patients. Modeling predicted that up to 60 cases of POAF and >$200 000 annually could be saved. A clinically based electronic medical record tool was implemented into the electronic medical record to aid preoperative clinic providers in identifying patients eligible for prophylactic amiodarone. Initial results during the 9-month period after implementation demonstrated a reduction in POAF in patients using the protocol, compared with those who qualified but did not receive amiodarone and those not evaluated (11.1% versus 38.7% and 38.8%; P=0.022); however, only 17.3% of patients used the protocol. A standardized methodological approach to quality improvement and electronic medical record integration has potential to significantly decrease the incidence of POAF, length of stay, and total variable cost in patients undergoing elective coronary artery bypass graft and valve surgeries. This framework for quality improvement interventions may be adapted to similar clinical problems beyond POAF.

Chest Compression Injuries Detected via Routine Post-arrest Care in Patients Who Survive to Admission after Out-of-hospital Cardiac Arrest.

Abstract Objective. To examine injuries produced by chest compressions in out-of-hospital cardiac arrest (OHCA) patients who survive to hospital admission. Methods. A retrospective cohort study was conducted among 235 consecutive patients who were hospitalized after nontraumatic OHCA in Minnesota between January 2009 and May 2012 (117 survived to discharge; 118 died during hospitalization). Cases were eligible if the patient had received prehospital compressions from an emergency medical services (EMS) provider. One EMS provider in the area was using a mechanical compression device (LUCASTM) as standard equipment, so the association between injury and use of mechanical compression was also examined. Prehospital care information was abstracted from EMS run sheets, and hospital records were reviewed for injuries documented during the post-arrest hospitalization that likely resulted from compressions. Results. Injuries were identified in 31 patients (13%), the most common being rib fracture (9%) and intrathoracic hemorrhage (3%). Among those who survived to discharge, the mean length of stay was not statistically significantly different between those with injuries (13.5 days) and those without (10.8 days; p = 0.23). Crude injury prevalence was higher in those who died prior to discharge, had received compressions for >10 minutes (versus ≤10 minutes) and underwent computer tomography (CT) imaging, but did not differ by bystander compressions or use of mechanical compression. After multivariable adjustment, only compression time > 10 min and CT imaging during hospitalization were positively associated with detected injury (OR = 7.86 [95% CI = 1.7-35.9] and 6.30 [95% CI = 2.6-15.5], respectively). Conclusion. In patients who survived OHCA to admission, longer duration of compressions and use of CT during the post-arrest course were associated positively with documented compression injury. Compression-induced injuries detected via routine post-arrest care are likely to be largely insignificant in terms of length of recovery.

Pharmacotherapy in the treatment of mitral regurgitation: a systematic review.

BACKGROUND AND AIM OF THE STUDY: Chronic mitral regurgitation (MR) causes volume overload on the left ventricle and, if uncorrected, will over time lead to left ventricular remodeling and heart failure. The benefits of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) in primary MR are not well defined. METHODS: MEDLINE was searched for studies in which the effects of ACE inhibitors and ARBs on chronic MR had been examined. The inclusion criteria required the patient population to have chronic MR, a normal left ventricular ejection fraction, and to report a quantitative measure of the change in MR severity. Studies in which patients had secondary MR were excluded. RESULTS: Nineteen studies met the inclusion criteria (13 daily therapy, five single-dose, and one combined study). The pooled mean decrease in regurgitant fraction (RF) was 7.7% [95% CI 4.9, 10.6] and 9.3% [95% CI 3.4, 15.2] for studies in patients with daily therapy and single-dose therapy, respectively. Among studies which reported changes in regurgitant volume (RV), the pooled mean decrease was 7.9 ml [95% CI 1.4, 14.5]. For patients with mitral valve prolapse (MVP), the pooled mean reduction in RF was 8.1% [95% CI 4.3, 11.9] and in rheumatic disease it was 3.4% [95% CI 13.2 - 7.0]. Across the seven studies of daily therapy which reported a change in left ventricular end-diastolic volume index (LVEDVI), the mean decrease was 11.5 ml/m2 [95% CI 2.4, 20.6]. CONCLUSION: ACE inhibitors and ARBs each reduced the RF, RV, and left ventricular size by a modest degree in chronic primary MR.

Correlates of delayed recognition and treatment of acute type A aortic dissection: the International Registry of Acute Aortic Dissection (IRAD).

BACKGROUND: In acute aortic dissection, delays exist between presentation and diagnosis and, once diagnosed, definitive treatment. This study aimed to define the variables associated with these delays. METHODS AND RESULTS: Acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and January 2007 were evaluated for factors contributing to delays in presentation to diagnosis and in diagnosis to surgery. Multiple linear regression was performed to determine relative delay time ratios (DTRs) for individual correlates. The median time from arrival at the emergency department to diagnosis was 4.3 hours (quartile 1-3, 1.5-24 hours; n=894 patients) and from diagnosis to surgery was 4.3 hours (quartile 1-3, 2.4-24 hours; n=751). Delays in acute aortic dissection diagnosis occurred in female patients; those with atypical symptoms that were not abrupt or did not include chest, back, or any pain; patients with an absence of pulse deficit or hypotension; or those who initially presented to a nontertiary care hospital (all P<0.05). The largest relative DTRs were for fever (DTR=5.11; P<0.001) and transfer from nontertiary hospital (DTR=3.34; P<0.001). Delay in time from diagnosis to surgery was associated with a history of previous cardiac surgery, presentation without abrupt or any pain, and initial presentation to a nontertiary care hospital (all P<0.001). The strongest factors associated with operative delay were prolonged time from presentation to diagnosis (DTR=1.35; P<0.001), race other than white (DTR=2.25; P<0.001), and history of coronary artery bypass surgery (DTR=2.81; P<0.001). CONCLUSIONS: Improved physician awareness of atypical presentations and prompt transport of acute aortic dissection patients could reduce crucial time variables.