Discharge Processes and 30-Day Readmission Rates of Patients Hospitalized for Heart Failure on General Medicine and Cardiology Services.

Given high rates of heart failure (HF) hospitalizations and widespread adoption of the hospitalist model, patients with HF are often cared for on General Medicine (GM) services. Differences in discharge processes and 30-day readmission rates between patients on GM and those on Cardiology during the contemporary hospitalist era are unknown. The present study compared discharge processes and 30-day readmission rates of patients with HF admitted on GM services and those on Cardiology services. We retrospectively studied 926 patients discharged home after HF hospitalization. The primary outcome was 30-day all-cause readmission after discharge from index hospitalization. Although 60% of patients with HF were admitted to Cardiology services, 40% were admitted to GM services. Prevalence of cardiovascular and noncardiovascular co-morbidities were similar between patients admitted to GM services and Cardiology services. Discharge summaries for patients on GM services were less likely to have reassessments of ejection fraction, new study results, weights, discharge vital signs, discharge physical examinations, and scheduled follow-up cardiologist appointments. In a multivariable regression analysis, patients on GM services were more likely to experience 30-day readmissions compared with those on Cardiology services (odds ratio 1.43 95% confidence interval [1.05 to 1.96], p = 0.02). In conclusion, outcomes are better among those admitted to Cardiology services, signaling the need for studies and interventions focusing on noncardiology hospital providers that care for patients with HF.

Role of Cardiac PET in Clinical Practice.

OPINION STATEMENT: Early identification of atherosclerosis and at-risk lesions plays a critical role in reducing the burden of cardiovascular disease. While invasive coronary angiography serves as the gold standard for diagnosing coronary artery disease, non-invasive imaging techniques provide visualization of both anatomical and functional atherosclerotic processes prior to clinical presentation. The development of cardiac positron emission tomography (PET) has greatly enhanced our capability to diagnose and treat patients with early stages of atherosclerosis. Cardiac PET is a powerful, versatile non-invasive diagnostic tool with utility in the identification of high-risk plaques, myocardial perfusion defects, and viable myocardial tissue. Cardiac PET allows for comparisons of myocardial function both at time of rest and stress, providing accurate assessments of both myocardial perfusion and viability. Furthermore, novel PET techniques with unique radiotracers yield clinically relevant data on high-risk plaques in active progressive atherosclerosis. While PET exercise stress tests were previously difficult to perform given short radiotracer half-life, the development of the novel radiotracer Flurpiridaz F-18 provides a promising future for PET exercise stress imaging. In addition, hybrid imaging with computed tomography angiography (CTA) and cardiac magnetic resonance (CMR) provides integration of cardiac function and structure. In this review article, we discuss the principles of cardiac PET, the clinical applications of PET in diagnosing and prognosticating patients at risk for future cardiovascular events, compare PET with other non-invasive cardiac imaging modalities, and discuss future applications of PET in CVD evaluation and management.

Role of molecular imaging with positron emission tomographic in aortic aneurysms.

Aortic aneurysms (AA) are often asymptomatic before the occurrence of acute, potentially fatal complications including dissection and/or rupture. Beyond aortic size, the ability to assess aortic wall characteristics and processes contributing to aneurysm development may allow improved selection of patients who may benefit from prophylactic surgical intervention. Current risk stratification for aneurysms relies upon routine noninvasive imaging of aortic size without assessing the underlying pathophysiologic processes, including features such as inflammation, which may be associated with aneurysm development and progression. The use of molecular imaging modalities with positron emission tomographic (PET) scan allows characterization of aortic wall inflammatory activity. Elevated uptake of Fuorine-2-deoxy-D-glucose (FDG), a radiotracer with elevated avidity in highly-metabolic cells, has been correlated with the development and progression of both abdominal and thoracic AA in a number of animal models and clinical studies. Other novel PET radiotracers targeting matrix metalloproteinases (MMPs), mitochondrial translocator proteins (TSPO) and endothelial cell adhesion molecules are being investigated for clinical utility in identifying progression of disease in AA. By further defining the activation of molecular pathways in assessing aortic regions at risk for dilatation, this imaging modality can be integrated into future clinical decision-making models.

Cost-Effectiveness of Dabigatran (150 mg Twice Daily) and Warfarin in Patients ≥ 65 Years With Nonvalvular Atrial Fibrillation.

Dabigatran has been shown to be superior to warfarin for stroke prevention in nonvalvular atrial fibrillation (NVAF) but with higher out-of-pocket costs for patients. Although dabigatran has been shown to be cost effective from a societal perspective, cost implications for individual patients and insurers are not well described. We aimed to assess cost perspectives of each payer (Medicare and patient) in relation to administration, monitoring, and adverse outcomes for dabigatran and warfarin in patients with and without prescription drug coverage. Using a Markov model, we performed a decision analysis comparing 2 treatment strategies (dose-adjusted warfarin and dabigatran 150 mg twice daily) in patients 65 years old with NVAF, CHADS2 scores ≥ 1, and Medicare insurance. Patients have a quality-adjusted life expectancy of 8.998 quality-adjusted life years with warfarin and 9.39 quality-adjusted life years with dabigatran 150 mg twice daily. From Medicare's perspective, the incremental cost-effectiveness ratio comparing dabigatran with warfarin was $35,311 for patients with Part D coverage and cost saving for patients without coverage. From the patient's perspective, the incremental cost-effectiveness ratio comparing dabigatran with warfarin was cost saving for patients with Part D coverage and $63,884 for those without coverage. In patients ≥ 65 years with NVAF and prescription insurance coverage, dabigatran 150 mg twice daily is both cost effective (Medicare's perspective) and cost saving (patient perspective) compared with warfarin, at a willingness-to-pay threshold of $100,000. However, patients without prescription drug coverage have a high out-of-pocket cost burden with dabigatran therapy, leading to a reduction in its cost-effectiveness compared with warfarin therapy. In conclusion, this Markov model suggests that Medicare Part D coverage influences the cost-effectiveness of dabigatran 150 mg daily compared with dose-adjusted warfarin from multiple payer perspectives.

Patterns, risk factors and treatment associated with PICC-DVT in hospitalized adults: A nested case-control study.

BACKGROUND: Peripherally inserted central catheters (PICCs) are associated with upper extremity-deep vein thrombosis (DVT). However, patterns, risk factors and treatment associated with this event remain poorly defined. OBJECTIVE: To determine patterns, risk factors and treatment related to PICC-DVT in hospitalized patients. DESIGN, SETTING & PATIENTS: Between 2012-2013, consecutive cases of ultrasound-confirmed, symptomatic PICC-DVT were identified. For each case, at least two contemporaneous controls were identified and matched by age and gender. Patient- and device-specific data were obtained through electronic-medical records. Using variables selected a priori, multivariable logistic regression models were fit to the outcome of PICC-DVT, comparing cases to controls. RESULTS: 909 adult hospitalized patients (268 cases, 641 controls) were included in the study. Indications for PICC placement included long-term intravenous antibiotic therapy (n=447; 49.1%), in-hospital venous access for blood draws or infusion of medications (n=342; 44.2%), and total parenteral nutrition (n=120; 6.7%). Patients with PICC-DVT were more likely to have a history of venous thromboembolism (OR 1.70, 95% CI=1.02-2.82) or have undergone surgery while the PICC was in situ (OR 2.17, 95%CI=1.17-4.01 for surgeries longer than two hours). Treatment for PICC-DVT varied and included heparin bridging, low molecular weight heparin only and device removal only; the average duration of treatment also varied across these groups. Compared to 4-Fr PICCs, 5- and 6-Fr PICCs were associated with greater risk of DVT (OR 2.74, 95%CI=0.75-10.09 and OR 7.40 95%CI=1.94-28.16, respectively). Patients who received both aspirin and statins were less likely to develop PICC-DVT than those that received neither treatment (OR 0.31, 95%CI=0.16-0.61). Receipt of pharmacological DVT prophylaxis during hospitalization showed a non-significant trend towards reduction in risk of PICC-DVT (OR=0.72, 95%CI=0.48-1.08). CONCLUSION: Several factors appear associated with PICC-DVT. While some of these characteristics may be non-modifiable, future studies that target potentially modifiable variables to prevent this adverse outcome would be welcomed.

Physician variation in perceived barriers to personal health.

OBJECTIVE: Physicians' personal health habits are associated with their counseling habits regarding physical activity. We sought to examine physicians' own barriers to a healthy lifestyle by level of training and gender. METHODS: Physicians at a major teaching hospital were surveyed regarding their lifestyle habits and barriers to healthy habits. The frequency of reported barriers was examined by years in practice (trainees vs staff physicians) and gender. RESULTS: 183 total responses were received. Over 20% of respondents were overweight. Work schedule was cited as the greatest barrier to regular exercise in 70.5% of respondents. Trainees were more likely to cite time constraints or cost as a barrier to a healthy diet compared to staff physicians. Staff physicians were more likely to report the time to prepare healthy foods as a barrier. For both trainees and staff physicians, time was a barrier to regular exercise. For trainees work schedule was a barrier, while both work schedule and family commitments were top barriers cited by staff physicians. Women were more likely to report family commitments as a barrier than men. Respondents suggested healthier options in vending machines and the hospital cafeteria, healthy recipes, and time and/or facilities for exercise at work as options to help overcome these barriers. CONCLUSION: Work schedules and family commitments are frequently reported by providers as barriers to healthy lifestyle. Efforts to reduce such barriers may lead to improved health habits among providers.