Faculty Bibliography

Several randomized trials and decision analysis models have found that remote monitoring may reduce health care utilization and expenditures in patients with cardiac implantable electronic devices (CIEDs), compared with in-office monitoring. However, little is known about the generalizability of these findings to unselected populations in clinical practice. To compare health care utilization and expenditures associated with remote monitoring and in-office monitoring in patients with CIEDs, we used Truven Health MarketScan Commercial Claims and Medicare Supplemental Databases. We selected patients newly implanted with an implantable cardioverter defibrillators (ICD), cardiac resynchronization therapy defibrillator (CRT-D), or permanent pacemaker (PPM), in 2009, who had continuous health plan enrollment 2 years after implantation. Generalized linear models and propensity score matching were used to adjust for confounders and estimate differences in health care utilization and expenditures in patients with remote or in-office monitoring. We identified 1,127; 427; and 1,295 pairs of patients with a similar propensity for receiving an ICD, CRT-D, or PPM, respectively. Remotely monitored patients with ICDs experienced fewer emergency department visits resulting in discharge (p = 0.050). Remote monitoring was associated with lower health care expenditures in office visits among patients with PPMs (p = 0.025) and CRT-Ds (p = 0.006) and lower total inpatient and outpatient expenditures in patients with ICDs (p <0.0001). In conclusion, remote monitoring of patients with CIEDs may be associated with reductions in health care utilization and expenditures compared with exclusive in-office care.

OBJECTIVE: To examine the cost and cost-effectiveness of implementing Students for Nutrition and eXercise (SNaX), a 5-week middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education. METHODS: Five intervention and 5 control middle schools (mean enrollment, 1520 students) from the Los Angeles Unified School District participated in a randomized controlled trial of SNaX. Acquisition costs for materials and time and wage data for employees involved in implementing the program were used to estimate fixed and variable costs. Cost-effectiveness was determined using the ratio of variable costs to program efficacy outcomes. RESULTS: The costs of implementing the program over 5 weeks were $5433.26 per school in fixed costs and $2.11 per student in variable costs, equaling a total cost of $8637.17 per school, or $0.23 per student per day. This investment yielded significant increases in the proportion of students served fruit and lunch and a significant decrease in the proportion of students buying snacks. The cost-effectiveness of the program, per student over 5 weeks, was $1.20 per additional fruit served during meals, $8.43 per additional full-priced lunch served, $2.11 per additional reduced-price/free lunch served, and $1.69 per reduction in snacks sold. CONCLUSIONS: SNaX demonstrated the feasibility and cost-effectiveness of a middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education. Its cost is modest and unlikely to be a significant barrier to adoption for many schools considering its implementation.

Background: Advancements in precision medicine hold significant promise for improving care among patients at risk for or diagnosed with cardiovascular disease. A blood-based age/ sex/gene expression score (ASGES) incorporating key features of precision medicine has shown clinical validity with a 96% negative predictive value in determining a patient's current likelihood of obstructive coronary artery disease (CAD). Objective(s): To better characterize the clinical utility of the ASGES, a community-based registry was established to evaluate its effect on clinical decision-making. Material/Methods: The prospective PRESET Registry enrolled stable, non-acute adult patients presenting with symptoms suggestive of obstructive CAD from 20 US primary care practices fromSeptember 2012 to August 2014. Demographics, clinical characteristics, and ASGES results (predefined as low [ASGES < 15] or elevated [ASGES > 15]) were collected, as were referrals to cardiology or further functional/anatomic cardiac testing (ETT, ECHO, MPI, CCTA, ICA) after ASGES testing. Patients were followed for 1-year post-ASGES testing. Results: Among the 288 women cohort (median age 57 years), clinicians referred 20/218 (9%) patients with low scores versus 31/70 (44%) patients with elevated scores to cardiology or advanced cardiac testing (unadjusted OR 0.13, p<0.0001; adjusted OR 0.14, p<0.0001). Six patients experienced major adverse cardiovascular outcomes during follow-up: all were considered unrelated to obstructive CAD. Conclusions: In this community-based cardiovascular registry, the age/sex/gene expression score demonstrated clinical utility and long-term safety in the evaluation of women with suspected obstructive CAD, thereby minimizing unnecessary referrals and additional testing of low-risk patients. Our work adds to the evidence base for precision medicine in cardiovascular care

BACKGROUND: Appropriate use criteria (AUC) for cardiac stress tests address concerns about utilization growth and patient safety. We systematically reviewed studies of appropriateness, including within physician specialties; evaluated trends over time and in response to AUC updates; and characterized leading indications for inappropriate/rarely appropriate testing. METHODS: We searched PubMed (2005-2015) for English-language articles reporting stress echocardiography or myocardial perfusion imaging (MPI) appropriateness. Data were pooled using random-effects meta-analysis and meta-regression. RESULTS: Thirty-four publications of 41,578 patients were included, primarily from academic centers. Stress echocardiography appropriate testing rates were 53.0% (95% CI, 45.3%-60.7%) and 50.9% (42.6%-59.2%) and inappropriate/rarely appropriate rates were 19.1% (11.4%-26.8%) and 28.4% (23.9%-32.8%) using 2008 and 2011 AUC, respectively. Stress MPI appropriate testing rates were 71.1% (64.5%-77.7%) and 72.0% (67.6%-76.3%) and inappropriate/rarely appropriate rates were 10.7% (7.2%-14.2%) and 15.7% (12.4%-19.1%) using 2005 and 2009 AUC, respectively. There was no significant temporal trend toward rising rates of appropriateness for stress echocardiography or MPI. Unclassified stress echocardiograms fell by 79% (p = 0.04) with updated AUC. There were no differences between cardiac specialists and internists. CONCLUSIONS: Rates of appropriate use tend to be lower for stress echocardiography compared to MPI, and updated AUC reduced unclassified stress echocardiograms. There is no conclusive evidence that AUC improved appropriate use over time. Further research is needed to determine if integration of appropriateness guidelines in academic and community settings is an effective approach to optimizing inappropriate/rarely appropriate use of stress testing and its associated costs and patient harms.

Objective: Better methods are needed for the evaluation of women presenting to the primary care physician (PCP) office with symptoms of obstructive coronary artery disease (CAD), as current methods are characterized by test overutilization, high costs, patient exposure to appreciable risks from radiation and contrast-dye reactions, and diagnostic uncertainty. A previously validated blood-based test combining age, sex, and gene expression levels into an algorithmic score has been shown to have a 96% negative predictive value in a combined population of men and women in determining a patient's current likelihood of obstructive CAD, thereby helping primary care clinicians rule out obstructive CAD diagnosis in low-to-intermediate risk symptomatic patients. We hypothesized that information from the age/sex/gene expression score (ASGES) would change medical decision making during the evaluation of participants presenting with stable chest pain or anginal equivalent symptoms. The primary outcome of this analysis was the association between ASGES and referrals for further cardiac evaluation in women. Design: The prospective PRESET Registry (NCT01677156) enrolled stable, non-acute adults evaluated for obstructive CAD from 21 US primary care, community-based practices over a one-year period. Primary care physicians, nurse practitioners, and physician assistants at primary care practices were educated and trained on the use and interpretation of the ASGES through a standardized in-service program. The laboratory reported the patient's ASGES to the primary care provider within a median of three days from the blood draw, who were then able to incorporate the ASGES test results, in conjunction with other clinical information, into their medical decision-making process for further diagnostic evaluation. Data collected included the patient demographics, comorbidities, and clinical presentation, and the clinician's treatment plan before vs. after receiving the ASGES results. We evaluated the relationship between the ASGES results (predefined as low [ASGES <15] or elevated [ASGES >15]) and decision making, including cardiology referrals and downstream cardiac diagnostic tests. Results: In the registry cohort of 718 evaluable patients, 369 (51%). were female participants with a median age of 59 years, median BMI of 29, and median ASGES of 9 (range, 1-40). The ASGES test showed that 272 of 369 patients (74%) had low scores. With regard to further diagnostic evaluation, which included either referral to cardiology and/or advanced cardiac testing (MPI, ECHO, CCTA, ICA), 21 of 272 (8%) of women with low ASGES and 31 of 97 (32%) of women with elevated ASGES were referred to cardiology or advanced diagnostic testing (OR 0.18, p<0.0001). The overall MACE event rate for the female cohort was 0.5% (2/369, both events were judged to be unrelated to the investigational agent or procedure) at 30-days post-ASGES. Conclusion: A blood test incorporating age, sex, and gene expression was adopted into clinical practice and showed clinical utility in helping clinicians rule-out obstructive CAD as the cause of women's symptoms in this large community-based primary care patient registry presenting with typical and atypical symptoms suggestive of obstructive CAD. There was a statistically significant and clinical relevant reduction in referral to cardiology and advanced cardiac testing among low ASGES women who have a low current likelihood for obstructive CAD, thus preventing unnecessary-and potentially harmful and invasive-downstream cardiac testing. The ASGES blood test may help address an important diagnostic challenge in cardiovascular medicine in the care of midlife women

OBJECTIVE: Clinicians need better approaches to evaluating women at midlife and beyond who present to primary care with chest pain and related symptoms. A previously validated blood-based test, which includes age, sex, and gene expression levels, showed a 96% negative predictive value for determining an individual's current likelihood of having obstructive coronary artery disease (CAD) in a combined population of men and women. We hypothesized that age/sex/gene expression score (ASGES) would be incorporated into medical decision-making and would influence the rate of further cardiac evaluation. METHODS: An aggregate analysis of female cohorts from the Investigation of a Molecular Personalized Coronary Gene Expression Test on Primary Care Practice Pattern (IMPACT-PCP; NCT01594411) and REGISTRY I (NCT01557855) studies was conducted. Data on 320 women presenting with stable symptoms suggestive of obstructive CAD and undergoing ASGES testing (from 16 primary care providers in geographically diverse sites) were pooled. The primary outcome of this analysis was the association between ASGES and referrals for further cardiac evaluation. RESULTS: The mean participant age was 57.8 years, and the mean ASGES (predefined as low [ASGES 15]) was 10.3. The referral rate for further cardiac evaluation was 4.0% (10 of 248) for women with low ASGES versus 83.3% (60 of 72) for women with elevated ASGES, with an overall follow-up major adverse cardiac event/revascularization rate of 1.2%. After adjustment for clinical covariates, women with low ASGES were significantly less likely to be referred for further cardiac evaluation (odds ratio, 0.013; P < 0.0001). CONCLUSIONS: ASGES can be incorporated into medical decision-making to help primary care providers rule out obstructive CAD among symptomatic women who are unlikely to benefit from further cardiac testing.