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Temporal trends in utilization and outcomes of transcatheter aortic valve replacement in different races: an analysis of the national inpatient sample

Ullah, Waqas; Al-Khadra, Yasser; Mir, Tanveer; Darmoch, Fahed; Pacha, Homam M; Sattar, Yasar; Ijioma, Nketchi; Mohamed, Mohamed O; Kwok, Chun S; Asfour, Abedelrahim I; Kapadia, Samir; Rizik, David; Zehr, Kenton; Mamas, Mamas A; Alraies, M Chadi
AIM:We sought to determine the racial and ethnical disparities in the delivery of TAVR and to evaluate the in-hospital outcomes and utilization of TAVR stratified by patient ethnicity. METHOD:Using a national inpatient sample database between 2011 and 2015, we identified all adult patients who had TAVR. Races were identified and white race was set as control. Multiple logistic regression analysis was performed for the primary outcome of in-hospital mortality. RESULTS:Out of 58 174 patients who underwent TAVR, 50 809 (87.3%) were white, 2327 (4.0%) were black, 2311 (4.0%) were Hispanic, 640 (1.1%) Asian, 105 (0.2%) Native American and 1982 (3.4%) of other ethnicities. We found a statistically significant linear uptrend in the utilization of TAVR in patients of all races between the years 2011 and 2015. White, black, Hispanic and Native American patients had a downward linear trend for mortality during the studied years (P ≤ 0.005 for all). Black patients had lower in-hospital mortality [2.8 vs. 3.6%, odds ratio (OR) = 0.62; 95% confidence interval (CI) 0.44, 0.81 P < 0.001] compared with white patients, whereas Hispanic patients and Native Americans had higher in-hospital mortality compared with white patients (4.5% OR 1.26; 95% CI 1.01, 1.56 P = 0.041), (9.5% OR 4.44; 95% CI 2.25, 8.77 P < 0.001), respectively. CONCLUSION:Overall, TAVR utilization is associated with lower mortality. There is a rising trend in utilization of TAVR in the black population with a significantly favorable mortality trend compared with the white population.
PMID: 34076606
ISSN: 1558-2035
CID: 5493322

Outcomes of Transradial Versus Transfemoral Access of Percutaneous Coronary Intervention in STEMI: Systematic Review and Updated Meta-analysis

Sattar, Yasar; Majmundar, Monil; Ullah, Waqas; Mamtani, Sahil; Kumar, Ashish; Robinson, Sam; Zghouzi, Mohamed; Mir, Tanveer; Dhamrah, Umaima; Al-Khadra, Yasser; Pacha, Homam Moussa; Darmoch, Fahed; Soud, Mohamad; Hakim, Zaher; Bagur, Rodrigo; Kaul, Prashant; Ijioma, Nkechinyere; Panchal, Ankur; Shroff, Adhir R; Alraies, M Chadi
BACKGROUND/UNASSIGNED:Transradial (TR) percutaneous coronary intervention (PCI) is a preferable PCI route. The complication difference between TR and TF approaches is controversial. METHODS/UNASSIGNED:PubMed, Embase, and the Cochrane databases were queried for PCI outcomes of TR TF in STEMI for major cardiac and cerebrovascular events (MACCE), major bleeding, and mortality. The odds ratio (OR) was calculated using the random-effect model. RESULTS/UNASSIGNED:We included 56 studies comprising of 68,733 patients (TR, n = 26,179; TF, n = 42,537). TR-PCI was associated with statistically significant lower odds of MACCE (OR = 0.66, 95% CI: 0.49-0.88, p-value = 0.005), major bleeding (OR = 0.47, 95% CI 0.32-0.68, p-value<0.001), mortality (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001) at in hospital follow-up. TR-PCI was associated with statistically significant lower MACCE (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001), major bleeding (OR = 0.58, 95% CI 0.49-0.68, p-value<0.001), and mortality (OR = 0.61, 95% CI 0.44-0.86, p-value = 0.005) at 30-day follow-up. The same difference was seen at 1-year. CONCLUSION/UNASSIGNED:TR-PCI was associated with lower odds of MACCE, major bleeding, and mortality during short- and long-term follow-up.
PMID: 33896335
ISSN: 1744-8344
CID: 4886362

Does a palliative care consult decrease the cost of caring for hospitalized patients with dementia?

Araw, Marissa; Kozikowski, Andrzej; Sison, Cristina; Mir, Tanveer; Saad, Maha; Corrado, Lauren; Pekmezaris, Renee; Wolf-Klein, Gisele
Objective: Advanced dementia (AD) is a terminal disease. Palliative care is increasingly becoming of critical importance for patients afflicted with AD. The primary objective of this study was to compare pharmacy cost before and after a palliative care consultation (PCC) in patients with end-stage dementia. A secondary objective was to investigate the cost of particular types of medication before and after a PCC. Method: This was a retrospective study of 60 hospitalized patients with end-stage dementia at a large academic tertiary care hospital from January 1, 2010 to October 1, 2011, in order to investigate pharmacy costs before and after a PCC. In addition to demographics, we carried out a comparison of the average daily pharmacy cost and comparison of the proportion of subjects taking each medication type (cardiac, analgesics, antibiotics, antipsychotics and antiemetics) before and after a PCC. Results: There was a significant decrease in overall average daily pharmacy cost from before to after a PCC ($31.16 +/- 24.71 vs. $20.83 +/- 19.56; p < 0.003). There was also a significant difference in the proportion of subjects taking analgesics before and after PCC (55 vs. 73.3%; p < 0.009), with a significant average daily analgesic cost rise from pre- to post-PCC: $1.36 +/- 5.07 (median = $0.05) versus. $2.35 +/- 5.35 (median = $0.71), respectively, p < 0.011; average daily antiemetics cost showed a moderate increase from pre- to post-PCC: $0.08 +/- 0.37 (median = $0) versus $0.23 +/- 0.75 (median = $0), respectively, p < 0.047. Significance of results: Our findings indicate that PCC is associated with overall decreased medication cost in hospitalized AD patients. Additionally, receiving a PCC was related to greater use of pain medications in hospitalized dementia patients. Our study corroborates the benefits of palliative care team intervention in managing elderly hospitalized dementia patients.
PMID: 24139019
ISSN: 1478-9515
CID: 832522

The relationship between the timing of a palliative care consult and utilization outcomes for ventilator-assisted intensive care unit patients

Pereira, Salonie; Kozikowski, Andrzej; Pekmezaris, Renee; Sunday, Suzanne; Mir, Tanveer; Saad, Maha; Corrado, Lauren; Wolf-Klein, Gisele
Objective: Given the great number of chronic care patients facing the end of life and the challenges of critical care delivery, there has been emerging evidence supporting the benefit of palliative care in the intensive care unit (ICU). We studied the relationship between the timing of a palliative care consult (PCC) and two utilization outcomes - length of stay (LOS) and pharmacy costs - in ventilator-assisted ICU patients. Method: A retrospective chart review was conducted (N = 90). Summed pharmacy costs were compared using a paired t test before and after PCC. Spearman correlations were performed between days to PCC and ICU LOS, ventilator days, and days to death following ventilator discontinuation. Results: Number of days from admission to PCC was correlated with total days on ventilator (rho = 0.685, p < 0.0001) and total ICU LOS (rho = 0.654, p < 0.0001). Number of days to PCC was correlated with pre-PCC total medication costs (rho = 0.539, p < 0.0001). Median medication costs were significantly reduced after the PCC (p < 0.0001), from $230.96 to 30.62. Median medication costs decreased for all categories except for analgesics, antiemetics, and opioids. The number of patients receiving opioid infusion increased (37 vs. 90%) after PCC (p < 0.0001). Significance of results: Earlier timing for PCC in the ICU is associated with a lower LOS through quicker mechanical ventilation (MV) withdrawal, presenting a unique opportunity to both decrease costs and improve patient care.
PMID: 24168762
ISSN: 1478-9515
CID: 832532

Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the american college of physicians

Qaseem, Amir; Mir, Tanveer P; Starkey, Melissa; Denberg, Thomas D
DESCRIPTION: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations based on the comparative effectiveness of risk assessment scales and preventive interventions for pressure ulcers. METHODS: This guideline is based on published literature on this topic that was identified by using MEDLINE (1946 through February 2014), CINAHL (1998 through February 2014), the Cochrane Library, clinical trials registries, and reference lists. Searches were limited to English-language publications. The outcomes evaluated for this guideline include pressure ulcer incidence and severity, resource use, diagnostic accuracy, measures of risk, and harms. This guideline grades the quality of evidence and strength of recommendations by using ACP's clinical practice guidelines grading system. The target audience for this guideline includes all clinicians, and the target patient population is patients at risk for pressure ulcers. RECOMMENDATION 1: ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. (Grade: weak recommendation, low-quality evidence). RECOMMENDATION 2: ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: strong recommendation, moderate-quality evidence). RECOMMENDATION 3: ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: weak recommendation, moderate-quality evidence).
PMID: 25732278
ISSN: 0003-4819
CID: 1480432

Treating persistent pain in the elderly: how do we proceed?

Corrado-McKeon, Lauren; Saad, Maha; Mir, Tanveer; Liberman, Tara; Cleary, Tara; Lu, Celia
OBJECTIVE: To describe a performance improvement initiative conducted in accordance with the American Geriatrics Society (AGS) guideline regarding pharmacological management of persistent pain in older adults. SETTINGS: Medical units of a tertiary care teaching hospital. PRACTICE DESCRIPTION: Elderly patients were included if treated for conditions associated with persistent pain. PRACTICE INNOVATION: Using three phases, the pharmacological management of persistent pain in older adults was evaluated before and after health care provider education on the AGS guideline recommendations. Educational seminars, in-service training, and handout materials focused on addressing specific shortfalls identified during the initial evaluation. MAIN OUTCOME MEASUREMENTS: Appropriate use of nonsteroidal anti-inflammatory agents (NSAIDs) and cyclooxygenase-2 selective inhibitors (coxibs), utilization of proper pain assessment tools, types of opioids used, and associated adverse effects. RESULTS: A total of 50 patients with comparable demographics were included in each phase. Following education, there was an improvement in the appropriate use of pain-assessment tools in cognitively impaired older adults. There was a trend toward improvement in the use of NSAIDs and coxibs, but there was no change in practice regarding the frequency of opioid use, combining long- and short-acting opioid preparations, or preventing opioid-induced constipation. CONCLUSION: Although findings from this study aided in recognizing areas for improvement in the management of persistent pain in older adults, further education of health care professionals is needed to ensure the safe and effective management of persistent pain.
PMID: 23906895
ISSN: 0888-5109
CID: 832542

Ethnicity, race, and advance directives in an inpatient palliative care consultation service

Zaide, Glenn B; Pekmezaris, Renee; Nouryan, Christian N; Mir, Tanveer P; Sison, Cristina P; Liberman, Tara; Lesser, Martin L; Cooper, Lynda B; Wolf-Klein, Gisele P
OBJECTIVE: Although race and ethnic background are known to be important factors in the completion of advance directives, there is a dearth of literature specifically investigating the effect of race and ethnicity on advance directive completion rate after palliative care consultation (PCC). METHOD: A chart review of all patients seen by the PCC service in an academic hospital over a 9-month period was performed. Data were compiled using gender, race, ethnicity, religion, and primary diagnosis. For this study, advance directives were defined as: "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI). RESULTS: Of the 400 medical records reviewed, 57% of patients were female and 71.3% documented their religion as Christian. The most common documented diagnosis was cancer (39.5%). Forty-seven percent reported their race as white. White patients completed more advance directives than did nonwhite patients both before (25.67% vs. 12.68%) and after (59.36% vs. 40.84%) PCC. There was a significantly higher proportion of whites who signed an advance directive after a PCC than of nonwhites (p = 0.021); of the 139 whites who did not have an advance directive at admission, 63 signed an advance directive after a PCC compared with 186/60 nonwhites (45% vs. 32%, respectively, p = 0.021). Further analysis revealed that African Americans differed from whites in the likelihood of advance directive execution rates pre-PCC, but not post-PCC. SIGNIFICANCE OF RESULTS: This study demonstrates the impact of a PCC on the completion of advance directives, on both whites and nonwhites. The PCC Intervention significantly reduced differences between whites and African Americans in completing advance directives, which have been consistently documented in the end-of-life literature.
PMID: 22874132
ISSN: 1478-9515
CID: 255532

The spectrum of neurological recovery

Mir, Tanveer P
The equivalence of brain death with death is largely, although not universally accepted. Patients may have suffered insults such as cardiac arrest, vascular catastrophe, poisoning, or head trauma. Early identification of patients at greatest risk of poor neurologic outcome and management in the appropriate critical care setting is the key to maximizing neurological recovery. Recent technological advances and neuroimaging have made it possible to predict neurological reversibility with great accuracy. Significant improvements in therapy such as hypothermia, will improve outcomes in neurological catastrophies, particularly in anoxic-ischemic encephalopathy. The clinical spectrum and diagnostic criteria of minimally conscious and vegetative states is reviewed. The current understanding of the differences in prognosis and prediction of meaningful cognitive and functional recovery in each neurological state is described. Establishing an understanding of the ethical principles that guide medical decisions in clinical practice related to different neurological states is evolving into a new field called neuroethics.
PMCID:3516123
PMID: 23610514
ISSN: 0899-8299
CID: 832512

Discussion: End-of-Life Issues at the Beginning of Life

Mir, Tanveer; Fadel, Hossam E; Nadroo, Ali M; Haque, Malika
PMCID:3516112
PMID: 23610510
ISSN: 0899-8299
CID: 832552

Care of the terminally ill: religious perspectives. Discussion

Shanawani, Hasan; Smith, Frederick A; Mir, Tanveer; Lahaj, Mary
PMCID:3516117
PMID: 23610505
ISSN: 0899-8299
CID: 832562