Faculty Bibliography

PURPOSE/OBJECTIVE:Despite known benefits of cardiac rehabilitation (CR), early termination (failure to complete >1 mo of CR) attenuates these benefits. We analyzed whether early termination varied by referral indication in the context of recent growth in patients referred for heart failure with reduced ejection fraction (HFrEF). METHODS:We reviewed records from 1111 consecutive patients enrolled in the NYU Langone Health Rusk CR program (2013-2017). Sessions attended, demographics, and comorbidities were abstracted, as well as primary referral indication: HFrEF or ischemic heart disease (IHD; including post-coronary revascularization, post-acute myocardial infarction, or chronic stable angina). We compared rates of early termination between HFrEF and IHD, and used multivariable logistic regression to determine whether differences persisted after adjusting for relevant characteristics (age, race, ethnicity, body mass index, smoking, hypertension, chronic obstructive pulmonary disease, and depression). RESULTS:Mean patient age was 64 yr, 31% were female, and 28% were nonwhite. Most referrals (85%) were for IHD; 15% were for HFrEF. Early termination occurred in 206 patients (18%) and was more common in HFrEF (26%) than in IHD (17%) (P < .01). After multivariable adjustment, patients with HFrEF remained at higher risk of early termination than patients with IHD (unadjusted OR = 1.73, 95% CI, 1.17-2.54; adjusted OR = 1.53, 95% CI, 1.01-2.31). CONCLUSIONS:Nearly 1 in 5 patients in our program terminated CR within 1 mo, with HFrEF patients at higher risk than IHD patients. While broad efforts at preventing early termination are warranted, particular attention may be required in patients with HFrEF.

BACKGROUND:Screening mammography has reduced breast cancer-associated mortality worldwide. Approximately 10% of patients require further diagnostic testing after an uncertain screening mammogram (Breast imaging reporting and data system [BI-RADS] = 0), and time to diagnostic resolution varies after BI-RADS = 0 screening mammogram. There is little data about factors associated with diagnostic resolution in patients of Chinese origin ("Chinese") receiving care in the US. METHODS:We performed a retrospective analysis to identify patterns of diagnostic resolution in an urban US hospital with a large population of Chinese patients. We evaluated whether location of primary care provider (PCP) impacted time to resolution among Chinese patients, hypothesizing that patients with a PCP outside of the hospital would have longer time to diagnostic resolution than those patients with a PCP within the institution. RESULTS:Between 2015 and 2016, 368 patients at Tufts Medical Center (Tufts MC) had resulting BI-RADS = 0 after screening mammogram. The majority of patients (341/368, 93%) achieved diagnostic resolution with median time to resolution 27 days (Q1: 14, Q3: 40). Seven percent (27/368) never achieved resolution. Among those with diagnostic resolution, 10% of patients required >60 days to achieve resolution. Chinese origin, no previous breast cancer, subsidized insurance, and outside referring physician were associated with longer time to resolution in univariable analysis. In multivariable regression, after adjusting for age, insurance, marital status, and prior breast cancer, Chinese patients with Tufts MC PCP experienced timelier diagnostic resolution vs Chinese patients without a Tufts MC PCP (hazard ratio [HR] = 1.85, P = .02). Location of PCP did not impact time to resolution among non-Chinese patients. CONCLUSION:We identified patterns of diagnostic resolution in an urban hospital with a large historically underserved population. We found that Chinese patients without integrated primary care within the institution are at risk for delayed diagnostic resolution. Future interventions need to target at-risk patients to prevent loss of follow-up after uncertain screening mammogram.

Background: Among older adults with cardiovascular disease (CVD), cardiac rehabilitation (CR) has multiple benefits including improved quality of life and reduced mortality. Despite the known benefits of CR, early termination (ET) by patients (attending <12/36 recommended sessions) may attenuate these benefits. Our aim was to determine the incidence of ET in our older adult patient population, as well as risk factors associated with this outcome.
Method(s): We reviewed records from 792 consecutive older adult patients (>= 65 years old) enrolled in the NYU Langone Rusk CR program (2013-2017). Sessions attended, demographics, comor-bidities, and primary referral diagnosis were abstracted. We analyzed the overall rate of ET (defined as attending <12 sessions). Categorical variables were described with percentages and continuous variables with mean values. Multivariable logistic regression was subsequently used to analyze predictors of ET, considering age, race, ethnicity, sex, body mass index, diabetes, chronic lung disease, coronary artery disease, heart failure, and stroke.
Result(s): In our total study population, mean age was 74 +/- 7 years, mean BMI was 26 +/- 5, 38% were female, and 18% were nonwhite. Most patients (65%) were referred to CR due to ischemic heart disease (chronic stable angina, post-myocardial infarction, CABG, or elective PCI), with an additional 23% referred for valvular heart disease, 9% for systolic heart failure, and 3% for congenital heart disease. Early termination occurred in 129 patients (16.3%). Patients who terminated early were significantly older (75.6 vs. 73.9, p=0.005) and less likely to have coronary artery disease (13.6% vs. 19.5%, p=0.03). After multivariable logistic regression, the independent risk factors for ET were age (adjusted OR 1.04, 95% CI 1.01-1.07) and Hispanic ethnicity (adjusted OR 2.32, 95% CI 1.01-5.33).
Conclusion(s): Nearly 1 in 6 older adults terminated CR within 1 month (<12/36 sessions), potentially limiting the benefits of CR within this subgroup. Among factors we analyzed, age and Hispanic ethnicity were risk factors for ET, but the overall strength of associ-ation was weak. Further research is necessary to identify novel risk factors for ET in order to better target prevention efforts

PURPOSE:The adolescent and young adult (AYA) population is a growing group of survivors, exceeding more than 600,000, at high risk for late effects of cancer-directed therapy. While many guidelines exist for cancer survivorship care, choosing which to use for an AYA cancer survivor is challenging, yet vital, to ensure comprehensive follow-up care. METHODS:Survivorship care plans (SCPs), including treatment summaries (TS) and follow-up care plans, were created for three clinical vignettes (acute lymphoblastic leukemia, osteosarcoma, and Hodgkin lymphoma). Four sets of guidelines were used, including the Children's Oncology Group Long-Term Follow-Up Guidelines (COG LTFU), National Comprehensive Cancer Network (NCCN) Guidelines for Age- Related Recommendations: AYA Oncology (NCCN-AYA), NCCN Guidelines for Treatment of Cancer by Site (NCCN-Site), and NCCN Guidelines for Supportive Care: Survivorship (NCCN-Survivorship) and NCCN supplemental cancer screening guidelines. The follow-up care plans were compared across guidelines to determine the extent and nature of the similarities and differences concerning AYA cancer survivorship care. RESULTS:The guidelines disagree on the link between treatment exposures and late effects, the population to be screened, the screening test to be used, and the time interval of testing. Specific examples of this include screening for cardiac toxicity, breast cancer, and neurocognitive deficits. CONCLUSIONS:While many guidelines exist for AYA survivorship care, there is discordance among the recommendations. This has significant implications for the long-term follow-up care of an AYA survivor. This study offers solutions to harmonize guidelines in order to ensure comprehensive quality survivorship care for this population.