Faculty Bibliography

BACKGROUND:Atrial fibrillation is the commonest arrhythmia which raises the risk of heart failure, thromboembolic stroke, morbidity and death. Pharmacological treatments of this condition are focused on heart rate control, rhythm control and reduction in risk of stroke. Selective ablation of cardiac tissues resulting in isolation of areas causing atrial fibrillation is another treatment strategy which can be delivered by two minimally invasive interventions: percutaneous catheter ablation and thoracoscopic surgical ablation. The main purpose of this trial is to compare the effectiveness and safety of these two interventions. METHODS/DESIGN/METHODS:Catheter Ablation versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation (CASA-AF) is a prospective, multi-centre, randomised controlled trial within three NHS tertiary cardiovascular centres specialising in treatment of atrial fibrillation. Eligible adults (n = 120) with symptomatic, long-standing, persistent atrial fibrillation will be randomly allocated to either catheter ablation or thoracoscopic ablation in a 1:1 ratio. Pre-determined lesion sets will be delivered in each treatment arm with confirmation of appropriate conduction block. All patients will have an implantable loop recorder (ILR) inserted subcutaneously immediately following ablation to enable continuous heart rhythm monitoring for at least 12 months. The devices will be programmed to detect episodes of atrial fibrillation and atrial tachycardia ≥ 30 s in duration. The patients will be followed for 12 months, completing appropriate clinical assessments and questionnaires every 3 months. The ILR data will be wirelessly transmitted daily and evaluated every month for the duration of the follow-up. The primary endpoint in the study is freedom from atrial fibrillation and atrial tachycardia at the end of the follow-up period. DISCUSSION/CONCLUSIONS:The CASA-AF Trial is a National Institute for Health Research-funded study that will provide first-class evidence on the comparative efficacy, safety and cost-effectiveness of thoracoscopic surgical ablation and conventional percutaneous catheter ablation for long-standing persistent atrial fibrillation. In addition, the results of the trial will provide information on the effects on patients' quality of life. TRIAL REGISTRATION/BACKGROUND:ISRCTN Registry, ISRCTN18250790 . Registered on 24 April 2015.

Aims: There are scant comparative data quantifying the risk of infective endocarditis (IE) and associated mortality in individuals with predisposing cardiac conditions. Methods and results: English hospital admissions for conditions associated with increased IE risk were followed for 5 years to quantify subsequent IE admissions. The 5-year risk of IE or dying during an IE admission was calculated for each condition and compared with the entire English population as a control. Infective endocarditis incidence in the English population was 36.2/million/year. In comparison, patients with a previous history of IE had the highest risk of recurrence or dying during an IE admission [odds ratio (OR) 266 and 215, respectively]. These risks were also high in patients with prosthetic valves (OR 70 and 62) and previous valve repair (OR 77 and 60). Patients with congenital valve anomalies (currently considered 'moderate risk') had similar levels of risk (OR 66 and 57) and risks in other 'moderate-risk' conditions were not much lower. Congenital heart conditions (CHCs) repaired with prosthetic material (currently considered 'high risk' for 6 months following surgery) had lower risk than all 'moderate-risk' conditions-even in the first 6 months. Infective endocarditis risk was also significant in patients with cardiovascular implantable electronic devices. Conclusion: These data confirm the high IE risk of patients with a history of previous IE, valve replacement, or repair. However, IE risk in some 'moderate-risk' patients was similar to that of several 'high-risk' conditions and higher than repaired CHC. Guidelines for the risk stratification of conditions predisposing to IE may require re-evaluation.

OBJECTIVE:To assess the association between anticoagulation, ischaemic stroke, gastrointestinal and cerebral haemorrhage, and all cause mortality in older people with atrial fibrillation and chronic kidney disease. DESIGN/METHODS:Propensity matched, population based, retrospective cohort analysis from January 2006 through December 2016. SETTING/METHODS:The Royal College of General Practitioners Research and Surveillance Centre database population of almost 2.73 million patients from 110 general practices across England and Wales. PARTICIPANTS/METHODS:, calculated using the chronic kidney disease epidemiology collaboration creatinine equation. Patients with a previous diagnosis of atrial fibrillation or receiving anticoagulation in the preceding 120 days were excluded, as were patients requiring dialysis and recipients of renal transplants. INTERVENTION/METHODS:Receipt of an anticoagulant prescription within 60 days of atrial fibrillation diagnosis. MAIN OUTCOME MEASURES/METHODS:Ischaemic stroke, cerebral or gastrointestinal haemorrhage, and all cause mortality. RESULTS:6977 patients with chronic kidney disease and newly diagnosed atrial fibrillation were identified, of whom 2434 were on anticoagulants within 60 days of diagnosis and 4543 were not. 2434 pairs were matched using propensity scores by exposure to anticoagulant or none and followed for a median of 506 days. The crude rates for ischaemic stroke and haemorrhage were 4.6 and 1.2 after taking anticoagulants and 1.5 and 0.4 in patients who were not taking anticoagulant per 100 person years, respectively. The hazard ratios for ischaemic stroke, haemorrhage, and all cause mortality for those on anticoagulants were 2.60 (95% confidence interval 2.00 to 3.38), 2.42 (1.44 to 4.05), and 0.82 (0.74 to 0.91) compared with those who received no anticoagulation. CONCLUSION/CONCLUSIONS:Giving anticoagulants to older people with concomitant atrial fibrillation and chronic kidney disease was associated with an increased rate of ischaemic stroke and haemorrhage but a paradoxical lowered rate of all cause mortality. Careful consideration should be given before starting anticoagulants in older people with chronic kidney disease who develop atrial fibrillation. There remains an urgent need for adequately powered randomised trials in this population to explore these findings and to provide clarity on correct clinical management.

BACKGROUND: Hospitalized medical patients undergoing transition of care by house staff teams at the end of a ward rotation are associated with an increased risk of mortality, yet best practices surrounding this transition are lacking. AIM: To assess the impact of a warm handoff protocol for end-of-rotation care transitions. SETTING: A large, university-based internal medicine residency using three different training sites. PARTICIPANTS: PGY-2 and PGY-3 internal medicine residents. PROGRAM DESCRIPTION: Implementation of a warm handoff protocol whereby the incoming and outgoing residents meet at the hospital to sign out in-person and jointly round at the bedside on sicker patients using a checklist. PROGRAM EVALUATION: An eight-question survey completed by 60 of 99 eligible residents demonstrated that 85% of residents perceived warm handoffs to be safer for patients (p < 0.001), while 98% felt warm handoffs improved their knowledge and comfort level of patients on day 1 of an inpatient rotation (p < 0.001) as compared to prior handoff techniques. Finally, 88% felt warm handoffs were worthwhile despite requiring additional time (p < 0.001). DISCUSSION: A warm handoff protocol represents a novel strategy to potentially mitigate the known risks associated with end-of-rotation care transitions. Additional studies analyzing patient outcomes will be needed to assess the impact of this strategy.

OBJECTIVES/SPECIFIC AIMS: Determine timing of risk of readmissions within 30 days among patients first discharged to a skilled nursing facilities (SNF) after heart failure hospitalization and subsequently discharged home. METHODS/STUDY POPULATION: This was a retrospective cohort study of patients with SNF stays of 30 days or less following discharge from a heart failure hospitalization. Patients were followed for 30 days following discharge from SNF. We categorized patients based on SNF length of stay (LOS): 1-6 days, 7-13 days, 14-30 days. We then fit a piecewise exponential Bayesian model with the outcome as time to readmission after discharge from SNF for each group. Our event of interest was unplanned readmission; death and planned readmissions were considered as competing risks. Our model examined 2 different time intervals following discharge from SNF: 0-3 days post SNF discharge and 4-30 days post SNF discharge. We reported the hazard rate (credible interval) of readmission for each time interval. We examined all Medicare fee-for-service (FFS) patients 65 and older admitted from July 2012 to June 2015 with a principal discharge diagnosis of HF, based on methods adopted by the Centers for Medicare and Medicaid Services (CMS) for hospital quality measurement. RESULTS/ANTICIPATED RESULTS: Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home [median age, 84 years (IQR; 78-89); female, 61.0%]; 13,257 (19.2%) were discharged with home care, 54,328 (80.4%) without. Median length of SNF admission was 17 days (IQR; 11-22). In total, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge; median time to readmission was 9 days (IQR; 3-18). The hazard rate of readmission for each group was significantly increased on days 0-3 after discharge from SNF compared with days 4-30 after discharge from SNF. In addition, the hazard rate of readmission during the first 0-3 days after discharge from SNF decreased as the LOS in SNF increased. DISCUSSION/SIGNIFICANCE OF IMPACT: The hazard rate of readmission after SNF discharge following heart failure hospitalization is highest during the first 6 days home. Length of stay at SNF also has an effect on risk of readmission immediately after discharge from SNF; patients with a longer length of stay in SNF were less likely to be readmitted in the first 3 days after discharge from SNF.

Background: Paper-based Early Recovery after Surgery (ERAS) path-ways have been shown to reduce length of stay, but there have been limited evaluations of electronic health record (EHR) based pathways. The objective of this study was to evaluate whether ERAS processes implemented with a novel pathway activity integrated with the EHR (E-Pathway) can reduce costs without resulting in increased 30 day readmissions. Methods: We performed a retrospective cohort study of surgical patients age>= 18 years hospitalized at an academic medical center from March 1, 2013 to August 31, 2016. The primary cohort consisted of patients admitted for elective colon surgery. We also studied a control group of patients undergoing elective procedures with similar length of stay as colon surgery (3-5 days). The E-Pathway was based on a pathway template developed by a common EHR vendor (Epic Systems, Verona, WI) with content developed by a multidisciplinary team based on ERAS principles. The E-Pathway was implemented on March 2, 2015. The primary outcome was variable costs per case. Secondary outcomes were observed to expected length of stay (O:E LOS) and 30 day readmissions to our hospital. For both groups, we performed an interrupted time series with segmented regression analysis with month being the unit of time. We used gamma regression for cost models and logistic models for the secondary outcomes. Results: We included 823 (470 and 353 in the pre-and post-intervention, respectively) colon surgery patients and 3415 (1,819 and 1,596 in the pre-and post-intervention) surgical control patients. Among the colon surgery cohort, we observed no changesin cost eitheratbaseline [-0.1% (95% CI-0.8%, 0.5%) per month] or with immediate introduction of the pathway. However, there was statistically significant (p = 0.040) decrease in costs of 1.3% (0.6% to 2.5%) per surgical encounter per month over the 18 month post intervention period. The surgical comparator group had no change in cost either at baseline or at the time of intervention and had a nonsignificant decrease in monthly costs of 0.6% (p = 0.231) post-intervention. There was statistically significant (p = 0.039) decrease in the O:E slope after the intervention of 1.49% per surgical encounter per month. The surgical comparator group had a nonsignificant (p = 0.761) increase in slope of 1.87%. For the 30 day readmission rates, there were no statistically significant changes in either the colon surgery or control groups. Conclusions: Our study is the first, to our knowledge, to report on the outcomes of a novel sophisticated E pathway integrated into an EHR. Following implementation of the E-pathway for colon surgery patients, we observed decreasing direct variable costs and O:E LOS over time. These improvements were not observed among comparable surgical patients. Consequently, as institutions continue to place increased emphasis on standardization of best practice care, E-pathways can be powerful vehicles to support those changes in the new EHR-centric care model

This paper explores the role of incentives in the English National Health Service. Until financial year 2009/2010, elective procedures that were cancelled after admission received a fixed reimbursement associated with a specific healthcare resource group code. We investigate whether this induced trusts to admit and then cancel, rather than cancel before admission and/or to cancel low fee over high fee work. As the tariff was ended in April 2010, we conduct an interrupted time series analysis to examine if their behaviour was affected after the tariff removal. The results indicate a small, yet statistically significant, decline in the probability of a last minute cancellation in the post-tariff period, especially for certain types of patients and diagnoses

OBJECTIVE: This study was conducted to describe the incidence of diabetes following pancreatic disease, assess how these patients are classified by clinicians, and compare clinical characteristics with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS: Primary care records in England (n = 2,360,631) were searched for incident cases of adult-onset diabetes between 1 January 2005 and 31 March 2016. We examined demographics, diabetes classification, glycemic control, and insulin use in those with and without pancreatic disease (subcategorized into acute pancreatitis or chronic pancreatic disease) before diabetes diagnosis. Regression analysis was used to control for baseline potential risk factors for poor glycemic control (HbA1c >/=7% [53 mmol/mol]) and insulin requirement. RESULTS: We identified 31,789 new diagnoses of adult-onset diabetes. Diabetes following pancreatic disease (2.59 [95% CI 2.38-2.81] per 100,000 person-years) was more common than type 1 diabetes (1.64 [1.47-1.82]; P < 0.001). The 559 cases of diabetes following pancreatic disease were mostly classified by clinicians as type 2 diabetes (87.8%) and uncommonly as diabetes of the exocrine pancreas (2.7%). Diabetes following pancreatic disease was diagnosed at a median age of 59 years and BMI of 29.2 kg/m2. Diabetes following pancreatic disease was associated with poor glycemic control (adjusted odds ratio, 1.7 [1.3-2.2]; P < 0.001) compared with type 2 diabetes. Insulin use within 5 years was 4.1% (3.8-4.4) with type 2 diabetes, 20.9% (14.6-28.9) with diabetes following acute pancreatitis, and 45.8% (34.2-57.9) with diabetes following chronic pancreatic disease. CONCLUSIONS: Diabetes of the exocrine pancreas is frequently labeled type 2 diabetes but has worse glycemic control and a markedly greater requirement for insulin.

Background/UNASSIGNED:How health care professionals address health literacy as part of the provider-client relationship is important for prevention and promoting self-management and symptom management. Research usually focuses on patients' health literacy and fails to examine provider practices, thus leaving a gap in the literature and patient outcomes analyses. Objective/UNASSIGNED:The study tested the reliability and validity of a series of questions developed to evaluate health care provider health literacy promotion practices on an interprofessional sample. Methods/UNASSIGNED:This exploratory cross-sectional study took place between 2013 and 2015. Participants included graduate level health professions students from nursing, midwifery, medicine, pharmacy, and social work. Exploratory factor analyses with varimax rotation examined the reliability and validity of the instrument as a measure of health literacy promotion practices. Key Results/UNASSIGNED:Of the participants in the programs, 198 completed the health literacy questions in the online survey. Exploratory factor analysis showed that questions loaded on two factors connected with either individual or organizational characteristics that facilitated health literacy promotion practices. The Cronbach's alpha for the instrument was 0.95. Conclusions/UNASSIGNED:. Plain Language Summary/UNASSIGNED:We sought to develop a survey instrument people could use to assess how health care providers help patients understand their health better. After getting responses from 198 health care providers, we ran statistical tests to check the quality of the questions for measuring provider practices. We found the questions were good at evaluating provider practices around promoting patient understanding of health issues.