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Intro:
Implementation strategies are integral to addressing gaps in AHA depression treatment guidelines in coronary heart disease (CHD) patients.
Methods:
From 2019 to 2023, we ...randomized 12 Columbia University affiliated primary care and cardiology clinics to timing of receiving a multi-level intervention. We enrolled separate pre and post EHR eligible patients/site (≥21 years old, English or Spanish speaking, CHD ICD10 and upcoming cardiologist/PCP
index
visit) with Patient Health Questionnaire(PHQ)9≥10 and not seeing a psychiatrist. Pre-implementation patients and their providers/sites received usual care. Post-implementation, a theory-informed intervention included problem-solving meetings for mental health social workers (MHSW), cardiologist/PCP “provider” education and a patient psychoeducation, activation, and treatment selection tool (with patient treatment preferences sent to MHSW/providers via EPIC). Blinded physicians extracted index visit pre vs. post provider behavior (i.e., documented CHD risk factor or mental health counseling, therapy/cardiac rehab referral, and/or antidepressant prescribing vs. none). We conducted a pre-post analysis using descriptive statistics and thematically analyzed any MHSW/provider responses to EPIC reports.
Results:
Of 10,625 EHR eligible CHD patients; 1759 patients were screened, 304 (16.5%) eligible and 253 (82.9%) enrolled; 52.0% were female, 56.1% Hispanic, 14.6% Black; mean age was 67.8 years old, PHQ9 13.1. Overall, all (n=71) intervention providers received EPIC messages with 67.8% of patients selecting ≥1 treatment; 29.7% of reports prompted a MHSW/provider response (themes:
thinking, talking,
action)
; more cardiologists acknowledged receipt/relayed plans than PCPs as did providers caring for commercially insured (vs. Medicaid) patients; 25% of providers optimized treatment pre- vs. 40% post-implementation.
Conclusion:
A multi-level strategy centered around patient activation may marginally improve provider guideline adherence. Key limitations are pre-post design and descriptive analyses without adjustment for temporal trends. Our ongoing study will adjust for temporality and examine impact on depressive symptoms and patient behavior.
Reducing cardiovascular disease disparities will require a concerted, focused effort to better adopt evidence-based interventions, in particular, those that address social determinants of health, in ...historically marginalized populations (ie, communities excluded on the basis of social identifiers like race, ethnicity, and social class and subject to inequitable distribution of social, economic, physical, and psychological resources). Implementation science is centered around stakeholder engagement and, by virtue of its reliance on theoretical frameworks, is custom built for addressing research-to-practice gaps. However, little guidance exists for how best to leverage implementation science to promote cardiovascular health equity. This American Heart Association scientific statement was commissioned to define implementation science with a cardiovascular health equity lens and to evaluate implementation research that targets cardiovascular inequities. We provide a 4-step roadmap and checklist with critical equity considerations for selecting/adapting evidence-based practices, assessing barriers and facilitators to implementation, selecting/using/adapting implementation strategies, and evaluating implementation success. Informed by our roadmap, we examine several organizational, community, policy, and multisetting interventions and implementation strategies developed to reduce cardiovascular disparities. We highlight gaps in implementation science research to date aimed at achieving cardiovascular health equity, including lack of stakeholder engagement, rigorous mixed methods, and equity-informed theoretical frameworks. We provide several key suggestions, including the need for improved conceptualization and inclusion of social and structural determinants of health in implementation science, and the use of adaptive, hybrid effectiveness designs. In addition, we call for more rigorous examination of multilevel interventions and implementation strategies with the greatest potential for reducing both primary and secondary cardiovascular disparities.
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Background:
Telemedicine use vastly expanded during the Covid-19 pandemic, with uncertain impact on cardiovascular care. quality.
Objectives:
To examine the association between ...telemedicine use and blood pressure (BP) control.
Methods:
This is a retrospective cohort study of 32,727 adult patients with hypertension (HTN) seen in primary care and cardiology clinics at an urban, academic medical center from February to December, 2020. The primary outcome was poor BP control, defined as having no BP recorded OR if the last recorded BP was ≥140/90 mmHg. Multivariable logistic regression was used to assess the association between telemedicine use during the study period (none, 1 telemedicine visit, 2+ telemedicine visits) and poor BP control, adjusting for demographic and clinical characteristics.
Results:
During the study period, no BP was recorded for 486/20,745 (2.3%) patients with in-person visits only, for 1,863/6,878 (27.1%) patients with 1 telemedicine visit, and for 1,277/5,104 (25.0%) patients with 2+ telemedicine visits. After adjustment, telemedicine use was associated with poor BP control (odds ratio OR, 2.06, 95% confidence interval CI 1.94 to 2.18, p<0.001 for 1 telemedicine visit, and OR 2.49, 95% CI 2.31 to 2.68, p<0.001 for 2+ telemedicine visits; reference, in-person visit only). This effect disappears when analysis was restricted to patients with at least one recorded BP (OR 0.89, 95% CI 0.83 to 0.95, p=0.001 for 1 telemedicine visit, and OR 0.91, 95% CI 0.83 to 0.99, p=0.03 for 2+ telemedicine visits).
Conclusions:
BP is less likely to be recorded during telemedicine visits, but telemedicine use does not negatively impact BP control when BP is recorded.
Purpose of Review
Sex and gender differences exist with regard to the association between depression and cardiovascular disease (CVD). This narrative review describes the prevalence, mechanisms of ...action, and management of depression and CVD among women, with a particular focus on coronary heart disease (CHD).
Recent Findings
Women versus men with incident and established CHD have a greater prevalence of depression. Comorbid depression and CHD in women may be associated with greater mortality, and treatment inertia. Proposed mechanisms unique to the association among women of depression and CHD include psychosocial, cardiometabolic, behavioral, inflammatory, hormonal, and autonomic factors.
Summary
The literature supports a stronger association between CHD and the prevalence of depression in women compared to men. It remains unclear whether depression treatment influences cardiovascular outcomes, or if treatment effects differ by sex and/or gender. Further research is needed to establish underlying mechanisms as diagnostic and therapeutic targets.
Abstract
BACKGROUND
Guidelines recommend that patients with newly elevated office blood pressure undergo ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to ...rule-out white coat hypertension before being diagnosed with hypertension. We explored patients’ perspectives of the barriers and facilitators to undergoing ABPM or HBPM.
METHODS
Focus groups were conducted with twenty English- and Spanish-speaking individuals from underserved communities in New York City. Two researchers analyzed transcripts using a conventional content analysis to identify barriers and facilitators to participation in ABPM and HBPM.
RESULTS
Participants described favorable attitudes toward testing including readily understanding white coat hypertension, agreeing with the rationale for out-of-office testing, and believing that testing would benefit patients. Regarding ABPM, participants expressed concerns over the representativeness of the day the test was performed and the intrusiveness of the frequent readings. Regarding HBPM, participants expressed concerns over the validity of the monitoring method and the reliability of home blood pressure devices. For both tests, participants noted that out-of-pocket costs may deter patient participation and felt that patients would require detailed information about the test itself before deciding to participate. Participants overwhelmingly believed that out-of-office testing benefits outweighed testing barriers, were confident that they could successfully complete either testing if recommended by their provider, and described the rationale for their testing preference.
CONCLUSIONS
Participants identified dominant barriers and facilitators to ABPM and HBPM testing, articulated testing preferences, and believed that they could successfully complete out-of-office testing if recommended by their provider.
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Background:
In 2015, the US Preventive Services Task Force (USPSTF) updated its primary care screening guidelines to recommend out-of-office BP testing with ABPM or HBPM for confirming ...the diagnosis of hypertension (HTN) in adult patients with high office BP.
Methods:
We applied the Behavior Change Wheel framework to develop a theory-informed strategy for increasing the uptake of the USPSTF HTN screening guideline. We then conducted a 2-arm cluster randomized trial in which 8 primary care practices (154 clinicians) in an ambulatory care network serving vulnerable communities in New York City were randomized to receive the implementation strategy (4 practices) or a wait-list control (4 practices). The strategy was implemented from October 2017 to March 2018, and consisted of: 1) clinician education about HTN screening recommendations; 2) clinician information on how to order ABPM and HPBM; 3) patient information on ABPM and HBPM; 4) nurse training on how to teach patients to conduct HBPM; 5) access to an ABPM testing service; 6) clinician feedback on out-of-office BP test ordering; and 7) embedded tools in the EHR to facilitate ABPM and HBPM ordering. The primary outcome was change in the proportion of patients completing ABPM or HBPM in the year before versus year after implementation.
Results:
There were 1069 eligible patients (mean age 53±16 years, 67% women) with high office BP but no diagnosis or treatment for HTN. In implementation practices, the proportion of patients with out-of-office BP test ordering increased from 0.5% in the year before implementation to 4.0% in the year after implementation (p<.001) whereas test ordering did not change in control practices (3.1% to 2.8%, p=0.66); p<.001 for interaction. Similarly, out-of-office BP test completion increased from 0.5% to 3.0% (p<.001) in implementation practices whereas test completion did not change in control practices (2.2% to 2.0%, p=0.76); p<.001 for interaction.
Conclusions:
A theory-informed implementation strategy increased out-of-office BP testing in adult primary care patients being screened for HTN. Yet, out-of-office BP testing in the context of HTN screening remained low in both implementation and control practices, suggesting a need for more potent implementation strategies.
IMPORTANCE: Patients with acute coronary syndrome (ACS) and elevated depressive symptoms are at increased risk for recurrent cardiovascular events and mortality, worse quality of life, and higher ...health care costs. These observational findings prompted multiple scientific panels to advise universal depression screening in survivors of ACS prior to evidence from randomized screening trials. OBJECTIVE: To determine whether systematically screening for depression in survivors of ACS improves quality of life and depression compared with usual care. DESIGN, SETTING, AND PARTICIPANTS: A 3-group multisite randomized trial enrolled 1500 patients with ACS from 4 health care systems between November 1, 2013, and March 31, 2017, with follow-up ending July 31, 2018. Patients were eligible if they had been hospitalized for ACS in the previous 2 to 12 months and had no prior history of depression. All analyses were performed on an intention-to-treat basis. INTERVENTIONS: Patients with ACS were randomly assigned 1:1:1 to receive (1) systematic depression screening using the 8-item Patient Health Questionnaire, with notification of primary care clinicians and provision of centralized, patient-preference, stepped depression care for those with positive screening results (8-item Patient Health Questionnaire score ≥10; screen, notify, and treat, n = 499); (2) systematic depression screening, with notification of primary care clinicians for those with positive screening results (screen and notify, n = 501); and (3) usual care (no screening, n = 500). MAIN OUTCOMES AND MEASURES: The primary outcome was change in quality-adjusted life-years. The secondary outcome was depression-free days. Adverse effects and mortality were assessed by patient interview and hospital records. RESULTS: A total of 1500 patients (424 women and 1076 men; mean SD age, 65.9 11.5 years) were randomized in the 18-month trial. Only 71 of 1000 eligible survivors of ACS (7.1%) had elevated 8-item Patient Health Questionnaire scores indicating depressive symptoms at screening. There were no differences in mean (SD) change in quality-adjusted life-years (screen, notify and treat, –0.06 0.20; screen and notify, −0.06 0.20; no screen, −0.06 0.18; P = .98) or cumulative mean (SD) depression-free days (screen, notify and treat, 343.1 179.0 days; screen and notify, 351.3 175.0 days; no screen, 339.0 176.6 days; P = .63). Harms including death, bleeding, or sleep difficulties did not differ among groups. CONCLUSIONS AND RELEVANCE: In patients with ACS without a history of depression, systematic depression screening with or without providing depression treatment did not alter quality-adjusted life-years, depression-free days, or harms. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01993017
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