The 2017 update of the ACC/AHA/HFSA guideline for heart failure (HF) management recommends replacing ACEIs or ARBs with an ARNi (class I recommendation, moderate-quality evidence) in chronic, ...symptomatic, or New York Heart Association (NYHA) class II or III HFrEF to further reduce morbidity and mortality, provided there are no contraindications. Surprisingly, only 10% of 2.29 million eligible patients use ARNi. There are limited data on the perception of ARNi among Internal Medicine (IM) Residency Program trainees, who provide a majority of hospital care in academic centers in the US. Objective: We sought to identify among IM Residency Program trainees the barriers and opportunities to clinical implementation of ARNi after acute heart failure decompensation as part of transitional care prescribing.
Two IM Residency Programs across 3 campuses at an urban, academic medical center were identified. An online, anonymous, 8-question survey using a Likert scale was created and distributed via e-mail. Survey questions included frequency in initiating or titrating ARNi prior to discharge as well as comfort level in prescribing in patients with and without chronic kidney disease (CKD). Questions on barriers to prescribing, such as hypotension and hyperkalemia, as well as knowledge of patient resources were also included. Finally, quality improvement opportunities and interventions were also listed. The survey was administered over a 2-week period in January 2022.
The survey was administered to 150 trainees and the response rate was 26.7%. Among respondents 62% stated that ARNi was initiated sometimes and 42% reported they were comfortable initiating ARNI during hospitalization. Conversely, 78% were slightly to not at all comfortable prescribing ARNi for patients with CKD. Perceived barriers to prescribing ARNi included cost to patient (87%), renal dysfunction (59%), hypotension (43%) and hyperkalemia (38%) and 82% were not at all familiar with patient resources such as the co-pay assistance program. To improve ARNi uptake, 58% of respondents suggested a consult to pharmacy and 47% thought a note in the electronic health record from would yield similar results.
Among IM trainees, CKD largely drives the low clinical implementation of ARNi in transitional care prescribing after acute HF exacerbation. Multidisciplinary initiatives with nephrology and pharmacy represent opportunities to improve provider adherence to guideline-directed medical therapy.
Academic medical centers render physician-led, team-based care for individuals admitted with acute decompensated heart failure with reduced ejection fraction (ADHF). These teams are responsible for ...implementing guideline-directed medical therapies such as Angiotensin Receptor-Neprilysin Inhibitors (ARNi) prior to discharge. However, adoption of ARNI into clinical practice has been historically slow. Baseline data at our institution revealed only 28.4% of eligible patients received a prescription for ARNi at the time of discharge. Objective: To improve clinical use of ARNi prior to discharge in patients with ADHF through a direct educational intervention among Internal Medicine (IM) residents across 3 hospitals of an urban, academic center.
Standardized face-to-face meetings were conducted by a quality improvement team of 4 IM residents. Meetings were conducted biweekly on the hospital units, lasted 15-20 minutes and used 3 learning strategies: visual, auditory, and reading. Common barriers to prescribing ARNi during hospitalization were reviewed and a visual algorithm providing evidence-based resources and management pearls for navigating ARNi in patients with renal dysfunction and hyperkalemia was created (Figure 1). Given the social complexity of the underserved area, financial details including insurance coverage and financial aid were discussed. Electronic health data was used to identify eligible patients and review medication list at the time of discharge.
A total of 32 educational sessions were provided to 16 house staff-led teams between January and March of 2022. At the end of the educational meeting series, there were 43 patients discharged after hospitalization for ADHF and eligible for ARNi prescription; mean age was 69.1 years (±15.2) and 69% were male, 25.6% were discharged on ARNi and 45.5% were on >50% of the target dose. Compared to baseline, ARNi utilization was not improved.
A short series of educational meetings did not increase the rate of ARNi prescribing prior to discharge among eligible patients hospitalized for ADHF. Future quality improvement initiatives may incorporate peer to peer education but should include additional interventions.
Guideline-directed medical therapy (GDMT) at discharge is a quality metric intended to reflect the care provided for patients with heart failure and reduced ejection fraction (ADHF). However, the use ...of GDMT, particularly RAAS inhibitors, remains suboptimal. While HF quality improvement (QI) initiatives in hospitals are common, participation and engagement among residents are often limited.
Creation of a house staff driven QI team will lead to an improvement in GDMT prescribing among patients with ADHF prior to discharge.
A QI team, comprised of internal medicine (IM) residents, a HF physician, and a hospital administrator, was formed at an urban, academic medical center. A SMART Aim was created, 3 key drivers were identified along with 5 interventions and change concepts (Figure 1). An anonymous electronic survey was administered to IM house staff to address perceptions and barriers to clinical implementation of GDMT and direct Plan-Do-Study-Act (PDSA) cycles. The first PDSA cycle consisted of biweekly, educational small group sessions with house staff and hospital medicine physicians. These sessions were conducted by the QI team residents and reviewed clinical indications in HFrEF specific populations and financial options for patients. A handout with prescribing pearls and references to clinical trials was also provided. The second PDSA cycle utilized an existing electronic medical record census report to identify patients with HFrEF currently admitted for ADHF. A standardized note suggesting ARNi prescription was written by the QI team. Interventions took place between January through March 2022.
Baseline data revealed 56.9% of eligible patients were discharged on a RAAS inhibitor. From a total of 150 IM house staff, 26.7% completed the initial survey. For PDSA cycle 1, 22 small group educational sessions were completed yielding a total of 74 trainees approached over 6 weeks. For PDSA cycle 2, a total of 28 electronic notes in electronic health record of qualifying patients were entered. The rate of RAAS inhibitor use did not improve significantly after either PDSA cycle.
House staff driven initiatives in quality improvement activities represent an opportunity help identify and incorporate systems-based changes to improve patient care for individuals with ADHF. Future PDSA cycles may require direct interventions with multidisciplinary team engagement.
Lack of absolute selectivity against cancer cells is a major limitation for current cancer therapies. In the previous study, we developed a prodrug strategy for selective cancer therapy using a ...masked cytotoxic agent puromycin Boc-Lys(Ac)-Puromycin, which can be sequentially activated by histone deacetylases (HDACs) and cathepsin L (CTSL) to kill cancer cells expressing high levels of both enzymes. Despite the promise as a selective cancer therapy, its requirement of relatively high dosage could be a potential issue in the clinical setting. To address this issue, we aimed to further improve the overall efficacy of our prodrug strategy. Since the proteolytic cleavage by CTSL is the rate-limiting step for the drug activation, we sought to improve the substrate structure for CTSL activity by modifying the α-amino protecting group of lysine. Here we show that protection with Fmoc Fmoc-Lys(Ac)-Puromycin exhibits a marked improvement in overall anticancer efficacy compared to the original Boc-Lys(Ac)-Puromycin and this is mainly due to the highly efficient cellular uptake besides its improved substrate structure. Furthermore, to address a concern that the improved drug efficacy might direct high toxicity to the normal cells, we confirmed that Fmoc-Lys(Ac)-Puromycin still retains excellent cancer selectivity in vitro and no obvious systemic off-target toxicity in vivo. Thus our preclinical evaluation data presented here demonstrate that the Fmoc-Lys(Ac)-Puromycin exhibits substantially improved anticancer efficacy, further supporting our approach for the selective cancer therapy.
Older adults with cancer use the emergency department (ED) for acute concerns.
Characterize the palliative care needs and clinical outcomes of advanced cancer patients in the ED.
A planned secondary ...data analysis of the Comprehensive Oncologic Emergencies Research Network (CONCERN) data.
Cancer patients who presented to the 18 CONCERN affiliated EDs in the United States.
Survey included demographics, cancer type, functional status, symptom burden, palliative and hospice care enrollment, and advance directive code status.
Of the total (674/1075, 62.3%) patients had advanced cancer and most were White (78.6%) and female (50.3%); median age was 64 (interquartile range 54-71) years. A small proportion of them were receiving palliative (6.5% 95% confidence interval; CI 3.0-7.6;
= 0.005) and hospice (1.3% 95% CI 1.0-3.2;
= 0.52) care and had a higher 30-day mortality rate (8.3%, 95% CI 6.2-10.4).
Patients with advanced cancer continue to present to the ED despite recommendations for early delivery of palliative care.
Purpose
Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important ...strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED.
Methods
We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay.
Results
Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6–19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index.
Conclusion
In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.
Economic stress, broadly defined, is associated with an increased likelihood of multiple forms of violence. Food insecurity is a distinct economic stressor and material hardship that is amenable to ...programmatic and policy intervention. To inform intervention and identify gaps in the current evidence base, we conducted a systematic review to synthesize and critically evaluate the existing literature regarding the association between food insecurity and five forms of interpersonal and self-directed violence: intimate partner violence (IPV), suicidality, peer violence and bullying, youth dating violence, and child maltreatment, in high-income countries. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and searched six electronic databases from their start date through February of 2022. We included studies that examined food insecurity as the exposure and an outcome measure of IPV, suicide, suicidality, peer violence, bullying, youth dating violence, or child maltreatment; were peer-reviewed and published in English; reported quantitative data; and took place in a high-income country. We identified 20 relevant studies. Nineteen studies found that food insecurity was associated with an increased likelihood of these forms of violence. Results highlight the potential for programs and policies that address food insecurity to function as primary prevention strategies for multiple forms of violence and underscore the importance of trauma-informed approaches in organizations providing food assistance. Additional theory-driven research with validated measures of food insecurity and clearly established temporality between measures of food insecurity and violence is needed to strengthen the existing evidence base.
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