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Racial Differences in the use of Genetic Testing among Patients with Hypertrophic Cardiomyopathy
The 23rd Annual Scientific Meeting HFSA adjudicators for appropriate clinical use while patients tolerating higher beta-blocker dose may represent a robust cohort in whom S/V may be better tolerated. Our observed higher rates of intolerance despite conservative low dose S/V initiation may call for more concerted efforts for clinical assessment and non-traditional dose initiation. Confirmation of these observations are warranted with larger registries and prospective studies.
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377 Racial Differences in the use of Genetic Testing among Patients with Hypertrophic Cardiomyopathy Lauren Anne Eberly1, Ijeoma Eleazu2, Nadine Channaoui1, Kermshlise Picard1, Allison Cirino1, Richard Cope1, Christine E. Seidman1, Carolyn Y. Ho1, Neal K. Lakdawala1; 1Brigham and Women’s Hospital, Boston, MA; 2Massachusetts General Hospital, Boston, MA Background: Hypertrophic cardiomyopathy (HCM), the prototypical cardiovascular genetic disease, is caused by dominantly inherited mutations in genes encoding sarcomeric proteins. Genetic testing is recommended for individuals with HCM, the results of which promote prevention of morbidity and mortality through detection of disease in at-risk relatives. However, utilization of genetic testing in clinical medicine has not been widely adopted. Prior studies of inherited cancer syndromes have noted racial inequities in access to genetic testing. The aim of this study was to investigate for structural inequities in referral to a cardiovascular genetics clinic for genetic testing and counseling among Black, Latinx, and female patients with HCM. Methods: We performed a case-control study (January 2012-December 2017) of 280 patients with HCM within a large academic health system. HCM patients were identified by ICD-9 diagnostic codes, and then verified by manual chart review. Of these 280 patients, 20% were referred to cardiovascular genetics clinic for genetic testing (cases) and 80% were not (controls). Demographic factors including race and gender were extracted for both cases and controls. Fischer exact, x2tests, and t tests were used to assess the statistical significance of difference in the characteristics of cases and controls as indicated. Results: HCM patients who were referred to cardiovascular genetics clinic for genetic testing (cases) were less likely to be black (5.4% of cases vs. 8.0% of controls) and less likely to be female (46.4% of cases vs 56.7% controls), but this did not achieve statistical significance (p=0.82 for race; p=0.17 for gender). English language was not associated with referral (p=0.30). Older patients, however, were significantly less likely to be referred for genetic testing (odds ratio 0.94 [95% CI 0.92, 0.96][p<0.0001]). Conclusions: Overall referral rates to a cardiovascular genetics clinic for genetic testing were low among patients with HCM. Additional ascertainment is important to understand if the demonstrated trends are significant on a larger scale.
378 376 Quality of Life in Heart Failure Patients Differs Based on the Interaction between Depression and Cognitive Function: A Pilot Study Courtney Alio1,2, Courtney Condiracci1,3, Kimberly D. Williams1, Alice V. Ely1; 1 Christiana Care, Newark, DE; 2Philadelphia College of Osteopathic Medicine, Philadelphia, PA; 3Geisinger Medical Center, Danville, PA Heart failure (HF) is a chronic condition and one of the leading causes of hospitalization. It is critical to recognize risk factors impacting quality of life (QOL) in these patients. Both depression and cognitive dysfunction are prevalent in HF, and each independently have been shown to negatively impact QOL. While a relationship between depression and cognitive function is established, how depression and cognitive function interact to predict QOL in patients with HF is unknown. Further, prior studies have typically used full neuropsychological batteries used to assess cognition, which are time consuming and expensive to conduct in the context of routine outpatient appointments. We hypothesized that cognitive dysfunction and depression would lead to reduced QOL as measured using gold standard brief screening tools. As a part of a pilot program to incorporate cognitive and behavioral health screening into regular outpatient treatment, 23 patients completed the Montreal Cognitive Assessment (MoCA), the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), the Patient Health Questionnaire (PHQ-2), and provided demographic and medical information during a regular medical visit. Participants with and without symptoms of depression were compared on the subscales of the KCCQ-12 using a multivariate analysis of variance controlling for age and severity of HF as measured by New York Heart Class (NYHC). MANCOVA revealed that the interaction of PHQ-2 and MoCA score was related to decreased QOL (Pillai’s Trace = 0.48, p = 0.047), adjusting for age and NYHC. Those endorsing symptoms of depression and lower cognitive function scored significantly worse on the Symptoms Frequency subscale of the KCCQ12 (F = 9.55, p = 0.007) as compared to those with greater cognitive function or without symptoms of depression. A main effect of depression was also revealed (Pillai’s Trace = 0.38, p = 0.027), such that those with depression symptomatology scored significantly worse on Symptom Frequency than those without (F = 11.27, p = 0.004), when controlling for age, NYHC and cognitive function. Our findings are consistent with research suggesting patients with HF who experience depressive symptoms or reduced cognitive function have decreased QOL regardless of age or severity of their illness. This are the first findings demonstrating an interaction effect using brief screening measures that can easily be incorporated into outpatient treatment. Further study is necessary to explore therapeutic strategies for patients with comorbid cognitive dysfunction and depression. This data demonstrates the need for routine cognitive and depressive screenings in outpatient settings to facilitate early intervention to improve QOL in patients with HF.
Outpatient Diuresis Clinic - A Patient Centered and Cost Saving Approach to Heart Failure Management Grayson Eubanks, Hubert Haywood, Mason Sanders, Mirnela Byku, Thelsa Weickert; University of North Carolina, Chapel Hill, NC Background: Heart failure (HF) remains one of the leading causes of hospital admissions, representing annual healthcare costs exceeding $30 billion in the United States. In an effort to reduce hospitalizations and transition to a value-based care model, Medicare’s Hospital Readmission Reduction Program penalizes hospitals that have above average 30 day readmission rates, withholding 3% of all Medicare reimbursement for these hospitals. While the national average for HF readmissions is currently at 22%, the 30 day readmission rate for HF at the University of North Carolina (UNC) is 23.9%. Fiscal incentives to reduce the burden of hospital admissions have fueled interest in ambulatory strategies that can better manage HF, including clinicbased administration of IV diuretics. Methods: The aim of this study was to assess the impact of an outpatient diuresis clinic on HF hospitalizations and resultant cost savings. The clinic is staffed by an advanced practice provider and a registered nurse with cardiologist oversight. There is also multidisciplinary support by pharmacy, nutrition, and social work. Data were collected retrospectively from 445 patient encounters between August 2017 and February 2019. Primary endpoints included observation stays, inpatient hospitalizations, and cost to payers. Results: As of February 2019, 162 unique patients had been treated in the diuresis clinic, totaling 445 encounters. Based on our FY2016 data, 90% of patients presenting to the emergency department with a diagnosis of HF are admitted for either an observation or inpatient stay. For patients admitted to UNC who require less than a 48 hour hospitalization, the total cost to payers was approximately $3.5 million. These 445 encounters would have resulted in a total payer cost of $1,184,145 for observation stays and $4,040,155 for inpatient admissions (less than 48 hours). In comparison, the cost to payer for each diuresis clinic visit is $276, resulting in a total cost of $122,820. In addition, assuming that each outpatient diuresis encounter substitutes for at least a 36 hour hospital stay (median length of stay in observation unit), this would, at minimum, result in 668 hospital bed days saved. Though transient electrolyte abnormalities and rare but reversible episodes of acute kidney injury were noted during clinic visits, there were no significant adverse events requiring hospitalizations during the study period. Conclusions: For stable patients with decompensated heart failure, the outpatient IV diuresis clinic is a patient-centered, safe, and cost savings alternative to hospital admission.
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377 Racial Differences in the use of Genetic Testing among Patients with Hypertrophic Cardiomyopathy Lauren Anne Eberly1, Ijeoma Eleazu2, Nadine Channaoui1, Kermshlise Picard1, Allison Cirino1, Richard Cope1, Christine E. Seidman1, Carolyn Y. Ho1, Neal K. Lakdawala1; 1Brigham and Women’s Hospital, Boston, MA; 2Massachusetts General Hospital, Boston, MA Background: Hypertrophic cardiomyopathy (HCM), the prototypical cardiovascular genetic disease, is caused by dominantly inherited mutations in genes encoding sarcomeric proteins. Genetic testing is recommended for individuals with HCM, the results of which promote prevention of morbidity and mortality through detection of disease in at-risk relatives. However, utilization of genetic testing in clinical medicine has not been widely adopted. Prior studies of inherited cancer syndromes have noted racial inequities in access to genetic testing. The aim of this study was to investigate for structural inequities in referral to a cardiovascular genetics clinic for genetic testing and counseling among Black, Latinx, and female patients with HCM. Methods: We performed a case-control study (January 2012-December 2017) of 280 patients with HCM within a large academic health system. HCM patients were identified by ICD-9 diagnostic codes, and then verified by manual chart review. Of these 280 patients, 20% were referred to cardiovascular genetics clinic for genetic testing (cases) and 80% were not (controls). Demographic factors including race and gender were extracted for both cases and controls. Fischer exact, x2tests, and t tests were used to assess the statistical significance of difference in the characteristics of cases and controls as indicated. Results: HCM patients who were referred to cardiovascular genetics clinic for genetic testing (cases) were less likely to be black (5.4% of cases vs. 8.0% of controls) and less likely to be female (46.4% of cases vs 56.7% controls), but this did not achieve statistical significance (p=0.82 for race; p=0.17 for gender). English language was not associated with referral (p=0.30). Older patients, however, were significantly less likely to be referred for genetic testing (odds ratio 0.94 [95% CI 0.92, 0.96][p<0.0001]). Conclusions: Overall referral rates to a cardiovascular genetics clinic for genetic testing were low among patients with HCM. Additional ascertainment is important to understand if the demonstrated trends are significant on a larger scale.
378 376 Quality of Life in Heart Failure Patients Differs Based on the Interaction between Depression and Cognitive Function: A Pilot Study Courtney Alio1,2, Courtney Condiracci1,3, Kimberly D. Williams1, Alice V. Ely1; 1 Christiana Care, Newark, DE; 2Philadelphia College of Osteopathic Medicine, Philadelphia, PA; 3Geisinger Medical Center, Danville, PA Heart failure (HF) is a chronic condition and one of the leading causes of hospitalization. It is critical to recognize risk factors impacting quality of life (QOL) in these patients. Both depression and cognitive dysfunction are prevalent in HF, and each independently have been shown to negatively impact QOL. While a relationship between depression and cognitive function is established, how depression and cognitive function interact to predict QOL in patients with HF is unknown. Further, prior studies have typically used full neuropsychological batteries used to assess cognition, which are time consuming and expensive to conduct in the context of routine outpatient appointments. We hypothesized that cognitive dysfunction and depression would lead to reduced QOL as measured using gold standard brief screening tools. As a part of a pilot program to incorporate cognitive and behavioral health screening into regular outpatient treatment, 23 patients completed the Montreal Cognitive Assessment (MoCA), the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), the Patient Health Questionnaire (PHQ-2), and provided demographic and medical information during a regular medical visit. Participants with and without symptoms of depression were compared on the subscales of the KCCQ-12 using a multivariate analysis of variance controlling for age and severity of HF as measured by New York Heart Class (NYHC). MANCOVA revealed that the interaction of PHQ-2 and MoCA score was related to decreased QOL (Pillai’s Trace = 0.48, p = 0.047), adjusting for age and NYHC. Those endorsing symptoms of depression and lower cognitive function scored significantly worse on the Symptoms Frequency subscale of the KCCQ12 (F = 9.55, p = 0.007) as compared to those with greater cognitive function or without symptoms of depression. A main effect of depression was also revealed (Pillai’s Trace = 0.38, p = 0.027), such that those with depression symptomatology scored significantly worse on Symptom Frequency than those without (F = 11.27, p = 0.004), when controlling for age, NYHC and cognitive function. Our findings are consistent with research suggesting patients with HF who experience depressive symptoms or reduced cognitive function have decreased QOL regardless of age or severity of their illness. This are the first findings demonstrating an interaction effect using brief screening measures that can easily be incorporated into outpatient treatment. Further study is necessary to explore therapeutic strategies for patients with comorbid cognitive dysfunction and depression. This data demonstrates the need for routine cognitive and depressive screenings in outpatient settings to facilitate early intervention to improve QOL in patients with HF.
Outpatient Diuresis Clinic - A Patient Centered and Cost Saving Approach to Heart Failure Management Grayson Eubanks, Hubert Haywood, Mason Sanders, Mirnela Byku, Thelsa Weickert; University of North Carolina, Chapel Hill, NC Background: Heart failure (HF) remains one of the leading causes of hospital admissions, representing annual healthcare costs exceeding $30 billion in the United States. In an effort to reduce hospitalizations and transition to a value-based care model, Medicare’s Hospital Readmission Reduction Program penalizes hospitals that have above average 30 day readmission rates, withholding 3% of all Medicare reimbursement for these hospitals. While the national average for HF readmissions is currently at 22%, the 30 day readmission rate for HF at the University of North Carolina (UNC) is 23.9%. Fiscal incentives to reduce the burden of hospital admissions have fueled interest in ambulatory strategies that can better manage HF, including clinicbased administration of IV diuretics. Methods: The aim of this study was to assess the impact of an outpatient diuresis clinic on HF hospitalizations and resultant cost savings. The clinic is staffed by an advanced practice provider and a registered nurse with cardiologist oversight. There is also multidisciplinary support by pharmacy, nutrition, and social work. Data were collected retrospectively from 445 patient encounters between August 2017 and February 2019. Primary endpoints included observation stays, inpatient hospitalizations, and cost to payers. Results: As of February 2019, 162 unique patients had been treated in the diuresis clinic, totaling 445 encounters. Based on our FY2016 data, 90% of patients presenting to the emergency department with a diagnosis of HF are admitted for either an observation or inpatient stay. For patients admitted to UNC who require less than a 48 hour hospitalization, the total cost to payers was approximately $3.5 million. These 445 encounters would have resulted in a total payer cost of $1,184,145 for observation stays and $4,040,155 for inpatient admissions (less than 48 hours). In comparison, the cost to payer for each diuresis clinic visit is $276, resulting in a total cost of $122,820. In addition, assuming that each outpatient diuresis encounter substitutes for at least a 36 hour hospital stay (median length of stay in observation unit), this would, at minimum, result in 668 hospital bed days saved. Though transient electrolyte abnormalities and rare but reversible episodes of acute kidney injury were noted during clinic visits, there were no significant adverse events requiring hospitalizations during the study period. Conclusions: For stable patients with decompensated heart failure, the outpatient IV diuresis clinic is a patient-centered, safe, and cost savings alternative to hospital admission.