Odunukan, Olufunso W.

Importance In patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited. Objective To report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial. Design, Setting, and Participants SURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021. Intervention Patients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis. Main Outcomes and Measures The prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years. Results A total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm 2 vs 1.8 [0.6] cm 2 ; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention. Conclusions and Relevance Among intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.

Background: Concerns for side-effects makes the identification of treatment targets of hypertension in the very elderly challenging. We sought to utilize natural language processing (NLP) to evaluate the prevalence of prespecified side-effects in a cohort of very elderly (≥80 years) patients. Methods and Results: We conducted a two-year, cross-sectional study involving 5169 very elderly patients with and without hypertension seen by primary or specialist providers. Hypertension patients had to have a prior hypertension ICD-9 code in the electronic medical records problem list and ≥2 office visits in 2008 and 2009. We used NLP to analyze extracted free text reports from last clinic visits between 2008 and 2009. Of the 10 prespecified side-effects, hypotension, fatigue, and dizziness were the commonest three conditions and hypotension was significantly higher in the HTN patients. Of the 2835 patients with no prior hypertension history and 2334 hypertension patients identified, the prevalence of each prespecified item in both groups were: acute renal failure (0.3% v 0.6%, p=0.13); syncope (2.8% v 2.2%, p = 0.17), dizziness (3.1% v 4.0%, p=0.09), history of fall (1.0% v 0.9%, p=0.65), fatigue (5.4% v 4.5%, p=0.19), femoral neck fracture (0.18% v 0.04%, p=0.16), palpitations (1.2% v 1.5%, p=0.35), hypotension (4.1% v 6.6%, p<0.001), hyperkalemia (1.1% v 1.7%, p=0.04), hypokalemia (0.4% v 0.9%, p=0.01). At least one presumed side-effect was present in 17.5% of all 5169 patients. Among hypertension patients, there was no significant difference in the prevalence of the side-effects among patients with BP above (578) or below 140/90 (1756) except for acute renal failure (1.21% vs 0.40%, p = 0.03). Conclusion: Analysis of free-text outpatient notes using NLP showed that hypotension and potassium abnormalities were significantly more prevalent in very elderly patients with hypertension compared to similarly aged patients with no hypertension history.

Background: Left ventricular hypertrophy (LVH) is considered a marker of stage B heart failure according to the ACC/AHA classification. Current guidelines recommend beta-blocker (BB) therapy for treatment but randomized control trials suggest that Angiotensin Receptor Blocker (ARB) therapy may be superior. Purpose: To compare survival among cohorts of LVH patients classified according to use of BB, ARB or neither (NONE) class of medications. Methods: A retrospective analysis of hypertension patients seen in the outpatient clinics was done. LVH was defined using the most stringent electrocardiogram (ECG) criteria whereas patients with minimal and moderate voltage criteria were excluded. Using hypertension medications from the year 2009 outpatient visits notes, 869 LVH patients were classified into BB (604), ARB (115) and NONE (150) cohort groups. Cox proportional hazard models were built. Results: Survival at 5 years was 85.2% with 17 deaths and 98 censored patients, (unadjusted hazard ratio HR 0.53, p=0.03) in the ARB cohort and 75.5 % with 148 deaths, 456 censored patients (HR 0.91, p=0.61) in the BB group compared to 74.0% in the NONE cohort with 39 deaths and 111 censored patients. After adjusting for age, sex, atrial fibrillation/flutter, heart failure, chronic kidney disease (CKD), coronary artery disease (CAD), acute myocardial infarction, stroke, obesity, diabetes, sleep apnea and pulmonary hypertension, HR was 0.40, p=0.006 for ARB and HR=0.80, p=0.278 for BB compared to the NONE group. At baseline, there was no significant difference in age, sex, and the prevalence in heart failure, stroke, obesity, sleep apnea, and pulmonary hypertension in all three groups although the BB group had significantly highest prevalence of atrial fibrillation/flutter, CAD, CKD and the lowest prevalence of diabetes. Conclusion: There was a significant mortality reduction benefit to hypertension patients with ECG diagnosed LVH treated with ARB which was not seen in similar patients on BB when compared to those treated with none of both medication classes. This effect persisted even after adjusting for cardiovascular comorbidities.

Background: Blood pressure (BP) measurement is a national core quality measure for hypertension care and hypertension control rates remain a major performance measure. It remains unclear whether improving measurement directly results in better control rates in hypertension management. Purpose: To utilize electronic medical records to explore the relationship between measurement of blood pressure and hypertension control rates among 4 eligible primary care providers groups - Primary Care Internal Medicine (PCIM), Family medicine (FM), General Internal Medicine (GIM), Preventive Medicine (PREV) - and 2 eligible specialist groups - Cardiology (CARD), Nephrology (NEPH) at an academic group medical practice. Methods: A two year cross sectional study involving adults seen by eligible primary or specialist providers at 2 or more office visits with a hypertension ICD-9 code in two years with at least one office visit in the measurement year. We measured the proportion of patients who had their BP measured at their last hypertension visit (LHV) in 2009 and 2010. We compared measurement rates with control rates as defined by the proportion of hypertension patients with BP < 140/90 mmHg at their LHV. Results: In 2009, 84.2% of 17989 patients (95% CI 83.6 - 84.7%) had their BP measured at their LHV compared to 85.3% (95% CI 84.8 - 85.8%) of 17992 patients in 2010, an increase of 1.2% (p=0.0026). Measurement rates varied widely across the different provider groups. PCIM, a high performing group, had significant improvement in measurement rates from 2009 to 2010 and demonstrated improvement in control rates. Lower performing groups, Nephrology and GIM, had significant improvement in measurement but did not see a direct translation to improved control rates. There was an associated worsening of the control rates for Preventive medicine along with a decrease in the measurement rates from 2009 to 2010. Conclusion: High BP measurement rates are associated with high hypertension control rates. Prioritizing BP measurement may result in improved intermediate outcomes in hypertension management.

Background: The diagnosis of hypertension requires systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg on at least 2 different occasions. Therefore, there is the possibility of patients with elevated BP remaining undiagnosed if not seen by the same provider. Purpose: To utilize electronic medical records (EMR) to identify patients not previously diagnosed with hypertension that have elevated blood pressure meeting criteria for a diagnosis of hypertension using a threshold of SBP ≥ 140mmHg or DBP ≥ 90 mmHg (high BP) on 2 or more occasions. Methods: This was a cross sectional design utilizing retrospective multi-year billing and clinical data from a large multi-specialty center in the Midwest. Using electronic records of all outpatient visits in each year from 2009 - 2011, patients with at least 2 visits with SBP ≥ 140mmHg or DBP ≥ 90 mmHg (2HBP) in the measurement year were identified. These patients were compared with previously identified cohorts of known hypertension patients (Known HTN) compiled using the EMR problem list. A sensitivity analysis was done using patients with high BP at 2 consecutive visits (2CHBP) and also those with high BP at 3 consecutive visits (3CHBP). We compared proportions of patients with high BP without a prior diagnosis of hypertension (UDHTN). Results: The proportion of patients with SBP ≥ 140mmHg or DBP ≥ 90 mmHg without a prior diagnosis of hypertension (UDHTN) when compared to the cohort of known patients with a diagnosis of hypertension (Known HTN) was 25% in 2009, 26% in 2010, and 28% in 2011 in the 2CHBP cohort compared to 27% in 2009, 28% in 2010, and 30% in 2011 in the 2HBP cohort and 18% in 2009, 19% in 2010 and 23% in 2011 in the 3CHBP cohort. Conclusion: About a quarter of patients meeting current thresholds on multiple and consecutive visits did not have a known diagnosis of hypertension. The use of EMR can identify these patients for commencement of appropriate management. Table 1

Background: Hypertension (HTN) control rate is a core clinical quality measure. It is presently assessed by manual review of a random sample of patients with HTN billing claims. There is an increasing push by regulators towards the use of electronic medical records (EMR) to assess quality of care. Purpose: To use EMR to obtain a more in-depth assessment of quality of hypertension care. Methods: Cross sectional study involving adults with HTN seen at 2 or more office visits in 2009 by eligible primary or specialist providers at a large medical group practice. We measured the proportion of HTN patients with blood pressure (BP) at goal (BP < 140/90 mm Hg) at their last hypertension visit (LHV). Results: Of a total of 10,401 patients, 5970 (57%) were controlled and 1959 (19%) were uncontrolled at their LHV. Control could not be assessed in 2472 (24%) as BP values were unavailable from the vital signs section of the visit notes in the EMR. Of a random sample of 250 patients with unavailable BP, only 94 (37.6%) had BP values documented in other parts of the visit note. In 29 patients (11.6%) billing for HTN was done without adequate evidence that it was addressed at that visit. Control rates were highest for primary care providers where measurement and documentation of BP was a focus - Family Medicine 77% controlled, 1% unavailable; Primary Care Internal Medicine 71% controlled, 4% unavailable. A considerable proportion of patients in the other four provider groups did not have BP available from their last hypertension visit - Cardiology 59% controlled, 22% unavailable; Nephrology 38% controlled, 47% unavailable; Preventive Medicine 48% controlled, 39% unavailable; General Internal Medicine 41% controlled, 45% unavailable. Control rates were similar across provider groups when patients with unavailable BP were excluded: Family Medicine 78%, Primary Care 74%, Cardiology 75%, Nephrology 73%, Preventive Medicine 79%, and General Medicine 75%. Conclusions: Up to a quarter of HTN patients did not have properly documented BP in the EMR at their LHV. For those with measurements recorded, control rates were similar across primary care and specialty clinics, but measurement rates were higher for primary care practices. Use of the EMR facilitates efficient and granular assessment of the measurement process and control rates for HTN among various provider groups.

Introduction: Patients with hypertension (HTN) may remain undiagnosed as the diagnosis requires systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg on ≥ 2 different occasions. Hypothesis: We sought to evaluate outcomes of patients without diagnosed hypertension who have elevated BP meeting current thresholds for hypertension on 2 consecutive episodes. Methods: Together with retrospective billing and clinical data, electronic records of all outpatient visits in 2009 were used to identify 24,277 patients with 2 consecutive visits (2CHBP) with SBP ≥ 140mmHg or DBP ≥ 90 mmHg and were compared with a previously identified cohort of 53,998 known hypertension patients. Among the 2CHBP group, 6,071 (25%) were identified without a prior diagnosis of hypertension and were categorized as undiagnosed hypertension. They were compared with patients with known hypertension who had ≥ 1 visit in 2009. Cross-sectional analysis of cardiovascular comorbidities and proportional hazards for survival were done. Results: Of 5,978 undiagnosed HTN patients, 49% were female compared to 51% of 10,311 known HTN. In the undiagnosed HTN group, 19.5% were ≥ 80 years compared to 30.4% of known HTN patients. Cardiovascular comorbidities were generally lower in the undiagnosed HTN group compared to the known HTN group - heart failure (7% v 8%; OR 0.88, 95% CI: 0.77 - 0.99; p < 0.038), atrial fibrillation (11% v 12%, OR 0.88 95% CI 0.79 - 0.97) and coronary artery disease (17% v 26%, OR 0.57 95% CI 0.52 - 0.61). However after a four year followup, mortality was higher in the undiagnosed HTN group with unadjusted hazard ratio HR 1.4 (95% CI 1.29 - 1.60, p<0.0001) and HR 2.41 (2.16 -2.68, p<0.0001) when adjusted for age, sex, heart failure and diabetes. Conclusions: Over a quarter of patients meeting current thresholds on 2 consecutive visits did not carry a known diagnosis of hypertension. Although younger and with less cardiovascular comorbidities than those with diagnosed hypertension, mortality after 4 years was significantly higher in those with undiagnosed hypertension. Electronic records can be used to identify these high risk patients.

Objectives: Somali people are among the largest refugee populations to resettle in North America and Europe over the past 2 decades, and health disparities are well documented, including barriers to effective navigation of primary health care systems. Patient–provider gender discordance has been described as a barrier to health-seeking behaviors and effective communication by Somali women in past qualitative work. The objective of this study was to elucidate provider and interpreter preferences during clinical encounters according to gender and race among Somali women in the United States. Methods: Fifty Somali women empanelled to a large primary care practice completed pictorial surveys to elucidate preferences of Somali women for providers of different genders and race for different components of the clinical examination using a Likert-type scale. Results: We found that Somali women generally preferred a female provider for conducting the physical examination, particularly for the pelvic, breast, and abdominal examinations. Likewise, Somali women strongly preferred female interpreters to be present during the physical examination. There was no stated preference for patient–provider racial concordance. Conclusions: These findings have implications for structural health care changes aimed at delivering culturally sensitive and effective primary care to Somali patients.

Although it has been assumed that telephone triage can directly benefit patients by facilitating early diagnosis and treatment, this potential benefit has not been well documented. Using appendicitis cases ascertained from claims data, we compared telephone triage recommendations with what the callers originally intended to do. Over a two-year period, there were 20,230 calls to a telephone triage centre in the US where insurance information was available. Of these, 12,709 calls (63%) had insurance claims made within seven days of the call. Among these calls, 46 had a diagnosis of appendicitis. In 72% of calls concerning appendicitis, the telephone triage recommendation was for a more rapid evaluation than the caller originally intended ( P < 0.0001). In 91% of the appendicitis cases, triage nurses directed callers to care within 8 h, but without triage advice, only 39% of callers stated they would have sought care within 8 h ( P < 0.0001). Telephone triage significantly reduced the delay in care for appendicitis in comparison with what the caller would have done. This suggests that telephone triage potentially reduces the morbidity associated with appendicitis.