YouTube as a Source of Information on Left Ventricular Assist Devices
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212 Cost Comparison between Heart Transplantation and Left Ventricular Assist Device Implantation Ahmet Kilic, Gary Phillips, Neeraj Chimanji, Chittoor B. Sai-Sudhakar, Ayesha Hasan, Robert S.D. Higgins, Bryan A. Whitson; The Ohio State University, Columbus, OH Background: The increasing number of end-stage heart failure patients along with improvements in technology and a relative donor organ shortage have led to an increased use of left ventricular assist devices (LVAD) as bridge-to-transplants (BTT). Given the current economic emphasis on cost versus patient benefit and outcome, we sought to compare the financial effectiveness of heart transplant (HTX) and LVAD surgeries. Materials and Methods: We retrospectively analyzed our prospectively maintained HTX and LVAD databases from 1/1/2009 to 6/30/ 2013. The patient’s records were cross referenced with institutional financial data. We limited our LVAD cohort to durable (i.e., not temporary) LVADs. We eval- uated overall charges, payments received; direct fixed and variable costs as well as LVAD pump charges. We did not analyze indirect costs as to keep our findings applicable to other institutions. Standard statistical methods were utilized. Results: We identified 141 LVAD and 63 HTX surgeries which met the inclusion criteria. Of those, 20 had both surgeries giving final cohorts of 121 LVAD alone, 43 HTX alone, and 20 LVAD followed by heart transplant (LVAD/HTX). Mean charge for LVAD along was $881,586 +/- 348,975 and for HTX alone was $686,289 +/- 400,764. For both surgeries in the LVAD/HTX cohort, the mean charge was $1,496,977 +/- 806,313. There were differences in cost and payment between groups (Table) and these were demonstrable when adjusted for length of stay. There were similar rates of readmissions with a mean of 4.65 per HTX patient and 4.53 per LVAD patient. 1-year survival for HTX was 87.8% and for LVAD, 78%. 3-year survival for HTX was 72.7% and for LVAD 55%. No differences were found between HTX surgery costs or payments. No LVAD cost or charge dif- ferences were found between LVAD and LVAD/HTX groups and LVAD cost was $79,581. Mean LVAD net was $74,320 with HTX net of $124,759. Conclusion: In an analysis of the cost effectiveness of HTX and LVAD surgeries, HTX alone appears to be more cost effective even when adjusting for length of stay. BTT pa- tients have less costly implant operations with actual LVAD pump costs accounting for a portion of the decreased revenue. From a fiscal perspective, primary heart transplantation may be the most cost effective approach to managing patients with advanced heart failure. However, the lack of suitable donors for many of these patients clearly highlights the value of LVADs in the armamentarium of advanced heart failure surgical options. 213 Plasma Neutrophil Gelatinase-Associated Lipocalin and Worsening Renal Function during Everolimus Therapy after Heart Transplantation Teruhiko Imamura 1 , Koichiro Kinugawa 2 , Kent Doi 3 , Maasaru Hatano 1 , Takeo Fujino 1 , Osamu Kinoshita 4 , Kan Nawata 4 , Shunei Kyo 2 , Minoru Ono 4 ; 1 Graduate School of Medicine, University of Tokyo, Tokyo, Japan; 2 Graduate School of Medicine, University of Tokyo, Tokyo, Japan; 3 Graduate School of Medicine, University of Tokyo, Tokyo, Japan; 4 Graduate School of Medicine, University of Tokyo, Tokyo, Japan Objective: Recently, mammalian target of rapamycin inhibitor, everolimus (EVL), has been introduced as a novel immunosuppressant for heart transplant (HTx) recip- ients, and is expected to preserve renal function compared to conventional calcineurin inhibitors (CNIs). However, a considerable number of recipients treated with EVL was not free from worsening renal function regardless of CNI reduction. The aim was to find predictors for worsening renal function during EVL treatment. Methods: Data were collected retrospectively from 27 HTx recipients who had received EVL (trough concentration, 3.1-9.2 ng/mL) along with reduced CNIs (%decreases in trough concentration, 27.3613.0%) and been followed over 1 year between Aug 2008 and Jan 2013. Findings: Estimated glomerular filtration rate (eGFR) decreased in five recipients (18.5%) during the study period. A univariable logistic regression analysis demonstrated that higher plasma neutrophil gelatinase-associated lipocalin (P-NGAL) level was an only significant predictor for the decreases in eGFR over 1-year EVL treatment among all baseline parameters (p50.008). eGFR and protein- uria worsened almost exclusively in patients with baseline P-NGAL $85 ng/mL, which was the cutoff value calculated by an ROC analysis (area under the curve, 0.955; sensitivity, 1.000; specificity, 0.955). Conclusions: Higher P-NGAL can be a novel predictor for the worsening of renal function after EVL treatment that is resis- tant to CNI reduction in HTx recipients. 214 YouTube as a Source of Information on Left Ventricular Assist Devices Nilay Kumar 1 , Kazeen Abdullah 2 , Neetika Garg 3 , Ambarish Pandey 2 ; 1 Cambridge Health Alliance/Harvard Medical School, Cambridge, MA; 2 University of Texas Southwestern Medical Center, Dallas, TX; 3 Beth Israel Deaconess Medical Center/ Harvard Medical School, Boston, MA Background and objectives: A substantial proportion of patients with chronic med- ical conditions use the Internet to obtain medical information. Accurate medical in- formation can equip patients with health education and promote self-management and long-term behavioral changes. This study sought to ascertain the proportion to useful material relating to left ventricular assist devices (LVADs) on the popular video sharing website YouTube. Methods: YouTube was searched using the search term “Left Ventricular Assist Device”, which yielded approximately 800 results. We screened the first 20 pages (400 videos) of which 379 met inclusion criteria for the study. Videos were classified as “useful” or “misleading” by an expert physician using current guidelines as the reference standard. Viewership was compared across cate- gories of usefulness and data on content, person in the video and uploading agency was recorded. We sought to identify whether variables that predicted number of views using separate binomial negative binomial regression models, a variant of Poisson regression. Parameter estimates were generated as Incidence Rate Ratios (IRR), which are predictive of the outcome on a multiplicative scale. Results: Of the 379 videos Table (212). Cost or charge Comparison Non-Adjusted Adjusted for LOS Ratio 95% CI P- value Ratio 95% CI P-value Total charge HTX vs. VAD 0.74 0.65 0.85 !0.001 0.83 0.76 0.91 0.002 VAD/HTX vs. VAD 1.64 1.37 1.97 !0.001 1.14 1.00 1.30 0.798 VAD/HTX vs HTX 2.21 1.80 2.71 !0.001 1.38 1.18 1.60 0.001 HTX comb vs. HTX only 1.12 0.87 1.44 O0.99 1.01 0.87 1.18 O0.99 VAD comb vs. VAD only 0.78 0.65 0.94 0.127 0.80 0.71 0.91 0.020 Total payment HTX vs. VAD 0.99 0.83 1.17 O0.99 1.09 0.93 1.27 O0.99 VAD/HTX vs. VAD 1.86 1.48 2.34 !0.001 1.41 1.14 1.76 0.043 VAD/HTX vs. HTX 1.89 1.46 2.44 !0.001 1.30 1.01 1.68 0.758 HTX comb vs. HTX only 1.05 0.82 1.35 O0.99 0.97 0.79 1.20 O0.99 VAD comb vs. VAD only 0.82 0.64 1.06 O0.99 0.85 0.69 1.07 O0.99 Total direct foxed cost HTX vs. VAD 1.59 1.33 1.90 !0.001 1.78 1.54 2.06 !0.001 VAD/HTX vs. VAD 2.55 2.00 3.25 !0.001 1.75 1.42 2.16 !0.001 VAD/HTX vs. HTX 1.61 1.23 2.11 0.013 0.98 0.77 1.25 O0.99 HTX comb vs. HTX only 1.14 0.87 1.48 O0.99 1.08 0.84 1.38 O0.99 VAD comb vs. VAD only 0.71 0.55 0.92 0.131 0.74 0.63 0.88 0.012 Total direct variable cost HTX vs. VAD 0.54 0.47 0.62 !0.001 0.59 0.53 0.67 !0.001 VAD/HTX vs. VAD 1.35 1.11 1.64 0.038 1.00 0.85 1.19 0.971 VAD/HTX vs. HTX 2.50 2.02 3.11 !0.001 1.69 1.40 2.05 !0.001 HTX comb vs. HTX only 1.11 0.83 1.48 O0.99 1.01 0.81 1.27 O0.99 VAD comb vs. VAD only 0.75 0.63 0.89 0.025 0.76 0.66 0.89 0.013 Interpretation of the ratios: By example, the ratio of total charges for HTX vs VAD is 0.83 indicates that the charges for HTX are 17% less than the charges for VAD and this result is significantly different (p-value 5 0.002) from a ratio of 1.0 (total charges are equivalent across the comparison). S84 Journal of Cardiac Failure Vol. 20 No. 8S August 2014
Transcript of YouTube as a Source of Information on Left Ventricular Assist Devices
S84 Journal of Cardiac Failure Vol. 20 No. 8S August 2014
212Cost Comparison between Heart Transplantation and Left Ventricular AssistDevice ImplantationAhmet Kilic, Gary Phillips, Neeraj Chimanji, Chittoor B. Sai-Sudhakar, AyeshaHasan, Robert S.D. Higgins, Bryan A. Whitson; The Ohio State University,Columbus, OH
Background: The increasing number of end-stage heart failure patients along withimprovements in technology and a relative donor organ shortage have led to anincreased use of left ventricular assist devices (LVAD) as bridge-to-transplants(BTT). Given the current economic emphasis on cost versus patient benefit andoutcome, we sought to compare the financial effectiveness of heart transplant(HTX) and LVAD surgeries. Materials and Methods: We retrospectively analyzedour prospectively maintained HTX and LVAD databases from 1/1/2009 to 6/30/2013. The patient’s records were cross referenced with institutional financialdata. We limited our LVAD cohort to durable (i.e., not temporary) LVADs. We eval-uated overall charges, payments received; direct fixed and variable costs as well asLVAD pump charges. We did not analyze indirect costs as to keep our findingsapplicable to other institutions. Standard statistical methods were utilized. Results:We identified 141 LVAD and 63 HTX surgeries which met the inclusion criteria. Ofthose, 20 had both surgeries giving final cohorts of 121 LVAD alone, 43 HTXalone, and 20 LVAD followed by heart transplant (LVAD/HTX). Mean chargefor LVAD along was $881,586 +/- 348,975 and for HTX alone was $686,289 +/-400,764. For both surgeries in the LVAD/HTX cohort, the mean charge was$1,496,977 +/- 806,313. There were differences in cost and payment betweengroups (Table) and these were demonstrable when adjusted for length of stay.There were similar rates of readmissions with a mean of 4.65 per HTX patientand 4.53 per LVAD patient. 1-year survival for HTX was 87.8% and for LVAD,78%. 3-year survival for HTX was 72.7% and for LVAD 55%. No differenceswere found between HTX surgery costs or payments. No LVAD cost or charge dif-ferences were found between LVAD and LVAD/HTX groups and LVAD cost was$79,581. Mean LVAD net was $74,320 with HTX net of $124,759. Conclusion:In an analysis of the cost effectiveness of HTX and LVAD surgeries, HTX aloneappears to be more cost effective even when adjusting for length of stay. BTT pa-tients have less costly implant operations with actual LVAD pump costs accountingfor a portion of the decreased revenue. From a fiscal perspective, primary hearttransplantation may be the most cost effective approach to managing patientswith advanced heart failure. However, the lack of suitable donors for many of thesepatients clearly highlights the value of LVADs in the armamentarium of advancedheart failure surgical options.
Table (212).
Cost or charge Comparison
Non-Adjusted Adjusted for LOS
Ratio 95% CI P- value Ratio 95% CI P-value
Total charge HTX vs. VAD 0.74 0.65 0.85 !0.001 0.83 0.76 0.91 0.002VAD/HTX vs. VAD 1.64 1.37 1.97 !0.001 1.14 1.00 1.30 0.798VAD/HTX vs HTX 2.21 1.80 2.71 !0.001 1.38 1.18 1.60 0.001HTXcomb vs. HTXonly 1.12 0.87 1.44 O0.99 1.01 0.87 1.18 O0.99VADcomb vs. VADonly 0.78 0.65 0.94 0.127 0.80 0.71 0.91 0.020
Total payment HTX vs. VAD 0.99 0.83 1.17 O0.99 1.09 0.93 1.27 O0.99VAD/HTX vs. VAD 1.86 1.48 2.34 !0.001 1.41 1.14 1.76 0.043VAD/HTX vs. HTX 1.89 1.46 2.44 !0.001 1.30 1.01 1.68 0.758HTXcomb vs. HTXonly 1.05 0.82 1.35 O0.99 0.97 0.79 1.20 O0.99VADcomb vs. VADonly 0.82 0.64 1.06 O0.99 0.85 0.69 1.07 O0.99
Total direct foxed cost HTX vs. VAD 1.59 1.33 1.90 !0.001 1.78 1.54 2.06 !0.001VAD/HTX vs. VAD 2.55 2.00 3.25 !0.001 1.75 1.42 2.16 !0.001VAD/HTX vs. HTX 1.61 1.23 2.11 0.013 0.98 0.77 1.25 O0.99HTXcomb vs. HTXonly 1.14 0.87 1.48 O0.99 1.08 0.84 1.38 O0.99VADcomb vs. VADonly 0.71 0.55 0.92 0.131 0.74 0.63 0.88 0.012
Total direct variable cost HTX vs. VAD 0.54 0.47 0.62 !0.001 0.59 0.53 0.67 !0.001VAD/HTX vs. VAD 1.35 1.11 1.64 0.038 1.00 0.85 1.19 0.971VAD/HTX vs. HTX 2.50 2.02 3.11 !0.001 1.69 1.40 2.05 !0.001HTXcomb vs. HTXonly 1.11 0.83 1.48 O0.99 1.01 0.81 1.27 O0.99VADcomb vs. VADonly 0.75 0.63 0.89 0.025 0.76 0.66 0.89 0.013
Interpretation of the ratios: By example, the ratio of total charges for HTX vs VAD is 0.83 indicates that the charges for HTX are 17% less than the charges for VAD and this resultis significantly different (p-value 5 0.002) from a ratio of 1.0 (total charges are equivalent across the comparison).
213Plasma Neutrophil Gelatinase-Associated Lipocalin and Worsening RenalFunction during Everolimus Therapy after Heart TransplantationTeruhiko Imamura1, Koichiro Kinugawa2, Kent Doi3, Maasaru Hatano1, TakeoFujino1, Osamu Kinoshita4, Kan Nawata4, Shunei Kyo2, Minoru Ono4; 1GraduateSchool of Medicine, University of Tokyo, Tokyo, Japan; 2Graduate School ofMedicine, University of Tokyo, Tokyo, Japan; 3Graduate School of Medicine,
University of Tokyo, Tokyo, Japan; 4Graduate School of Medicine, University ofTokyo, Tokyo, Japan
Objective: Recently, mammalian target of rapamycin inhibitor, everolimus (EVL),has been introduced as a novel immunosuppressant for heart transplant (HTx) recip-ients, and is expected to preserve renal function compared to conventional calcineurininhibitors (CNIs). However, a considerable number of recipients treated with EVLwas not free from worsening renal function regardless of CNI reduction. The aimwas to find predictors for worsening renal function during EVL treatment. Methods:Data were collected retrospectively from 27 HTx recipients who had received EVL(trough concentration, 3.1-9.2 ng/mL) along with reduced CNIs (%decreases intrough concentration, 27.3613.0%) and been followed over 1 year between Aug2008 and Jan 2013. Findings: Estimated glomerular filtration rate (eGFR) decreasedin five recipients (18.5%) during the study period. A univariable logistic regressionanalysis demonstrated that higher plasma neutrophil gelatinase-associated lipocalin(P-NGAL) level was an only significant predictor for the decreases in eGFR over1-year EVL treatment among all baseline parameters (p50.008). eGFR and protein-uria worsened almost exclusively in patients with baseline P-NGAL $85 ng/mL,which was the cutoff value calculated by an ROC analysis (area under the curve,0.955; sensitivity, 1.000; specificity, 0.955). Conclusions: Higher P-NGAL can bea novel predictor for the worsening of renal function after EVL treatment that is resis-tant to CNI reduction in HTx recipients.
214YouTube as a Source of Information on Left Ventricular Assist DevicesNilay Kumar1, Kazeen Abdullah2, Neetika Garg3, Ambarish Pandey2; 1CambridgeHealth Alliance/Harvard Medical School, Cambridge, MA; 2University of TexasSouthwestern Medical Center, Dallas, TX; 3Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
Background and objectives: A substantial proportion of patients with chronic med-ical conditions use the Internet to obtain medical information. Accurate medical in-formation can equip patients with health education and promote self-managementand long-term behavioral changes. This study sought to ascertain the proportion touseful material relating to left ventricular assist devices (LVADs) on the popularvideo sharing website YouTube. Methods: YouTube was searched using the searchterm “Left Ventricular Assist Device”, which yielded approximately 800 results.
We screened the first 20 pages (400 videos) of which 379 met inclusion criteria for thestudy. Videos were classified as “useful” or “misleading” by an expert physician usingcurrent guidelines as the reference standard. Viewership was compared across cate-gories of usefulness and data on content, person in the video and uploading agencywas recorded. We sought to identify whether variables that predicted number of viewsusing separate binomial negative binomial regression models, a variant of Poissonregression. Parameter estimates were generated as Incidence Rate Ratios (IRR), whichare predictive of the outcome on a multiplicative scale. Results: Of the 379 videos
The 18th Annual Scientific Meeting � HFSA S85
included in the study, 363 (95.78%) were designated as useful and 16 (4.22%) asmisleading. Cumulative viewership was 3,240,128 (95.78%) for useful videos and392,829 (10.81%) for misleading videos. Median number of views was lower for use-ful compared to misleading videos (350 vs. 16,300, p!0.01). Useful videos mostoften provided general information on LVADs (n5153,42.15%), had an MD present-ing the information (n5120,33.15%) and were uploaded by individuals (n5165,45.6%). Videos that contained technical information on LVAD implantation hadthe highest predicted number of views per day followed by those with general infor-mation and MD presenters. Conclusions: YouTube contains a large number of videoswith information on LVADs of which most are useful. Misleading videos were foundto be more engaging than useful videos. Viewers prefer videos with technical andgeneral information on LVAD implantation and those presented by an MD.
Table (214). Characteristics of videos by category
Useful (n5363, 95.78%) Misleading (n516, 4.22%) p-value
Cumulative viewership 3,240,128 (89.18%) 392,829 (10.81%) naNumber of views (median6interquartile
range)350 (100-1440) 16,300 (950-46,902) p!0.001
Views per day(median6IQR) 0.63 (0.22-1.95) 11.00 (1.27-18.55) !0.001Days online(median6IQR) 691 (320-1115) 1618 (595-2450) 0.003Content Patient education: 122 (33.61%)Technical
information on LVAD implantation: 66(18.18%)General information: 153(42.15%)Others: 22 (6.06%)
Patient education: 0 (0%)Technicalinformation on LVAD implantation: 0(0%)General information: 2 (12.5%)Others: 14 (87.50%)
!0.001
Person in video Patient: 102 (28.18%) MD: 120 (33.15%)Others: 54 (14.2%)Both patient/MD: 46(12.71%)No audio: 40 (11.05%)
Patient: 2 (12.5%)MD: 0 (0%)Others: 13(81.25%)Both patient/MD: 1 (6.25%)Noaudio: 0 (0%)
!0.001
Uploading agency Individuals: 165 (45.6%)Hospital orhealth agency: 136 (37.6)LVADdevelopers: 31 (8.6%)Others: 30 (8.3%)
Individuals: 13 (81.3%)Hospital or healthagency: 1 (6.3%)LVAD developers: 0(0%)Others: 2 ((12.5%)
0.019
Table. Predictors of viewership, numbers are Incidence rate ratios (IRR)
CONTENT Model 1
Patient education 1.00(reference)Technical information on LVAD
implantation5.59 (95% CI 3.16 - 9.88; p!0.001)
General information 4.39 (95% CI 2.78 - 6.92; p!0.001)Overall model significance p!0.0001PERSON IN VIDEO Model 2Patient 1.00 (reference)MD 4.48 (95% CI 2.76 - 7.26; p!0.001)Both MD and patient 1.16 (95% CI 0.61 - 2.22; p!0.643)No audio 0.89 (95% CI 0.45 - 1.79; p!0.760)Overall model significance P!0.0001UPLOADING AGENCY Model 3Individuals 1.00 (reference)Hospitals or health agency 0.25 (95% CI 0.17 - 0.38; p!0.001)LVAD developers 0.52 (95% CI 0.27 - 1.02; p50.058)Overall model significance p!0.0001
215Temporal Trends in the Incidence of Sudden and Non-Sudden Death after HeartTransplantationKairav Vakil, Ziad Taimeh, Kashan Syed Abidi, Alok Sharma, Monica Colvin-Adams, Selcuk Adabag; University of Minnesota, Minneapolis, MN
Background: The temporal trends in the incidence of sudden and non-suddendeaths after heart transplantation have not been examined in a large, multi-cen-ter cohort of heart transplant recipients. Methods: Adults ($ 18 years) who un-derwent first time heart transplantation in the United States between 1987 and2012 were retrospectively identified from the United Network for Organ Sharingregistry. The study cohort was divided into tertiles - patients transplanted in1987-1997, 1998-2007, and 2008-2012 constituted tertiles 1, 2 and 3,
respectively. Patients with sudden cardiac arrest as the primary cause of deathconstituted the sudden cardiac death (SCD) group. Results: Data on 37,492 hearttransplant recipients (mean age 51.9611.7 years; 77% males; 78% Caucasian)were analyzed. During a mean follow-up of 6.565.7 years, there were 17,324(46%) deaths, of which 1,659 (9.6%) were due to SCD. There was a significanttemporal improvement in the incidence of non-sudden deaths over the studyperiod (log-rank p!0.001) (Figure A). In contrast, the incidence of SCD didnot change during the same period (log-rank p5NS) (Figure B). Conclusion:Whereas the incidence of non-sudden deaths after heart transplantation hasimproved significantly since 1987, there has been a minimal change in the inci-dence of SCD. Strategies to prevent SCD after heart transplantation are urgentlyneeded.
216Low Prevalence of Left Ventricular Thrombus in Patients UndergoingVentricular Assist Device EvaluationJennaKay1,AnnPekarek1,KristinWittersheim1, Robert T. Cole1, SonjoyR. Laskar1, DucNguyen2, J. David Vega2, Daniel B. Sims3; 1Emory University Hospital, Atlanta, GA;2Emory University Hospital, Atlanta, GA; 3Montefiore Medical Center, Bronx, NY
Introduction: International mechanical circulatory support guidelines recommendpre-operative screening for intracardiac thrombus prior to placement of a left ventric-ular assist device (LVAD). No data exists on the prevalence of left ventricular (LV)thrombus in advanced heart failure patients referred for LVAD evaluation. Hypoth-esis: LV thrombus has a high prevalence in patients with advanced heart failure un-dergoing evaluation for LVAD. Methods: A retrospective chart review of all patientswith advanced heart failure referred for LVAD evaluation at a tertiary care centerfrom 7/2007 to 11/2013 was performed. All patients underwent a contrast transtho-racic echocardiogram to evaluate specifically for LV thrombus as part of a standard-ized LVAD evaluation. Results: A standardized LVAD evaluation was performed on172 patients with advanced heart failure. Mean age was 51.2 +/- 13.4 years and 66%of patients were male. Ischemic cardiomyopathy was the etiology of the heart failurein 28% of patients. Mean ejection fraction was 11.4 +/- 4.6% and 41% of patients hada history of atrial fibrillation. Contrast echocardiogram during pre-operativescreening visualized LV thrombus in 8 patients (4.6%). Of these 8 patients, 4 diedwithout implantation of an LVAD. Follow-up contrast echocardiogram revealed res-olution on the LV thrombus in 2 patients who subsequently underwent LVAD
Figure.
