New Grants Support Groundbreaking Studies of Post-Discharge and Ambulatory Cardiac Care

Ruth Masterson Creber, PhD, a professor at Columbia Nursing, recently received two major grants for studies of post-discharge and ambulatory care in cardiac patients—one from the National Institutes of Health (NIH) and the other from the Patient Centered Outcomes Research Institute (PCORI).

Her $2.6 million NIH grant is for an R01 study titled “Improve the Meaning of Patient-Reported Outcomes to Evaluate Effectiveness for Cardiac Care (IMPROVECardiac Care).” In its first phase, the fouryear project will seek to identify minimally important clinical differences (MCIDs) in patient-reported outcomes for people with advanced heart disease. Masterson Creber and her team will then investigate how that information can be translated back meaningfully to health care professionals to inform patient-centered clinical decision-making.

In recent years, there has been growing recognition in many areas of health care that patient-reported outcomes, or PROs, can be a valuable complement to standard diagnostic measures. “PROs provide a holistic picture of where patients are on the disease trajectory, both during routine management and during recovery from major clinical events,” Masterson Creber explains. “In cardiac care, however, research on PROs has two important gaps. The first is that MCIDs—defined as the smallest change in outcome that patients perceive as meaningful—have not been established for specific cohorts of patients. The second gap is a lack of guidance on how to incorporate MCIDs into clinical practice.”

IMPROVE-Cardiac Care will strive to fill in those blanks. The team will study approximately 800 participants in the United States and Great Britain, divided into three groups: patients who are recovering after a coronary artery bypass graft; patients with heart failure (HF) who are recovering after hospitalization; and HF patients with a preserved ejection fraction who are undergoing ambulatory management. The researchers will begin by examining the relationship between clinical indicators and patients’ perceived degree of improvement. Using advanced mathematical modeling techniques, they’ll establish MCIDs for patients in each cohort.

Next, the team will look for effective ways to use PROs in health care settings. To do so, they’ll collect video data on 60 patientprovider dyads as they’re in the process of using validated PROs to guide shared decision-making. The researchers will employ video ethnography to evaluate patient-provider interactions, which will be analyzed by anthropologists or sociologists to measure verbal and nonverbal cues. The team will also interview providers to understand how PROs can be better integrated into the clinical workflow to improve the quality of care.

The project’s long-term goal is to leverage patients’ perspectives to improve outcomes. “Right now, many of our tools for assessing PROs in cardiac patients are too generic to guide individual-level decision-making,” says Masterson Creber. “It’s crucial to understand the MCIDs for specific conditions and demographic groups. We may find that there are significant differences between men and women, for example, or between older and younger patients. We just don’t know yet.”

Masterson Creber also received $4.2 million from PCORI, with co-principal investigator Brock Daniels, MD, of Weill Cornell Medicine. This grant will go toward an ongoing study titled “Using Mobile Integrated Health and Telehealth to Support Transitions of Care among Patients with Heart Failure (MIGHTY-Heart).”

The project addresses a persistent problem among patients who’ve been hospitalized for heart failure: within a month of discharge, 25 percent are readmitted. The challenges of accessing follow-up care—especially for members of low-income and minority populations— are an important factor behind that statistic. “Patients face barriers when they are getting discharged from the hospital—from getting their medications, to follow-up appointments, to managing their own symptoms,” Masterson Creber observes. “This study facilitates access to telehealth with an emergency medicine physician to help bridge the gap while patients wait to see their cardiologist. Without the support of the mobile integrated health team, many more patients would be back to the emergency room for things that are preventable.”

She and her colleagues are randomizing patients at 12 New York City hospitals to one of two types of follow-up care: a standard model, in which patients receive a phone call from a care transitions coordinator after their discharge, and a new approach called mobile integrated care. Under that protocol, patients get a follow-up phone call from a nurse, who coordinates continuing access to community paramedics. If a patient has a health concern, a paramedic can make a house call and do a real-time telehealth consult with an on-call emergency medicine doctor. After doing point-of-care testing and addressing the patient’s concerns, the paramedic can either leave the patient for home-based treatment or take the patient to the hospital.

The researchers are in the process of recruiting 2,100 patients and will follow them up for six months following their discharge. They will track whether patients are readmitted to the hospital and will also survey them at intervals about their symptoms, ability to function, quality of life, and other metrics.

“The idea is to bridge the hospital-tohome transition using facilitated telehealth. We are trying to meet patients’ needs in their home by bringing components of the emergency department to them and getting them connected with their cardiologist to try and avoid a quick bounce-back to the hospital,” Masterson Creber says.