Nancy Gardetto | Azusa Pacific University (original) (raw)

Papers by Nancy Gardetto

Patient Education and Counseling, Jul 1, 2005

There has been a lack of research regarding nonpharmacologic interventions in heart failure. The ... more There has been a lack of research regarding nonpharmacologic interventions in heart failure. The objective was to determine the effect of behavioral management on health related quality of life (HRQL) in patients with heart failure. Participants (N = 116) were randomly assigned to one of two groups: usual care for heart failure (n = 58) and the 15-week behavioral management program (n = 58). Outcomes included exercise performance (6-min walk), physical and mental functioning (SF-36), general health perceptions (SF-36), and disease specific HRQL (Minnesota Living with Heart Failure Questionnaire-MLHF). Outcomes were assessed at baseline, 4, 10 and 16 months. Participants were mostly male (95%) and Caucasian (75%), with a mean age of 67 years (S.D. = 10). Intervention patients showed significantly improved self-reported disease specific HRQL (MLHF physical dimension scores) over time compared to control patients. There were no group differences in exercise performance, physical functioning, mental functioning or general health perceptions.

Journal of Cardiac Failure, Aug 1, 2014

to a skilled nursing facility as their all cause 30 day readmission was found to be higher than p... more to a skilled nursing facility as their all cause 30 day readmission was found to be higher than patients who did not have aortic stenosis.

Circulation-cardiovascular Quality and Outcomes, Nov 1, 2011

Background Disease management and chronic care models have evidenced success with heart failure (... more Background Disease management and chronic care models have evidenced success with heart failure (HF) patients but have not fully explored patients' engagement/activation in self- care. Objective Determine efficacy of a patient activation intervention (Heart PACT Program) compared to usual care on activation and self-care management in HF. Methods This study was a 4-year, randomized, 2-group, repeated-measures design (baseline, 3 months, and 6 months). Following consent, 84 patients were stratified by activation level and randomly assigned to usual care (n = 41), or usual care plus the activation intervention (n = 43). The primary outcome variables were patient activation using the Patient Activation Measure (PAM) (Hibbard et al., 2005), and self-care using the Self-Care for Heart Failure Index (SCHFI) (Riegel et al., 2004) and the Medical Outcomes Study (MOS) Specific Adherence Scale. The intervention consisted of individual meetings and phone call follow-up over 6 months based on the patient's level of activation: stage 1 or 2 (low activation), stage 3 (medium), or stage 4 (high) as assessed by the patient's self-report PAM score and brief interview. The leaders collaborated with patients to improve activation and self-management of HF: adhering to medications; monitoring weight, blood pressure, and symptoms; and implementing health behavior goals. Findings Participants were primarily male (99%), Caucasian (77%), and classified as NYHA III (52%). The mean age was 66 years (SD 11). The majority (71%) of participants reported 3 or more comorbid conditions. The intervention group compared to the usual care group showed a significant increase in activation/PAM scores from baseline to 6 months (significant group by time interaction linear contrast, F=16.90, p=.02). Although the baseline MOS mean was lower in the intervention group, results revealed a significant group by time effect (F=9.16, p = .001) with the intervention group improving more over time. There were no significant group by time interactions for the SCHFI. Conclusion Patient activation can be improved through targeted intervention. The patient activation model has the potential to change approaches to tailored patient education for self-management in heart failure.

Journal of multidisciplinary healthcare, Mar 1, 2011

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their famili... more Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real "cures". Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-today activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to selfmanagement is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.

American Heart Journal, Mar 1, 2001

in those patients who have a low probability of cardiac dysfunction. 6,7 B-natriuretic peptide (B... more in those patients who have a low probability of cardiac dysfunction. 6,7 B-natriuretic peptide (BNP) is a cardiac neurohormone secreted from the cardiac ventricles as a response to ventricular volume expansion and pressure overload. 8-10 BNP levels are elevated in patients with symptomatic LV dysfunction and correlate with New York Heart Association (NYHA) class as well as with prognosis. 10-19 However, the utility of plasma BNP as a screening test has been limited by the same standard assay issues common to other hormones or cytokines also elevated in heart failure. 20-22 By use of a rapid immunoassay for BNP, we sought to determine whether BNP levels could serve as a screen to patients referred for echocardiography at the San Diego Veteran's Health Care System. Although patients with left ventricular (LV) dysfunction have improved survival on medications such as angiotensin-converting enzyme inhibitors and β-blockers, 1,2 this may be a difficult diagnosis to make by conventional criteria. 3,4 No blood test can rapidly determine whether a patient has LV dysfunction, 5 and echocardiography may not always be cost-effective as a screening device, especially

Critical pathways in cardiology, Sep 1, 2008

Background: Acute decompensated heart failure (ADHF) is a major public health problem and leading... more Background: Acute decompensated heart failure (ADHF) is a major public health problem and leading cause for hospitalization in people 65 years and older. Admission rates for ADHF, accounted for more than 1 million heart failure (HF) hospitalizations in 2004, and more than 6.5 million inpatient hospital days. Despite significant advances in HF management, including pharmacotherapy and devices; and extensive collaborative efforts of the American College of Cardiology, and American Heart Association to disseminate evidence-based practice guidelines for management of chronic HF in adults; 3 patients continue to present to the emergency departments in ADHF. The hospital treatment of HF frequently does not follow published guidelines, potentially contributing to the high morbidity, mortality, and economic cost of this disorder. This highlights an ongoing need for development of quality improvement programs that focus on delivering reliable, evidence-based care for patients with ADHF. Consequently, the development of clinical pathways has the potential to reduce the current variability in care, enhance guideline adherence, and improve outcomes for patients. Methods: The Veterans Affairs San Diego Healthcare System (VASDHCS) formed a multidisciplinary HF performance improvement team. The team set forth on the task of developing standard order sets for patients with ADHF. After analyzing local care processes, reviewing evidence of best care practices, and defining appropriate goals to satisfy the multidimensional needs of HF patient; the team developed a computerized pathway in a userfriendly format that is simple, yet comprehensive; and focuses on early stages of HF evaluation and treatment for patients presenting to the emergency department. Results: Successful strategies to improve care for HF patients need to assist health care providers with rapid recognition and early aggressive treatment, while creating a reliable process that ensures continuity of care. This critical pathway for management of acute HF at the VASDHCS provides computerized order sets that guide health care providers through accepted treatment regimens, providing documentation of treatment and assists with compliance data collection. The quality of the care is assessed by monitoring the nationally established performance measures for HF. Through the use of the HF computerized order sets, the VASDHCS currently achieves a performance level above most Joint Commission accredited organizations and in many areas achieves the best possible results compared with the top 10% of hospitals in the nation.

Circulation, Feb 5, 2002

Background-Although Doppler echocardiography has been used to identify abnormal left ventricular ... more Background-Although Doppler echocardiography has been used to identify abnormal left ventricular (LV) diastolic filling dynamics, inherent limitations suggest the need for additional measures of diastolic dysfunction. Because data suggest that B-natriuretic peptide (BNP) partially reflects ventricular pressure, we hypothesized that BNP levels could predict diastolic abnormalities in patients with normal systolic function. Methods and Results-We studied 294 patients referred for echocardiography to evaluate ventricular function. Patients with abnormal systolic function were excluded. Cardiologists making the assessment of LV function were blinded to BNP levels. Patients were classified as normal, impaired relaxation, pseudonormal, and restrictivelike filling patterns. Patients diagnosed with evidence of abnormal LV diastolic function (nϭ119) had a mean BNP concentration of 286Ϯ31 pg/mL; those in the normal LV group (nϭ175) had a mean BNP concentration of 33Ϯ3 pg/mL. Patients with restrictivelike filling patterns on echocardiography had the highest BNP levels (408Ϯ66 pg/mL), and patients with symptoms had higher BNP levels in all diastolic filling patterns. The area under the receiver-operating characteristic curve for BNP to detect any diastolic dysfunction was 0.92 (95% CI, 0.87 to 0.95; PϽ0.001). A BNP value of 62 pg/mL had a sensitivity of 85%, a specificity of 83%, and an accuracy of 84% for detecting diastolic dysfunction. Conclusions-A rapid assay for BNP can reliably detect the presence of diastolic abnormalities on echocardiography. In patients with normal systolic function, elevated BNP levels and diastolic filling abnormalities might help to reinforce the diagnosis diastolic dysfunction. (Circulation. 2002;105:595-601.

European Journal of Heart Failure, Jun 1, 2000

Future Cardiology, Nov 1, 2006

Congestive heart failure (CHF) is a progressive disease whose outcome largely depends on early, a... more Congestive heart failure (CHF) is a progressive disease whose outcome largely depends on early, accurate and prompt diagnosis, accompanied by evidence-based treatment. The explosion of uptake of natriuretic peptides (NPs) in clinical practice belies an understanding of how peptides are used. The signal for NP release is the same signal that causes symptoms of CHF, such as increased wall stress. Thus, NPs can reliably add to the information a physician brings to the table as they attempt to diagnose the acutely dyspneic patient with CHF. Additionally, NPs have strong prognostic utility in the emergency room and the hospital. Monitoring of NPs during treatment for acute CHF may help manage the patient. In the future, it is possible that NPs will play a more prominent role in early detection of left ventricular dysfunction as well as guiding chronic CHF treatment.

Clinical Chemistry, Sep 1, 2004

Amino-terminal form of parathyroid hormone (PTH) with immunologic similarities to hPTH(1-84) is o... more Amino-terminal form of parathyroid hormone (PTH) with immunologic similarities to hPTH(1-84) is overproduced in primary and secondary hyperparathyroidism. Clin Chem 2003;49:2037-44.

Journal of the American College of Cardiology 43(5 Suppl. A), Mar 23, 2004

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine, 2008

Background: Acute decompensated heart failure (ADHF) is a major public health problem and leading... more Background: Acute decompensated heart failure (ADHF) is a major public health problem and leading cause for hospitalization in people 65 years and older. Admission rates for ADHF, accounted for more than 1 million heart failure (HF) hospitalizations in 2004, and more than 6.5 million inpatient hospital days. Despite significant advances in HF management, including pharmacotherapy and devices; and extensive collaborative efforts of the American College of Cardiology, and American Heart Association to disseminate evidence-based practice guidelines for management of chronic HF in adults; 3 patients continue to present to the emergency departments in ADHF. The hospital treatment of HF frequently does not follow published guidelines, potentially contributing to the high morbidity, mortality, and economic cost of this disorder. This highlights an ongoing need for development of quality improvement programs that focus on delivering reliable, evidence-based care for patients with ADHF. Consequently, the development of clinical pathways has the potential to reduce the current variability in care, enhance guideline adherence, and improve outcomes for patients. Methods: The Veterans Affairs San Diego Healthcare System (VASDHCS) formed a multidisciplinary HF performance improvement team. The team set forth on the task of developing standard order sets for patients with ADHF. After analyzing local care processes, reviewing evidence of best care practices, and defining appropriate goals to satisfy the multidimensional needs of HF patient; the team developed a computerized pathway in a userfriendly format that is simple, yet comprehensive; and focuses on early stages of HF evaluation and treatment for patients presenting to the emergency department. Results: Successful strategies to improve care for HF patients need to assist health care providers with rapid recognition and early aggressive treatment, while creating a reliable process that ensures continuity of care. This critical pathway for management of acute HF at the VASDHCS provides computerized order sets that guide health care providers through accepted treatment regimens, providing documentation of treatment and assists with compliance data collection. The quality of the care is assessed by monitoring the nationally established performance measures for HF. Through the use of the HF computerized order sets, the VASDHCS currently achieves a performance level above most Joint Commission accredited organizations and in many areas achieves the best possible results compared with the top 10% of hospitals in the nation.

Journal of the American College of Cardiology, 2004

Background: The use of left ventricular assist devices (LVAD) to support non-transplant candidate... more Background: The use of left ventricular assist devices (LVAD) to support non-transplant candidates is controversial. We reviewed a large bridge-to-transplant database and found patients (pts) who were poor transplant candidates by virtue of advanced age or significant end-organ dysfunction. The goal of this analysis was to assess the efficacy of LVAD support in this population. Methods: We retrospectively reviewed the clinical data of the 225 pts enrolled in a US bridge-to-transplant trial. All patients had evidence of cardiogenic shock and high cardiac filling pressures despite optimal medical therapy. High-dose inotropic medications and intraaortic balloon counterpulsation also satisfied inclusion criteria. Low-risk recipients (LRR; n=146) were < 65 years of age and had a BUN < 100 mg/dl, Cr <2.5 mg/dl, bilirubin < 5.0 mg/dl, negative blood cultures and a pulmonary vascular resistance < 480 dyne sec/cm 5. High-risk recipients (HRR; n=44) had at least one value discordant with those listed above. A control group (Co; n=35) was identified that met LVAD criteria but did not receive a device as a result of pt preference, device unavailability, or a mechanical aortic valve. Intergroup comparisons were analyzed using a student's t-test with p<0.05 considered significant. Kaplan-Meier analysis was used to estimate survival using log-rank test to assess significance. Results: Compared to LRR, the HRR had a lower mean blood pressure (63.9 vs 69.2, p<0.02), a higher pulmonary vascular resistance (282 vs 219, p=0.01), a higher BUN and Cr (52 vs 31, p <0.05; 2.3 vs 1.3, p=0.003), and a higher bilirubin (2.2 vs 1.5, p=0.003). The median survival was 11 days in Co vs 197 days in HRR vs 467 in LRR. The HRR survival at 30-, 60-, and 90-days was lower than LRR (77%, 72%, 68% vs 89%, 83%, 80%; p=0.02). The median survival of both LVAD groups was statistically superior to Co (p<0.0001). Conclusions: 1) Nearly 25% of the bridge-to-transplant LVAD implantation occurs in HRR who are poor transplant candidates. 2) The early post-implant mortality is predictably higher in HRR 3). Regardless of age and comorbidities, LVAD treated pts had superior survival compared to those managed with optimal medical therapy.

Journal of Cardiac Failure, 2007

Critical pathways in cardiology, Mar 1, 2006

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their famili... more Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real "cures". Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-today activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to selfmanagement is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their famili... more Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real "cures". Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-today activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to selfmanagement is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their famili... more Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real "cures". Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-today activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to selfmanagement is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their famili... more Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real "cures". Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-today activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to selfmanagement is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.

Patient Education and Counseling, Jul 1, 2005

There has been a lack of research regarding nonpharmacologic interventions in heart failure. The ... more There has been a lack of research regarding nonpharmacologic interventions in heart failure. The objective was to determine the effect of behavioral management on health related quality of life (HRQL) in patients with heart failure. Participants (N = 116) were randomly assigned to one of two groups: usual care for heart failure (n = 58) and the 15-week behavioral management program (n = 58). Outcomes included exercise performance (6-min walk), physical and mental functioning (SF-36), general health perceptions (SF-36), and disease specific HRQL (Minnesota Living with Heart Failure Questionnaire-MLHF). Outcomes were assessed at baseline, 4, 10 and 16 months. Participants were mostly male (95%) and Caucasian (75%), with a mean age of 67 years (S.D. = 10). Intervention patients showed significantly improved self-reported disease specific HRQL (MLHF physical dimension scores) over time compared to control patients. There were no group differences in exercise performance, physical functioning, mental functioning or general health perceptions.

Journal of Cardiac Failure, Aug 1, 2014

to a skilled nursing facility as their all cause 30 day readmission was found to be higher than p... more to a skilled nursing facility as their all cause 30 day readmission was found to be higher than patients who did not have aortic stenosis.

Circulation-cardiovascular Quality and Outcomes, Nov 1, 2011

Background Disease management and chronic care models have evidenced success with heart failure (... more Background Disease management and chronic care models have evidenced success with heart failure (HF) patients but have not fully explored patients&amp;#39; engagement/activation in self- care. Objective Determine efficacy of a patient activation intervention (Heart PACT Program) compared to usual care on activation and self-care management in HF. Methods This study was a 4-year, randomized, 2-group, repeated-measures design (baseline, 3 months, and 6 months). Following consent, 84 patients were stratified by activation level and randomly assigned to usual care (n = 41), or usual care plus the activation intervention (n = 43). The primary outcome variables were patient activation using the Patient Activation Measure (PAM) (Hibbard et al., 2005), and self-care using the Self-Care for Heart Failure Index (SCHFI) (Riegel et al., 2004) and the Medical Outcomes Study (MOS) Specific Adherence Scale. The intervention consisted of individual meetings and phone call follow-up over 6 months based on the patient&amp;#39;s level of activation: stage 1 or 2 (low activation), stage 3 (medium), or stage 4 (high) as assessed by the patient&amp;#39;s self-report PAM score and brief interview. The leaders collaborated with patients to improve activation and self-management of HF: adhering to medications; monitoring weight, blood pressure, and symptoms; and implementing health behavior goals. Findings Participants were primarily male (99%), Caucasian (77%), and classified as NYHA III (52%). The mean age was 66 years (SD 11). The majority (71%) of participants reported 3 or more comorbid conditions. The intervention group compared to the usual care group showed a significant increase in activation/PAM scores from baseline to 6 months (significant group by time interaction linear contrast, F=16.90, p=.02). Although the baseline MOS mean was lower in the intervention group, results revealed a significant group by time effect (F=9.16, p = .001) with the intervention group improving more over time. There were no significant group by time interactions for the SCHFI. Conclusion Patient activation can be improved through targeted intervention. The patient activation model has the potential to change approaches to tailored patient education for self-management in heart failure.

Journal of multidisciplinary healthcare, Mar 1, 2011

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their famili... more Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real "cures". Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-today activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to selfmanagement is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.

American Heart Journal, Mar 1, 2001

in those patients who have a low probability of cardiac dysfunction. 6,7 B-natriuretic peptide (B... more in those patients who have a low probability of cardiac dysfunction. 6,7 B-natriuretic peptide (BNP) is a cardiac neurohormone secreted from the cardiac ventricles as a response to ventricular volume expansion and pressure overload. 8-10 BNP levels are elevated in patients with symptomatic LV dysfunction and correlate with New York Heart Association (NYHA) class as well as with prognosis. 10-19 However, the utility of plasma BNP as a screening test has been limited by the same standard assay issues common to other hormones or cytokines also elevated in heart failure. 20-22 By use of a rapid immunoassay for BNP, we sought to determine whether BNP levels could serve as a screen to patients referred for echocardiography at the San Diego Veteran's Health Care System. Although patients with left ventricular (LV) dysfunction have improved survival on medications such as angiotensin-converting enzyme inhibitors and β-blockers, 1,2 this may be a difficult diagnosis to make by conventional criteria. 3,4 No blood test can rapidly determine whether a patient has LV dysfunction, 5 and echocardiography may not always be cost-effective as a screening device, especially

Critical pathways in cardiology, Sep 1, 2008

Background: Acute decompensated heart failure (ADHF) is a major public health problem and leading... more Background: Acute decompensated heart failure (ADHF) is a major public health problem and leading cause for hospitalization in people 65 years and older. Admission rates for ADHF, accounted for more than 1 million heart failure (HF) hospitalizations in 2004, and more than 6.5 million inpatient hospital days. Despite significant advances in HF management, including pharmacotherapy and devices; and extensive collaborative efforts of the American College of Cardiology, and American Heart Association to disseminate evidence-based practice guidelines for management of chronic HF in adults; 3 patients continue to present to the emergency departments in ADHF. The hospital treatment of HF frequently does not follow published guidelines, potentially contributing to the high morbidity, mortality, and economic cost of this disorder. This highlights an ongoing need for development of quality improvement programs that focus on delivering reliable, evidence-based care for patients with ADHF. Consequently, the development of clinical pathways has the potential to reduce the current variability in care, enhance guideline adherence, and improve outcomes for patients. Methods: The Veterans Affairs San Diego Healthcare System (VASDHCS) formed a multidisciplinary HF performance improvement team. The team set forth on the task of developing standard order sets for patients with ADHF. After analyzing local care processes, reviewing evidence of best care practices, and defining appropriate goals to satisfy the multidimensional needs of HF patient; the team developed a computerized pathway in a userfriendly format that is simple, yet comprehensive; and focuses on early stages of HF evaluation and treatment for patients presenting to the emergency department. Results: Successful strategies to improve care for HF patients need to assist health care providers with rapid recognition and early aggressive treatment, while creating a reliable process that ensures continuity of care. This critical pathway for management of acute HF at the VASDHCS provides computerized order sets that guide health care providers through accepted treatment regimens, providing documentation of treatment and assists with compliance data collection. The quality of the care is assessed by monitoring the nationally established performance measures for HF. Through the use of the HF computerized order sets, the VASDHCS currently achieves a performance level above most Joint Commission accredited organizations and in many areas achieves the best possible results compared with the top 10% of hospitals in the nation.

Circulation, Feb 5, 2002

Background-Although Doppler echocardiography has been used to identify abnormal left ventricular ... more Background-Although Doppler echocardiography has been used to identify abnormal left ventricular (LV) diastolic filling dynamics, inherent limitations suggest the need for additional measures of diastolic dysfunction. Because data suggest that B-natriuretic peptide (BNP) partially reflects ventricular pressure, we hypothesized that BNP levels could predict diastolic abnormalities in patients with normal systolic function. Methods and Results-We studied 294 patients referred for echocardiography to evaluate ventricular function. Patients with abnormal systolic function were excluded. Cardiologists making the assessment of LV function were blinded to BNP levels. Patients were classified as normal, impaired relaxation, pseudonormal, and restrictivelike filling patterns. Patients diagnosed with evidence of abnormal LV diastolic function (nϭ119) had a mean BNP concentration of 286Ϯ31 pg/mL; those in the normal LV group (nϭ175) had a mean BNP concentration of 33Ϯ3 pg/mL. Patients with restrictivelike filling patterns on echocardiography had the highest BNP levels (408Ϯ66 pg/mL), and patients with symptoms had higher BNP levels in all diastolic filling patterns. The area under the receiver-operating characteristic curve for BNP to detect any diastolic dysfunction was 0.92 (95% CI, 0.87 to 0.95; PϽ0.001). A BNP value of 62 pg/mL had a sensitivity of 85%, a specificity of 83%, and an accuracy of 84% for detecting diastolic dysfunction. Conclusions-A rapid assay for BNP can reliably detect the presence of diastolic abnormalities on echocardiography. In patients with normal systolic function, elevated BNP levels and diastolic filling abnormalities might help to reinforce the diagnosis diastolic dysfunction. (Circulation. 2002;105:595-601.

European Journal of Heart Failure, Jun 1, 2000

Future Cardiology, Nov 1, 2006

Congestive heart failure (CHF) is a progressive disease whose outcome largely depends on early, a... more Congestive heart failure (CHF) is a progressive disease whose outcome largely depends on early, accurate and prompt diagnosis, accompanied by evidence-based treatment. The explosion of uptake of natriuretic peptides (NPs) in clinical practice belies an understanding of how peptides are used. The signal for NP release is the same signal that causes symptoms of CHF, such as increased wall stress. Thus, NPs can reliably add to the information a physician brings to the table as they attempt to diagnose the acutely dyspneic patient with CHF. Additionally, NPs have strong prognostic utility in the emergency room and the hospital. Monitoring of NPs during treatment for acute CHF may help manage the patient. In the future, it is possible that NPs will play a more prominent role in early detection of left ventricular dysfunction as well as guiding chronic CHF treatment.

Clinical Chemistry, Sep 1, 2004

Amino-terminal form of parathyroid hormone (PTH) with immunologic similarities to hPTH(1-84) is o... more Amino-terminal form of parathyroid hormone (PTH) with immunologic similarities to hPTH(1-84) is overproduced in primary and secondary hyperparathyroidism. Clin Chem 2003;49:2037-44.

Journal of the American College of Cardiology 43(5 Suppl. A), Mar 23, 2004

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine, 2008

Background: Acute decompensated heart failure (ADHF) is a major public health problem and leading... more Background: Acute decompensated heart failure (ADHF) is a major public health problem and leading cause for hospitalization in people 65 years and older. Admission rates for ADHF, accounted for more than 1 million heart failure (HF) hospitalizations in 2004, and more than 6.5 million inpatient hospital days. Despite significant advances in HF management, including pharmacotherapy and devices; and extensive collaborative efforts of the American College of Cardiology, and American Heart Association to disseminate evidence-based practice guidelines for management of chronic HF in adults; 3 patients continue to present to the emergency departments in ADHF. The hospital treatment of HF frequently does not follow published guidelines, potentially contributing to the high morbidity, mortality, and economic cost of this disorder. This highlights an ongoing need for development of quality improvement programs that focus on delivering reliable, evidence-based care for patients with ADHF. Consequently, the development of clinical pathways has the potential to reduce the current variability in care, enhance guideline adherence, and improve outcomes for patients. Methods: The Veterans Affairs San Diego Healthcare System (VASDHCS) formed a multidisciplinary HF performance improvement team. The team set forth on the task of developing standard order sets for patients with ADHF. After analyzing local care processes, reviewing evidence of best care practices, and defining appropriate goals to satisfy the multidimensional needs of HF patient; the team developed a computerized pathway in a userfriendly format that is simple, yet comprehensive; and focuses on early stages of HF evaluation and treatment for patients presenting to the emergency department. Results: Successful strategies to improve care for HF patients need to assist health care providers with rapid recognition and early aggressive treatment, while creating a reliable process that ensures continuity of care. This critical pathway for management of acute HF at the VASDHCS provides computerized order sets that guide health care providers through accepted treatment regimens, providing documentation of treatment and assists with compliance data collection. The quality of the care is assessed by monitoring the nationally established performance measures for HF. Through the use of the HF computerized order sets, the VASDHCS currently achieves a performance level above most Joint Commission accredited organizations and in many areas achieves the best possible results compared with the top 10% of hospitals in the nation.

Journal of the American College of Cardiology, 2004

Background: The use of left ventricular assist devices (LVAD) to support non-transplant candidate... more Background: The use of left ventricular assist devices (LVAD) to support non-transplant candidates is controversial. We reviewed a large bridge-to-transplant database and found patients (pts) who were poor transplant candidates by virtue of advanced age or significant end-organ dysfunction. The goal of this analysis was to assess the efficacy of LVAD support in this population. Methods: We retrospectively reviewed the clinical data of the 225 pts enrolled in a US bridge-to-transplant trial. All patients had evidence of cardiogenic shock and high cardiac filling pressures despite optimal medical therapy. High-dose inotropic medications and intraaortic balloon counterpulsation also satisfied inclusion criteria. Low-risk recipients (LRR; n=146) were < 65 years of age and had a BUN < 100 mg/dl, Cr <2.5 mg/dl, bilirubin < 5.0 mg/dl, negative blood cultures and a pulmonary vascular resistance < 480 dyne sec/cm 5. High-risk recipients (HRR; n=44) had at least one value discordant with those listed above. A control group (Co; n=35) was identified that met LVAD criteria but did not receive a device as a result of pt preference, device unavailability, or a mechanical aortic valve. Intergroup comparisons were analyzed using a student's t-test with p<0.05 considered significant. Kaplan-Meier analysis was used to estimate survival using log-rank test to assess significance. Results: Compared to LRR, the HRR had a lower mean blood pressure (63.9 vs 69.2, p<0.02), a higher pulmonary vascular resistance (282 vs 219, p=0.01), a higher BUN and Cr (52 vs 31, p <0.05; 2.3 vs 1.3, p=0.003), and a higher bilirubin (2.2 vs 1.5, p=0.003). The median survival was 11 days in Co vs 197 days in HRR vs 467 in LRR. The HRR survival at 30-, 60-, and 90-days was lower than LRR (77%, 72%, 68% vs 89%, 83%, 80%; p=0.02). The median survival of both LVAD groups was statistically superior to Co (p<0.0001). Conclusions: 1) Nearly 25% of the bridge-to-transplant LVAD implantation occurs in HRR who are poor transplant candidates. 2) The early post-implant mortality is predictably higher in HRR 3). Regardless of age and comorbidities, LVAD treated pts had superior survival compared to those managed with optimal medical therapy.

Journal of Cardiac Failure, 2007

Critical pathways in cardiology, Mar 1, 2006

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their famili... more Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real "cures". Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-today activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to selfmanagement is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their famili... more Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real "cures". Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-today activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to selfmanagement is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their famili... more Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real "cures". Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-today activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to selfmanagement is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their famili... more Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real "cures". Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-today activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to selfmanagement is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.