Eleanor Levin

All Publications

• An initiative to promote value-based stress test selection in primary care and cardiology clinics: A mixed methods evaluation. Journal of evaluation in clinical practice Kling, S. M., Kalwani, N. M., Winget, M., Gupta, K., Saliba-Gustafsson, E. A., Baratta, J., Garvert, D. W., Veruttipong, D., Brown-Johnson, C. G., Vilendrer, S., Gaspar, C., Levin, E., Tsai, S. 2023

  Abstract

  Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics.Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2.Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001).This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.

  View details for DOI 10.1111/jep.13896

  View details for PubMedID 37459156

• Appropriateness And Clinical Utility Of Echocardiograms For (Pre)Syncope And Palpitations In An Academic Primary Care Practice QCOR Gupta, K., Kalwani , N., Gaspar, C., Bokokalonova, Z., Paul, R., Tsai, S., Levin, E. 2022
• Implementation of guideline-concordant use of stress echocardiography in primary care and cardiology clinics: a mixed methods evaluation. 15th Annual Conference on the Science of Dissemination and Implementation in Health Kling, S., Kalwani, N., Saliba-Gustafsson , E., Barrata, J., Brown-Johnson , C., Garvert , D., Gaspar, C., Levin, E., Tsai, S., Veruttipong , D., Winget , M., Vilendrer, S. 2022
• AN ELECTRONIC HEALTH RECORD INTERVENTION TO INCREASE USE OF LIMITED ECHOCARDIOGRAMS IN CARDIOLOGY CLINIC:  A MIXED METHODS EVALUATION ACC Virtual Cardiovascular Summit Kalwani, N. M., Kling, S. M., Barrata, J., Salina-Gustafsson , E. A., Veruttipong, D., Brown-Johnson, C. G., Vilendrer, S., Gaspar, C., Tsai, S., Winget, M., Levin, E. 2022
• Association of Neighborhood Income with Clinical Outcomes Among Pregnant Patients with Cardiac Disease Reproductive Sciences Carland, C., Panelli, D. M., Leonard, S. A., Bryant, E., Sherwin , E. B., Lee, C. J., Levin, E., Jimenez , S., Tremmel, J. A., Tsai , S., Heidenreich , P. A., Bianco , K., Khandelwal , A. 2022

  View details for DOI 10.1007/s43032-022-00978-z

• Digital Health Interventions for Cardiac Rehabilitation: Systematic Literature Review. Journal of medical Internet research Wongvibulsin, S., Habeos, E. E., Huynh, P. P., Xun, H., Shan, R., Porosnicu Rodriguez, K. A., Wang, J., Gandapur, Y. K., Osuji, N., Shah, L. M., Spaulding, E. M., Hung, G., Knowles, K., Yang, W. E., Marvel, F. A., Levin, E., Maron, D. J., Gordon, N. F., Martin, S. S. 2021; 23 (2): e18773

  Abstract

  BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death worldwide. Despite strong evidence supporting the benefits of cardiac rehabilitation (CR), over 80% of eligible patients do not participate in CR. Digital health technologies (ie, the delivery of care using the internet, wearable devices, and mobile apps) have the potential to address the challenges associated with traditional facility-based CR programs, but little is known about the comprehensiveness of these interventions to serve as digital approaches to CR. Overall, there is a lack of a systematic evaluation of the current literature on digital interventions for CR.OBJECTIVE: The objective of this systematic literature review is to provide an in-depth analysis of the potential of digital health technologies to address the challenges associated with traditional CR. Through this review, we aim to summarize the current literature on digital interventions for CR, identify the key components of CR that have been successfully addressed through digital interventions, and describe the gaps in research that need to be addressed for sustainable and scalable digital CR interventions.METHODS: Our strategy for identifying the primary literature pertaining to CR with digital solutions (defined as technology employed to deliver remote care beyond the use of the telephone) included a consultation with an expert in the field of digital CR and searches of the PubMed (MEDLINE), Embase, CINAHL, and Cochrane databases for original studies published from January 1990 to October 2018.RESULTS: Our search returned 31 eligible studies, of which 22 were randomized controlled trials. The reviewed CR interventions primarily targeted physical activity counseling (31/31, 100%), baseline assessment (30/31, 97%), and exercise training (27/31, 87%). The most commonly used modalities were smartphones or mobile devices (20/31, 65%), web-based portals (18/31, 58%), and email-SMS (11/31, 35%). Approximately one-third of the studies addressed the CR core components of nutrition counseling, psychological management, and weight management. In contrast, less than a third of the studies addressed other CR core components, including the management of lipids, diabetes, smoking cessation, and blood pressure.CONCLUSIONS: Digital technologies have the potential to increase access and participation in CR by mitigating the challenges associated with traditional, facility-based CR. However, previously evaluated interventions primarily focused on physical activity counseling and exercise training. Thus, further research is required with more comprehensive CR interventions and long-term follow-up to understand the clinical impact of digital interventions.

  View details for DOI 10.2196/18773

  View details for PubMedID 33555259

• An Education and Electronic Health Record Intervention Increased Utilization of Exercise Tolerance Testing at an Academic Medical Center Cardiovascular Summit Virtual, from February 1-April 30, 2021. ACC Virtual Cardiovascular Summit Kalwani, N., Tsai, S., Gaspar, C., Gafencu, M., Paul, R., Bobokalonova , Z., Levin , E. 2021
• Recurrence of Atrial Myxoma in Pregnancy: Successful Intrapartum Management and Postpartum Resection Cardiology and Cardiovascular Medicine Joudi, N., Levin, E., Miller, P., Nieman, K., Lathi, R., Boyd, J., El-Sayed, Y. Y., Khandelwal, A. 2021; 5 (1)

  View details for DOI 10.26502/fccm.92920188

• Cumulative Adherence to Secondary Prevention Guidelines and Mortality After Acute Myocardial Infarction Cumulative Adherence to Secondary Prevention Guidelines and Mortality After Acute Myocardial Infarction Solomon, M., Leong, T., Levin, E., et al 2020

  View details for DOI 10.1161/JAHA.119.014415

• Bicuspid Aortic Valve and Ascending Aortic Aneurysm in a Twin Pregnancy. JACC. Case reports Bryant, E., Tsai, S., Levin, E., Fleischman, D., Ansari, J., Fischbein, M., Bianco, K., Khandelwal, A. 2020; 2 (1): 96-100

  Abstract

  Bicuspid aortic valve with ascending aortic aneurysm is a common condition encountered in pregnancy. There are limited data on how to manage these patients. To our knowledge, we report the only case of a bicuspid aortic valve and aortic aneurysm with twin gestations. (Level of Difficulty: Intermediate.).

  View details for DOI 10.1016/j.jaccas.2019.12.012

  View details for PubMedID 34316973

• Effect of Social Determinants on Outcomes in a High-risk Cardio-obstetrics Population AHA Scientific Sessions Carland, C., Panelli, D., Lee, C., Sherwin, E., Levin, E., Zarafshar, S., Tremmel, J. A., Tsai, S., Bianco, K., Khandelwal, A. 2020: 1

  View details for DOI 10.1161/circ.142.suppl_3.16364Circulation. 2020;142:A16364

• SUCCESS OF A HOME-BASED CARDIAC REHABILITATION PROGRAM IN A POPULATION OF NEARLY 4 MILLION Levin, E. G., von Coll, S., Dlott, R. ELSEVIER SCIENCE INC. 2017: 1731

  View details for Web of Science ID 000397342302453

• Adherence to Secondary Prevention Guidelines and Mortality After Acute Myocardial Infarction Solomon, M. D., Leong, T. K., Sung, S. H., Jaffe, M., Levin, E., Rana, J. S., Go, A. S. American Heart Association. Circulation. 2017 ; 136 (A16268):
• Outcomes of Chest Pain Calls to an Advice and Appointment Call Center Bhargava, R., Temkin, T. L., Fireman, B., Levin, E., Amaral, D. LIPPINCOTT WILLIAMS & WILKINS. 2012

  View details for Web of Science ID 000208885007225

• Standardized Discharge Orders after Stroke Results of the Quality Improvement in Stroke Prevention (QUISP) Cluster Randomized Trial ANNALS OF NEUROLOGY Johnston, S., Sidney, S., Hills, N. K., Grosvenor, D., Klingman, J. G., Bernstein, A., Levin, E. 2010; 67 (5): 579–89

  Abstract

  Proven strategies to reduce risk of stroke recurrence are under-utilized. We sought to evaluate the impact of standardized stroke discharge orders on treatment practices in a cluster-randomized trial.The Quality Improvement in Stroke Prevention (QUISP) trial randomized 12 hospitals to continue usual care or to receive assistance in the development and implementation of standardized stroke discharge orders. All patients with ischemic stroke were identified during a 12-month period prior to implementation and for 12 months afterward, and were followed for 6 months after discharge. The primary outcome was optimal treatment at 6 months, defined as taking a statin, having blood pressure <140/90mmHg, and receiving anticoagulation if atrial fibrillation was diagnosed. The primary analysis treated the hospital as the unit of analysis, comparing optimal treatment rates-adjusted for race, age, dementia, atrial fibrillation, and history of bleeding-between intervention and non-intervention hospitals using a paired t test.In the primary analysis with hospital as the unit of analysis, the odds of optimal treatment was not significantly increased at intervention compared to non-intervention hospitals (odds ratio, 1.39; 95% confidence interval, 0.71-2.76; p = 0.27). However, in analyses conducted at the level of the individual patients (N = 3,361), rates of optimal treatment increased from 37% to 45% in the intervention hospitals (p = 0.001) and did not change significantly in the non-intervention hospitals (39% to 40%; p = 0.27).Implementation of standardized discharge orders after stroke was associated with increased rates of optimal secondary prevention; this improvement was not significant in the primary analysis at the hospital level.

  View details for DOI 10.1002/ana.22019

  View details for Web of Science ID 000277190000004

  View details for PubMedID 20437555

• Standardized Discharge Orders After Stroke: Results of the Quality Improvement in Stroke Prevention (QUISP) Trial Johnston, S., Sidney, S., Hills, N. K., Grosvenor, D., Klingman, J. G., Bernstein, A., Levin, E. LIPPINCOTT WILLIAMS & WILKINS. 2010: E289

  View details for Web of Science ID 000276106100385

• Preventing Heart Attack and Stroke Everyday (PHASE): Optimizing Cardiovascular Risk Reduction in a Coronary Artery Disease-Equivalent Population Within a Large Integrated Health Care System Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke, Oral Presentations Levin, E., Sidney, S., Selby, J. V., Jaffe, M. 2009
• Blood pressure control among women six months after ischemic stroke Hills, N., Grosvenor, D., Sidney, S., Klingman, J., Bernstein, A., Levin, E., Johnston, S. LIPPINCOTT WILLIAMS & WILKINS. 2008: A232

  View details for Web of Science ID 000257197201277

• Race and blood pressure control six months after ischemic stroke Hills, N. K., Nguyen-Huynh, M., Grosvenor, D., Sidney, S., Klingman, J., Bernstein, A., Levin, E., Johnston, S. C. LIPPINCOTT WILLIAMS & WILKINS. 2008: 622–23

  View details for Web of Science ID 000252726100432

• Successful clinical guidelines implementation in a large integrated healthcare system Levin, E., Emerson, L., Whippy, A., Steimle, A. E., Pearl, R. LIPPINCOTT WILLIAMS & WILKINS. 2007: 785

  View details for Web of Science ID 000250394303564

• Acute Coronary Syndromes Clinical Practice Guidelines. Critical pathways in cardiology Brindis, R. G., Fischer, E., Besinque, G., Gjedsted, A., Lee, P. C., Padgett, T., Petru, M., Raley, J., Levin, E., Strohmeier, A. 2006; 5 (2): 69-102

  View details for DOI 10.1097/01.hpc.0000221568.67190.df

  View details for PubMedID 18340221

• Myocardial infarction in Asian Indians (MIAI) study: The Kaiser Permanente Northern California experience Rau, J., Johnsen, N., Lee, P., Chandra, M., Go, A., Levin, E. LIPPINCOTT WILLIAMS & WILKINS. 2006: E378

  View details for Web of Science ID 000235620100382

• Gender bias in the use of lipid-lowering therapy Bhargava, R., Sandhu, G., Armstrong, M., Nasiri, H., Sah, A., Levin, E. LIPPINCOTT WILLIAMS & WILKINS. 2005: U893

  View details for Web of Science ID 000232956406182

• Differential association between statin exposure and elevated levels of creatine kinase ANNALS OF PHARMACOTHERAPY Chan, J., Hui, R. L., Levin, E. 2005; 39 (10): 1611–16

  Abstract

  Although hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) are generally well tolerated, myopathy can be a serious adverse event. The association among different statins, doses, and related risk factors is not well understood.To determine the prevalence of elevated creatine kinase (CK) levels in patients taking statins, specific doses of these drugs, and other factors. Simvastatin and lovastatin were the drugs of primary interest.In a modified prevalence (cross-sectional) study, prescriptions and laboratory data for 215,191 patients exposed to a statin in 2002 were reviewed. A log-linear Poisson regression model was used to determine the statistical relationship of an elevated CK level to other independent variables.Prevalence of high elevation of CK levels (ie, n of cases/1000 pts. exposed to statins) was 1.6; prevalence of mild to moderate elevation of CK levels was 6.4. For high elevations, the prevalence ratios were lower for low doses of lovastatin than for high doses of simvastatin. A higher prevalence ratio was associated with elevated serum creatinine (SCr) levels (2.44), exposure to interacting drugs (1.62), male gender (1.48), and evidence of diabetes (1.34). For mild to moderate elevation, a higher prevalence ratio was associated with elevated SCr (1.45), exposure to interacting drugs (1.21), male gender (3.19), age < or =65 years (1.35), and evidence of diabetes (1.34). Lower prevalence ratios were associated with all doses of lovastatin compared with those of high doses of simvastatin.Compared with simvastatin, lovastatin was generally associated with a lower prevalence of high elevation and mild to moderate elevation of CK levels. An elevated SCr level, exposure to interacting drugs, male gender, evidence of diabetes, and age < or =65 years were associated with higher prevalence ratios.

  View details for PubMedID 16160000

• Successful conversion of patients with hypercholesterolemia from a brand name to a generic cholesterol-lowering drug Cheetham, T. C., Chan, J., Benson, Richmond, C., Levin, E., Campen, D. AMER MED PUBLISHING, M W C COMPANY. 2005: 546–52

  Abstract

  To evaluate the safety and effectiveness of a simvastatin-to-lovastatin therapeutic conversion program.Observational database study of a therapeutic conversion in members of the Northern and Southern California regions of Kaiser Permanente, using a pretest/posttest design.All patients actively converted from simvastatin to lovastatin between April 1, 2002, and March 31, 2003, were identified for inclusion in the analysis. The conversion from simvastatin to lovastatin was based on an equipotent dose ratio of 1 mg of simvastatin to 2 mg of lovastatin. Electronic prescription record and laboratory data were collected for converted patients beginning 365 days before changing therapy through June 30, 2003. The primary effectiveness end point was a comparison of the preconversion and postconversion low-density lipoprotein cholesterol (LDL-C) levels. Safety end points included an analysis of preconversion and postconversion alanine aminotransferase (ALT) tests and creatine kinase values.A total of 33,318 converted patients met criteria for inclusion in the analysis. The mean LDL-C was lowered from 110.9 to 108.4 mg/dL (P < .001) following the conversion to lovastatin. The percentage of patients with serum ALT levels greater than 3 times the upper limit of normal (ULN) was similar before (0.7%) and after (0.6%) conversion from simvastatin to lovastatin. Creatine kinase elevations greater then 10 times the ULN occurred at similar rates before and after the conversion.Overall, patients had an improvement in their lipid profile without evidence of hepatic or muscle enzyme elevations. Appropriately selected patients can be safely and effectively converted from simvastatin to lovastatin.

  View details for PubMedID 16159044

• Women at Risk for Coronary Heart Disease: How Research is Translated Into Innovation and Quality Outcomes at Kaiser Permanente. The Permanente journal Levin, E., Arango, J. 2005; 9 (1): 48-51

  View details for PubMedID 21687483

  View details for PubMedCentralID PMC3108413

• Chronic Kidney Disease and Lipid Control in Patients with Coronary Artery Disease American Society of Nephrology Nasiri, H., Armstrong, M., Sandhu, G., Levin, E., Bhargava, R., Hung, Y. 2005
• Successful conversion of 33,318 patients with hypercholesterolernia from a brand-name to a generic cholesterol-lowering drug Levin, E., Cheetham, C. T., Chan, J., Richmond, C., Benson, V. M., Campen, D. LIPPINCOTT WILLIAMS & WILKINS. 2004: 819

  View details for Web of Science ID 000224783504346

• Putting Heart Disease Guidelines into Practice: Kaiser Permanente Leads the Way The Permanente Journal L, P., Ralph, B., Levin, E. 2003; 7 (1)
• Population-based approach to heart failure management is associated with improved outcomes Steimle, A., Levin, E., Arango, J., Kim, E., Stone, B. LIPPINCOTT WILLIAMS & WILKINS. 2002: 568

  View details for Web of Science ID 000179142702845

• Myocardial infarction mortality in patients administered thrombolytic therapy versus primary percutaneous coronary intervention: A two-county comparison in northern California Levin, E., Brindis, R., Petru, M., Lee, P. LIPPINCOTT WILLIAMS & WILKINS. 2002: 761

  View details for Web of Science ID 000179142703773

• Innovative approach to guidelines implementation is associated with declining cardiovascular mortality in a population of three million Levin, E. G., Arango, J., Steimle, A. E., Lee, P. C., Fireman, B. LIPPINCOTT WILLIAMS & WILKINS. 2001: 789

  View details for Web of Science ID 000171895003675

• Home-based cardiac rehabilitation program is associated with excellent outcomes Krowley, J., Levin, E. G. LIPPINCOTT WILLIAMS & WILKINS. 2001: 800

  View details for Web of Science ID 000171895003725

• COMPARISON OF PSYLLIUM HYDROPHILIC MUCILLOID AND CELLULOSE AS ADJUNCTS TO A PRUDENT DIET IN THE TREATMENT OF MILD TO MODERATE HYPERCHOLESTEROLEMIA ARCHIVES OF INTERNAL MEDICINE LEVIN, E. G., MILLER, V. T., MUESING, R. A., STOY, D. B., BALM, T. K., LAROSA, J. C. 1990; 150 (9): 1822–27

  Abstract

  The effects of the administration of 5.1 g of psyllium or placebo (cellulose) twice daily for 16 weeks were compared as adjuncts to a prudent diet in the management of moderate hypercholesterolemia in a parallel, double-blind study. Psyllium decreased the total cholesterol level by 5.6% and the low-density lipoprotein cholesterol level by 8.6%, whereas the levels were unchanged in the placebo group. The high-density lipoprotein cholesterol level decreased during the diet stabilization period in both groups and returned to near-baseline values by week 16. Plasma triglyceride levels did not change substantially in either group. Subject compliance to treatment was greater than 95%. These data suggest that psyllium hydrophilic mucilloid in a twice-daily regimen may be a useful and safe adjunct to a prudent diet in the treatment of moderate hypercholesterolemia.

  View details for DOI 10.1001/archinte.150.9.1822

  View details for Web of Science ID A1990DY36400007

  View details for PubMedID 2203322

• Improving Cardiac Rehabilitation Referral Rate in a Post-PCI Population: Using NCDR CathPCI® Registry and Integrated Electronic Medical Record, ACC NCDR 11, April 1, 2011 Chen, S., Lee, A., Levin, E., Jackson, J., Ford, T. 2011
• Comparison of Screening Outcomes Among Different Healthcare Delivery Systems for Three Major Diseases: February 2008, Oral Presentation Preventive Medicine Society Annual Scientific Meeting Levin, E., Loftus, B., Pearl, R. 2008