Rebecca Lauren Tisdale

All Publications

• Gaps in Stroke Risk Documentation for Veterans with Incident Atrial Fibrillation Kalwani, N., Tisdale, R., Koos, H., Din, N., Fan, J., Safarnejad, L., Perino, A., Chan, D., Sandhu, A., Heidenreich, P. LIPPINCOTT WILLIAMS & WILKINS. 2025

  View details for DOI 10.1161/circ.152.suppl_3.4357628

  View details for Web of Science ID 001618603800048

• Variation in Telehealth Use for Patients With Incident Atrial Fibrillation Across the Veterans Health Administration: Retrospective Cohort Study. Journal of medical Internet research Tisdale, R. L., Kalwani, N. M., Koos, H., Fan, J., Din, N., Perino, A. C., Chan, D. C., Sandhu, A. T., Heidenreich, P. A. 2025; 27: e76177

  Abstract

  Telehealth is a potential tool to alleviate geographic clinician shortages, but there are limited data regarding current telehealth use for common cardiology conditions, including atrial fibrillation (AF).We aimed to evaluate variation in telehealth use in primary care and cardiology clinics for patients with incident AF in the Veterans Health Administration.We included patients diagnosed with AF in the outpatient setting between January 2022 and September 2023. We assessed the association between any video visit and any telehealth use (including phone) for primary care or cardiology visits within 90 days of an AF diagnosis, adjusting for selected patient- and facility-level characteristics using Bayesian logistic regression with facility-level random intercepts. We evaluated facility variation in video visit and telehealth use with the median odds ratio (MOR).Our cohort included 36,929 patients with 80,596 visits across 125 facilities. Of the 63,835 primary care visits, 2088 (3.27%) were delivered via video and 13,403 (21%) via telehealth; of the 16,761 cardiology visits, 323 (1.93%) were delivered via video and 3288 (19.62%) via telehealth. On average, the mean age of the patients was 73.6 (SD 10.9) years; 2.91% (1075/36,929) were female; 77.71% (28,698/36,929) were White. In adjusted analyses, older age was associated with lower use of video visits for both primary and cardiology care and lower use of any telehealth for cardiology care (eg, adjusted odds ratio [AOR] 0.61, 95% credible interval [CrI] 0.42-0.85 for the use of video cardiology care for patients aged above 77 years). Living more than 65 km from the care site was associated with increased use of both video and any telehealth for primary and cardiology care (eg, AOR 1.91, 95% CrI 1.21-3.00 for video cardiology care); however, living in a rural location was associated with lower odds of using video or any telehealth for primary care (video: AOR 0.73, 95% CrI 0.64-0.84; telehealth: AOR 0.89, 95% CrI 0.83-0.96). There was marked variability across facilities in the use of video care (range 0%-17.4% of visits for cardiology care; 0%-12.5% for primary care) and telehealth (range 0%-82.6% for cardiology care; 3.8%-61.6% for primary care). The facility-level adjusted MOR for video care use was 1.97 (95% CrI 1.77-2.24) for primary care and 4.95 (95% CrI 3.39-7.98) for cardiology care. Similarly, the adjusted MOR for any telehealth use was 1.79 for primary care (95% CrI 1.65-1.96) and 2.61 for cardiology care (95% CrI 2.25-3.13).Following an incident AF diagnosis, telehealth may increase access to primary and cardiology care for veterans living at a distance, but its use remains lower for older patients and those in rural areas. There was substantial variation in telehealth use across facilities, which was not explained by differences in patient and facility characteristics. Standardizing telehealth use across Veterans Health Administration facilities may improve access to AF care.

  View details for DOI 10.2196/76177

  View details for PubMedID 41151044

• An approach to evaluating the impact of virtual specialty care: the Veterans Health Administration's clinical resource hub as case study. JAMIA open Tisdale, R. L., Burnett, K., Rogers, M., Nelson, K., Heyworth, L., Zulman, D. M. 2025; 8 (3): ooaf038

  Abstract

  Telemedicine for specialty medical care is evolving from a COVID-19 pandemic-era requirement to an option for patients and clinicians alike, requiring evidence to guide optimal use of virtual specialty care. Heterogeneity across medical specialties complicates this evidence generation. To address this gap in the literature, we present an approach to evaluation of telehealth across specialties with the potential to generate findings generalizable across specialties and health systems.We describe an approach to evaluation of virtual specialty care that balances widely generalizable metrics, such as patient and clinician satisfaction and avoided travel or cost, and those that are specialty-specific. We use the Veterans Health Administration (VA)'s Clinical Resource Hub program to illustrate potential applications of this approach.Clinical Resource Hub clinics leverage a hub-and-spoke model to deliver virtual care across many specialties, compensating for staffing shortages and expanding access to more specialized services not available at every VA site. Use cases for these clinics span the spectrum of short-term, episodic care to long-term substitution for a usual source of specialty care and offer opportunities to apply a range of evaluation metrics that generalize across telehealth use cases.Clinical Resource Hub clinics provide a variety of examples for this approach, demonstrating a path forward for virtual specialty care evaluation.As the Clinical Resource Hub case illustrates, combining universal and specialty- or use case-specific metrics has the potential to build the evidence base for virtual specialty care.

  View details for DOI 10.1093/jamiaopen/ooaf038

  View details for PubMedID 40396160

  View details for PubMedCentralID PMC12092080

• Differential Selection of Obesity Treatments by Race/Ethnicity: Insights From the Veterans Affairs Healthcare System. JACC. Advances Tisdale, R. L., Beyene, T. J., Tang, W., Sandhu, A. T., Heidenreich, P., Asch, S., Yong, C. M. 2025; 4 (6 Pt 2): 101819

  View details for DOI 10.1016/j.jacadv.2025.101819

  View details for PubMedID 40579055

• Learning Health Systems Research: Continued Progress and Ongoing Challenges. Medical care Tisdale, R. L., Sarkar, U. 2025; 63 (5): 331-333

  Abstract

  Learning health systems research (LHSR) builds on concepts of systems-based participatory research to form a new paradigm for partnered research.Defines LHSR and its ongoing challenges and future directions.Qualitative description of relevant dimensions of LHSR.In LHSR, researchers and health system stakeholders co-create research with dual aims of producing internal quality improvement and generalizable, disseminable knowledge. This approach aligns research priorities with community and health system needs, resulting in interventions that are both feasible and acceptable in real-world settings and effective. LHSR methods and outcomes reflect elements of implementation science, particularly participatory implementation science and the use of mixed methods, but the field is distinct in its emphasis on co-creation with health system leaders and the use of theory to inform rather than drive the work. Practitioners of LHSR face challenges related to the complex and multi-stakeholder nature of the field, including the time-intensive nature of building partnerships, conflicting project time horizons, imprecision inherent in real-world data, and barriers to publication of the smaller studies that typically result from LHSR.Continued advancement of the field requires confronting these challenges with a variety of interventions, including explicit institutional support and incentives for this type of work, training and career development opportunities, a diversity of funding sources, investment in data resources and expertise, and inclusive research governance structures.

  View details for DOI 10.1097/MLR.0000000000002121

  View details for PubMedID 40194918

• Balancing Efficiency and Equity in Population-Wide CKD Screening. JAMA network open Cusick, M. M., Tisdale, R. L., Adams, A. S., Chertow, G. M., Owens, D. K., Salomon, J. A., Goldhaber-Fiebert, J. D. 2025; 8 (4): e254740

  Abstract

  Importance: In the era of sodium-glucose cotransporter 2 (SGLT2) inhibitors, population-wide screening for chronic kidney disease (CKD) may provide good value, yet implications across racial and ethnic groups are unknown.Objective: To evaluate the health outcomes, costs, and cost-effectiveness of population-wide CKD screening for 4 racial and ethnic groups.Design, Setting, and Participants: In this cost-effectiveness analysis, a decision-analytic Markov model was separately calibrated to simulate CKD progression among simulated cohorts of US Hispanic adults, non-Hispanic Black adults, non-Hispanic White adults, and adults who belong to additional racial and ethnic groups (ie, Asian and multiracial individuals and those self-reporting other race and ethnicity). Effectiveness of SGLT2 inhibitors was derived from the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease trial. Mortality, quality-of-life weights, and cost estimates were obtained from published cohort studies, randomized clinical trials, and Centers for Medicare & Medicaid Services data. Analyses were conducted from January 1, 2023, to November 6, 2024.Exposures: One-time or periodic (every 10 or 5 years) screening for albuminuria, initiated between age 35 and 75 years, with and without addition of SGLT2 inhibitors to angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy for CKD.Main Outcomes and Measures: Lifetime cumulative incidence of kidney failure requiring kidney replacement therapy (KRT); discounted life-years (LYs), quality-adjusted LYs (QALYs), lifetime health care costs (in 2024 US dollars), and incremental cost-effectiveness ratios.Results: Under the status quo, non-Hispanic Black adults aged 35 years had the highest lifetime incidence of kidney failure requiring KRT (6.2% [95% UI, 2.8%-10.6%]) compared with Hispanic adults (3.6% [95% UI, 1.1%-6.7%]), non-Hispanic White adults (2.3% [95% UI, 0.4%-5.2%]), and adults from additional racial and ethnic groups (3.3% [95% UI, 1.2%-6.5%]). Screening every 5 years from ages 55 to 75 years combined with SGLT2 inhibitors reduced incidence of KRT and increased LYs across all racial and ethnic groups, with the largest average changes observed for non-Hispanic Black adults (0.8-percentage point decrease and 0.19-year increase). Every 5-year screening from age 55 to 75 years cost $99 100/QALY gained for the overall population and less than $150 000/QALY gained across racial and ethnic groups, with the lowest cost observed for non-Hispanic Black adults ($73 400/QALY gained). Screening starting at age 35 years was only cost-effective for non-Hispanic Black adults ($115 000/QALY gained).Conclusions and Relevance: In this cost-effectiveness analysis, population-wide screening for CKD from ages 55 to 75 years was projected to improve population health, was cost-effective, and reduced disparities across 4 racial and ethnic groups. Starting population-wide screening at younger ages was projected to further benefit non-Hispanic Black adults.

  View details for DOI 10.1001/jamanetworkopen.2025.4740

  View details for PubMedID 40227684

• Predicted Mortality and Cardiology Follow-Up Following Heart Failure Hospitalizations Among Veterans Health Administration Patients. Journal of cardiac failure Tisdale, R. L., Cao, F., Skye, M., Vardeny, O., Sallam, K., Kalwani, N., Hsaio, S., Varshney, A. S., Heidenreich, P. A., Sandhu, A. T. 2025

  Abstract

  Guidelines recommend timely follow-up with a cardiology specialist for patients hospitalized with heart failure (HF), but it is unknown whether the timeliness of specialty cardiovascular care post-discharge correlates with clinical risk.Assess the association between estimated mortality risk and post-HF hospitalization cardiology follow-up.In a cohort of Veterans hospitalized with HF in acute care VA hospitals between 1/1/2018 and 9/15/2022, we estimated the association of mortality risk at discharge with post-discharge cardiology encounters via logistic regression. We also evaluated the association between cardiology visits and sociodemographic and clinical characteristics, and described variability in post-discharge follow-up rates across VA facilities.We identified a cohort of 84,348 Veterans hospitalized with HF with 120,619 hospital admissions. Of a sub-cohort of 57,554 Veterans with 79,866 hospitalizations surviving at least one year after discharge, 32.1% of hospitalizations were followed by a cardiology visit within two weeks, and 49.3% within one month. Marginal probabilities of two-week and one-month follow-up were higher for hospitalizations in the highest-risk quintile than those in the lowest-risk quintile (34% vs. 30% and 51% vs. 47%, respectively; p<0.001 for both intervals). In a time-to-event model in the full cohort, there was a slightly negative association between risk and likelihood of one-month follow-up (coefficient for MAGGIC score = -0.004, 95% confidence interval [CI] -0.005 - -0.003). Black Veterans were less likely to have either two-week or one-month follow-up (adjusted odds ratios 0.93 [95% confidence interval [CI] 0.90-0.97] for two weeks and 0.93 [95% CI 0.89-0.96] for one month). Female Veterans were also less likely to have follow-up within one month of hospital discharge (adjusted odds ratio 0.90 [95% CI 0.90-0.98]). Conversely, patients with a primary versus secondary hospital diagnosis of HF and those with reduced versus preserved ejection fraction were more likely to have two-week follow-up (adjusted odds ratios 1.67 [95% CI 1.62-1.73] and 1.72 [95% CI 1.67-1.78], respectively) and one-month follow-up (adjusted odds ratios 1.83 [95% CI 1.78-1.88] and 1.85 [95% CI 1.80-1.90], respectively). One-month follow-up rates varied from 5% to 69% across VA facilities.The rate of visits with a cardiologist within two weeks or one month following HF hospitalization was low overall, was at most modestly associated with estimated mortality risk at discharge, and varied by sex, race/ethnicity, and across VA facilities. Increasing visit rate after HF hospitalization should be evaluated as a mechanism to improve outcomes after HF hospitalizations, particularly for higher-risk individuals.

  View details for DOI 10.1016/j.cardfail.2024.12.006

  View details for PubMedID 39778675

• Opportunities to Address Specialty Care Deserts and the Digital Divide through the Veterans Health Administration's Telehealth Hub-and-Spoke Cardiology Clinic: Retrospective Cohort Study. Journal of medical Internet research Tisdale, R. L., Purmal, C., Kalwani, N., Sandhu, A., Heidenreich, P., Zulman, D., Hussain, T. 2024; 26: e53932

  Abstract

  To address geographic barriers to specialty care access for services such as cardiology, the Veterans Health Administration (VA) has implemented a novel, regionalized telehealth care hub. The Clinical Resource Hub (CRH) model extends care, including cardiology services, to individuals in low-access communities across the region. Little is known, however, about the reach of such programs.This study aimed to describe the initial CRH program implementation in terms of growth in users and clinical encounters, as well as the association between user characteristics and the use of CRH cardiology care, in VA's Sierra Pacific region (Northern California, Nevada, and the Pacific Islands).We compared patients who used CRH cardiology services (CRH users) to those using non-CRH cardiology services (CRH nonusers) in the Sierra Pacific region between July 15, 2021, and March 31, 2023. After characterizing changes in the numbers of CRH users and nonusers and clinical encounters over the study period, we used multivariable logistic regression to estimate the association between patient-level factors and the odds of being a CRH user.There were 804 CRH users over the study period, with 1961 CRH encounters concentrated at 3 main CRH sites. The CRH program comprised a minority of cardiology users and encounters in the region, with 19,583 CRH nonusers with 83,489 encounters. The numbers of CRH patients and encounters both increased at a steady-to-increasing rate over the study period, with increases of 37% (n=292 vs n=213) in users and 64% (n=584 vs n=356) in encounters in the first quarter of 2023 compared with the last quarter of 2022. Among CRH users, 8.3% (67/804) were female and 41.4% (333/804) were aged ≥75 years, compared with 4.3% (840/19,583) and 49% (9600/19,583), respectively, among CRH nonusers. The proportions of rural (users: 205/804, 25.5%; nonusers: 4936/19,583, 25.2%), highly disabled (users: 387/804, 48.1%; nonusers: 9246/19,583, 47.2%), and low-income (users: 165/804, 20.5%; nonusers: 3941/19,583, 20.1%) veterans in both groups were similar. In multivariable logistic models, adjusted odds ratios of using CRH were higher for female veterans (1.70, 95% CI 1.29-2.24) and lower for older veterans (aged ≥75 years; 0.33, 95% CI 0.23-0.47). Rural veterans also had a higher adjusted odds ratio of using CRH (1.19, 95% CI 1.00-1.42; P=.046).The VA's Sierra Pacific CRH cardiology program grew substantially in its first 2 years of operation, serving disproportionately more female and rural veterans and similar proportions of highly disabled and low-income veterans compared to conventional VA care. This model appears to be effective for overcoming specialty care access barriers for certain individuals, although targeted efforts may be required to reach older veterans. While this study focuses on a single region, specialty, and health care system, lessons from implementing regionalized telehealth hub models may be applicable to other settings.

  View details for DOI 10.2196/53932

  View details for PubMedID 39607997

• Racial and Ethnic Differences in Semaglutide Prescriptions for Veterans With Overweight or Obesity in the Veterans Affairs Healthcare System. Circulation. Cardiovascular quality and outcomes Tisdale, R. L., Beyene, T. J., Tang, W., Heidenreich, P., Asch, S. M., Yong, C. M. 2024: e011649

  View details for DOI 10.1161/CIRCOUTCOMES.124.011649

  View details for PubMedID 39524000

• Populationwide Screening for Chronic Kidney Disease: A Cost-Effectiveness Analysis. JAMA health forum Cusick, M. M., Tisdale, R. L., Chertow, G. M., Owens, D. K., Goldhaber-Fiebert, J. D., Salomon, J. A. 2024; 5 (11): e243892

  Abstract

  Sodium-glucose cotransporter-2 (SGLT2) inhibitors have changed clinical management of chronic kidney disease (CKD) and made populationwide screening for CKD a viable strategy. Optimal age of screening initiation has yet to be evaluated.To compare the clinical benefits, costs, and cost-effectiveness of population-wide CKD screening at different initiation ages and screening frequencies.This cost-effectiveness study used a previously published decision-analytic Markov cohort model that simulated progression of CKD among US adults from age 35 years and older and was calibrated to population-level data from the National Health and Nutrition Examination Survey (NHANES). Effectiveness of SGLT2 inhibitors was derived from the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial. Mortality, quality-of-life weights, and cost estimates were obtained from published cohort studies, randomized clinical trials, and US Centers for Medicare & Medicaid Services data. Analyses were performed from June 2023 through September 2024.One-time or periodic (every 10 or 5 years) screening for albuminuria, initiated at ages between 35 and 75 years, with and without addition of SGLT2 inhibitors to conventional CKD therapy (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers).Cumulative incidence of kidney failure requiring kidney replacement therapy (KRT); life years, quality-adjusted life years (QALYs), lifetime health care costs (2024 US currency), and incremental cost-effectiveness ratios discounted at 3% annually.For those aged 35 years, starting screening at age 55 years, and continuing every 5 years through age 75 years, combined with SGLT2 inhibitors, decreased the cumulative incidence of kidney failure requiring KRT from 2.4% to 1.9%, increased life expectancy by 0.13 years, and cost $128 400 per QALY gained. Although initiation of screening every 5 years at age 35 or 45 years yielded greater gains in population-wide health benefits, these strategies cost more than $200 000 per additional QALY gained. The comparative values of starting screening at different ages were sensitive to the cost and effectiveness of SGLT2 inhibitors; if SGLT2 inhibitor prices drop due to patent expirations, screening at age 55 years continued to be cost-effective even if SGLT2 inhibitor effectiveness were 30% lower than in the base case.This study found that, based on conventional benchmarks for cost-effectiveness in medicine, initiating population-wide CKD screening with SGLT2 inhibitors at age 55 years would be cost-effective.

  View details for DOI 10.1001/jamahealthforum.2024.3892

  View details for PubMedID 39514193

• Patient-, Provider-, and Facility-Level Contributors to the Use of Cardiology Telehealth Care in the Veterans Health Administration: Retrospective Cohort Study. Journal of medical Internet research Tisdale, R. L., Ferguson, J. M., Van Campen, J., Greene, L., Wray, C. M., Zulman, D. M. 2024; 26: e53298

  Abstract

  Telehealth (care delivered by phone or video) comprises a substantial proportion of cardiology care delivered in the Veterans Health Administration (VHA). Little is known about how factors specific to patients, clinicians, and facilities contribute to variation in cardiology telehealth use.The aim of this study is to estimate the relative extent to which patient-, clinician-, and facility-level factors affect cardiology telehealth use in VHA.This was a retrospective, nation-wide cohort study of veterans' use of VHA cardiology telehealth care during the first 2 years of the COVID-19 pandemic (March 11, 2020, to March 10, 2022). We constructed multilevel, multivariable, logistic regression models of patient-level cardiology telehealth use (telephone or video-based care). Models included random effects for the patient, the patient's main cardiology provider, and the patient's primary facility (ie, VHA medical center) for specialty care and fixed effects for patient sociodemographic and clinical characteristics.Our analytic cohort comprised 223,809 veterans with 989,271 encounters among 2235 unique clinicians. The veterans' average age was 70.2 years, and 3.4% (n=7616) were women. Of the 989,271 encounters, 4.2% (n=41,480) were video based and 34.3% (n=338,834) were phone based. Adjusted odds of telehealth use were slightly higher for women versus men (adjusted odds ratio [AOR] 1.08, 95% CI 1.05-1.10), individuals identifying as Hispanic or Latino versus not Hispanic or Latino (AOR 1.46, 95% CI 1.43-1.49), and those with medium and long drive times versus short drive time (AOR 1.11, 95% CI 1.10-1.12 and AOR 1.09, 95% CI 1.07-1.10, respectively). Further, 40.5% of the variation in a veteran's likelihood of using cardiology telehealth care was found at the patient level, 30.8% at the clinician level, and 7% at the facility level.The largest share of the attributable variability in VHA cardiology telehealth use in this cohort was explained by the patient, followed closely by the clinician. Little variability was attributed to the primary facility through which the veteran received their cardiology care. These results suggest that policy solutions intended to improve equity of cardiology telehealth care use in VHA may be most impactful when directed at patients and clinicians.

  View details for DOI 10.2196/53298

  View details for PubMedID 39454198

• Equity in Heart Failure Care: A Get With the Guidelines Analysis of Between- and Within-Hospital Differences in Care by Sex, Race, Ethnicity, and Insurance. Circulation. Heart failure Sandhu, A. T., Grau-Sepulveda, M. V., Witting, C., Tisdale, R. L., Zheng, J., Rodriguez, F., Edward, J. A., Ambrosy, A. P., Greene, S. J., Alhanti, B., Fonarow, G. C., Joynt Maddox, K. E., Heidenreich, P. A. 2024: e011177

  Abstract

  BACKGROUND: Disparities in guideline-based quality measures likely contribute to differences in heart failure (HF) outcomes. We evaluated between- and within-hospital differences in the quality of care across sex, race, ethnicity, and insurance for patients hospitalized for HF.METHODS: This retrospective analysis included patients hospitalized for HF across 596 hospitals in the Get With the Guidelines-HF registry between 2016 and 2021. We evaluated performance across 7 measures stratified by patient sex, race, ethnicity, and insurance. We evaluated differences in performance with and without adjustment for the treating hospital. We also measured variation in hospital-specific disparities.RESULTS: Among 685 227 patients, the median patient age was 72 (interquartile range, 61-82) and 47.2% were women. Measure performance was significantly lower (worse) for women compared with men for all 7 measures before adjustment. For 4 of 7 measures, there were no significant sex-related differences after patient-level adjustment. For 20 of 25 other comparisons, racial and ethnic minorities and Medicaid/uninsured patients had similar or higher (better) adjusted measure performance compared with White and Medicare/privately insured patients, respectively. Angiotensin receptor neprilysin inhibitor measure performance was significantly lower for Asian, Hispanic, and Medicaid/uninsured patients, and cardiac resynchronization therapy implant/prescription was lower among women and Black patients after hospital adjustment, indicating within-hospital differences. There was hospital-level variation in these differences. For cardiac resynchronization therapy implantation/prescription, 278 hospitals (46.6%) had ≥2% lower implant/prescription for Black versus White patients compared with 109 hospitals (18.3%) with the same or higher cardiac resynchronization therapy implantation/prescription for Black patients.CONCLUSIONS: HF quality measure performance was equitable for most measures. There were within-hospital differences in angiotensin receptor neprilysin inhibitor and cardiac resynchronization therapy implant/prescription for historically marginalized groups. The magnitude of hospital-specific disparities varied across hospitals.

  View details for DOI 10.1161/CIRCHEARTFAILURE.123.011177

  View details for PubMedID 39291393

• Equity in the Setting of Heart Failure Diagnosis: An Analysis of Differences Between and Within Clinician Practices. Circulation. Heart failure Gupta, A., Tisdale, R. L., Calma, J., Stafford, R. S., Maron, D. J., Hernandez-Boussard, T., Ambrosy, A. P., Heidenreich, P. A., Sandhu, A. T. 2024: e010718

  Abstract

  BACKGROUND: Timely heart failure (HF) diagnosis can lead to earlier intervention and reduced morbidity. Among historically marginalized patients, new-onset HF diagnosis is more likely to occur in acute care settings (emergency department or inpatient hospitalization) than outpatient settings. Whether inequity within outpatient clinician practices affects diagnosis settings is unknown.METHODS: We determined the setting of incident HF diagnosis among Medicare fee-for-service beneficiaries between 2013 and 2017. We identified sociodemographic and medical characteristics associated with HF diagnosis in the acute care setting. Within each outpatient clinician practice, we compared acute care diagnosis rates across sociodemographic characteristics: female versus male sex, non-Hispanic White versus other racial and ethnic groups, and dual Medicare-Medicaid eligible (a surrogate for low income) versus nondual-eligible patients. Based on within-practice differences in acute diagnosis rates, we stratified clinician practices by equity (high, intermediate, and low) and compared clinician practice characteristics.RESULTS: Among 315 439 Medicare patients with incident HF, 173 121 (54.9%) were first diagnosed in acute care settings. Higher adjusted acute care diagnosis rates were associated with female sex (6.4% [95% CI, 6.1%-6.8%]), American Indian (3.6% [95% CI, 1.1%-6.1%]) race, and dual eligibility (4.1% [95% CI, 3.7%-4.5%]). These differences persisted within clinician practices. With clinician practice adjustment, dual-eligible patients had a 4.9% (95% CI, 4.5%-5.4%) greater acute care diagnosis rate than nondual-eligible patients. Clinician practices with greater equity across dual eligibility also had greater equity across sex and race and ethnicity and were more likely to be composed of predominantly primary care clinicians.CONCLUSIONS: Differences in HF diagnosis rates in the acute care setting between and within clinician practices highlight an opportunity to improve equity in diagnosing historically marginalized patients.

  View details for DOI 10.1161/CIRCHEARTFAILURE.123.010718

  View details for PubMedID 38847082

• Teleoncology in the Veterans Health Administration: Models of Care and the Veteran Experience. American Society of Clinical Oncology educational book. American Society of Clinical Oncology. Annual Meeting Parikh, D. A., Rodgers, T. D., Passero, V. A., Chang, J. C., Tisdale, R., Kelley, M. J., Das, M. 2024; 44 (3): e100042

  Abstract

  The Veterans Health Administration (VHA) has pioneered teleoncology to address access challenges faced by Veterans requiring cancer care. This ASCO Educational Book highlights the development of teleoncology programs within the VHA: the local VA Pittsburgh Healthcare System (VAPHS) Virtual Cancer Care Center, the National TeleOncology Program (NTO), and the regional Clinical Resource Hub (CRH) Oncology Program. These initiatives provide oncology care using a hub-and-spoke model, which centralizes expertise at hub sites and reaches Veterans at distant spoke sites through synchronous and asynchronous care. The deployment of these teleoncology programs has resulted in significant benefits, such as decreased travel for Veterans, high levels of patient satisfaction, and improved access to specialized treatments. Despite these advancements, disparities in teleoncology utilization and access to clinical trials persist. This educational manuscript highlights the successes and challenges of tele-oncology within the VHA, underscoring the critical role of telehealth in overcoming access barriers.

  View details for DOI 10.1200/EDBK_100042

  View details for PubMedID 38870449

• RACIAL AND ETHNIC DIFFERENCES IN OBESITY TREATMENT IN THE VETERANS AFFAIRS HEALTHCARE SYSTEM Tisdale, R. L., Beyene, T. J., Tang, W. L., Yong, C. M. SPRINGER. 2024: S800-S801

  View details for Web of Science ID 001433572702205

• CARDIOLOGY FOLLOWUP CARE FOR VETERANS WITH HEART FAILURE Cao, F., Tisdale, R., Heidenreich, P. A., Sandhu, A. ELSEVIER SCIENCE INC. 2024: 402

  View details for Web of Science ID 001291434300403

• RACIAL AND ETHNIC DIFFERENCES IN OBESITY TREATMENT STRATEGIES IN THE VETERANS AFFAIRS HEALTHCARE SYSTEM Tang, W., Tisdale, R., Beyene, T., Yong, C. M. ELSEVIER SCIENCE INC. 2024: 1701

  View details for Web of Science ID 001324901501733

• CARDIOLOGY FOLLOWUP CARE FOR VETERANS WITH HEART FAILURE Cao, F., Tisdale, R., Heidenreich, P. A., Sandhu, A. ELSEVIER SCIENCE INC. 2024: 402

  View details for Web of Science ID 001324901500403

• The prevalence of cardiovascular disease risk factors among adults living in extreme poverty. Nature human behaviour Geldsetzer, P., Tisdale, R. L., Stehr, L., Michalik, F., Lemp, J., Aryal, K. K., Damasceno, A., Houehanou, C., Jorgensen, J. M., Lunet, N., Mayige, M., Saeedi Moghaddam, S., Mwangi, K. J., Bommer, C., Marcus, M., Theilmann, M., Ebert, C., Atun, R., Davies, J. I., Flood, D., Manne-Goehler, J., Seiglie, J., Barnighausen, T., Vollmer, S. 2024

  Abstract

  Evidence on cardiovascular disease (CVD) risk factor prevalence among adults living below the World Bank's international line for extreme poverty (those with income <$1.90 per day) globally is sparse. Here we pooled individual-level data from 105 nationally representative household surveys across 78 countries, representing 85% of people living in extreme poverty globally, and sorted individuals by country-specific measures of household income or wealth to identify those in extreme poverty. CVD risk factors (hypertension, diabetes, smoking, obesity and dyslipidaemia) were present among 17.5% (95% confidence interval (CI) 16.7-18.3%), 4.0% (95% CI 3.6-4.5%), 10.6% (95% CI 9.0-12.3%), 3.1% (95% CI 2.8-3.3%) and 1.4% (95% CI 0.9-1.9%) of adults in extreme poverty, respectively. Most were not treated for CVD-related conditions (for example, among those with hypertension earning <$1.90 per day, 15.2% (95% CI 13.3-17.1%) reported taking blood pressure-lowering medication). The main limitation of the study is likely measurement error of poverty level and CVD risk factors that could have led to an overestimation of CVD risk factor prevalence among adults in extreme poverty. Nonetheless, our results could inform equity discussions for resource allocation and design of effective interventions.

  View details for DOI 10.1038/s41562-024-01840-9

  View details for PubMedID 38480824

• Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease. Journal of general internal medicine Tisdale, R., Der-Martirosian, C., Yoo, C., Chu, K., Zulman, D., Leung, L. 2024

  Abstract

  BACKGROUND: Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered.OBJECTIVE: Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension.DESIGN: Retrospective cohort study.PATIENTS: Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years.MAIN MEASURES: The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering.KEY RESULTS: Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06).CONCLUSIONS: Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.

  View details for DOI 10.1007/s11606-023-08475-y

  View details for PubMedID 38252244

• Population-Wide Screening for Chronic Kidney Disease. Annals of internal medicine Cusick, M. M., Tisdale, R. L., Chertow, G. M., Owens, D. K., Goldhaber-Fiebert, J. D. 2024; 177 (1): eL230370

  View details for DOI 10.7326/L23-0370

  View details for PubMedID 38224602

• PATIENT, CLINICIAN, AND FACILITY CONTRIBUTIONS TO VARIABILITY IN USE OF VA VIRTUAL CARDIOLOGY CARE Tisdale, R. L., Ferguson, J. M., Greene, A. L., Van Campen, J., Wagner, T. H., Zulman, D. SPRINGER. 2023: S253-S254

  View details for Web of Science ID 001043057200423

• DISPARITIES IN VIDEO CARE USE AMONG VETERANS WITH CARDIOVASCULAR DISEASE Tisdale, R. L., Der-Martirosian, C., Yoo, C., Chu, K., Zulman, D., Leung, L. B. SPRINGER. 2023: S173

  View details for Web of Science ID 001043057200227

• Population-Wide Screening for Chronic Kidney Disease : A Cost-Effectiveness Analysis. Annals of internal medicine Cusick, M. M., Tisdale, R. L., Chertow, G. M., Owens, D. K., Goldhaber-Fiebert, J. D. 2023

  Abstract

  BACKGROUND: Sodium-glucose cotransporter-2 (SGLT2) inhibitors have the potential to alter the natural history of chronic kidney disease (CKD), and they should be included in cost-effectiveness analyses of screening for CKD.OBJECTIVE: To determine the cost-effectiveness of adding population-wide screening for CKD.DESIGN: Markov cohort model.DATA SOURCES: NHANES (National Health and Nutrition Examination Survey), U.S. Centers for Medicare & Medicaid Services data, cohort studies, and randomized clinical trials, including the DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease) trial.TARGET POPULATION: Adults.TIME HORIZON: Lifetime.PERSPECTIVE: Health care sector.INTERVENTION: Screening for albuminuria with and without adding SGLT2 inhibitors to the current standard of care for CKD.OUTCOME MEASURES: Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), all discounted at 3% annually.RESULTS OF BASE-CASE ANALYSIS: One-time CKD screening at age 55 years had an ICER of $86300 per QALY gained by increasing costs from $249800 to $259000 and increasing QALYs from 12.61 to 12.72; this was accompanied by a decrease in the incidence of kidney failure requiring dialysis or kidney transplant of 0.29 percentage points and an increase in life expectancy from 17.29 to 17.45 years. Other options were also cost-effective. During ages 35 to 75 years, screening once prevented dialysis or transplant in 398000 people and screening every 10 years until age 75 years cost less than $100000 per QALY gained.RESULTS OF SENSITIVITY ANALYSIS: When SGLT2 inhibitors were 30% less effective, screening every 10 years during ages 35 to 75 years cost between $145400 and $182600 per QALY gained, and price reductions would be required for screening to be cost-effective.LIMITATION: The efficacy of SGLT2 inhibitors was derived from a single randomized controlled trial.CONCLUSION: Screening adults for albuminuria to identify CKD could be cost-effective in the United States.PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality, Veterans Affairs Office of Academic Affiliations, and National Institute of Diabetes and Digestive and Kidney Diseases.

  View details for DOI 10.7326/M22-3228

  View details for PubMedID 37216661

• Opportunities to Enhance the Implementation of Veterans Affairs Video-Based Care: Qualitative Perspectives of Providers from Diverse Specialties. Journal of medical Internet research Slightam, C., Wray, C., Tisdale, R. L., Zulman, D. M., Gray, C. 2023; 25: e43314

  Abstract

  Increasing the adoption of digital care tools, including video visits, is a long-term goal for the US Department of Veterans Affairs (VA). While previous work has highlighted patient-specific barriers to the use of video visits, few have examined how clinicians view such barriers and how they have overcome them during the rapid uptake of web-based care.This study sought input from providers, given their role as critical participants in video visit implementation, to qualitatively describe successful strategies providers used to adapt their practices to a web-based care setting.We conducted interviews with 28 VA providers (physicians and nurse practitioners) from 4 specialties that represent diverse clinical services: primary care (n=11), cardiology (n=7), palliative care (n=5), and spinal cord injury (n=5). All interviews were audio recorded and transcribed, and transcripts were reviewed and coded according to an iteratively created codebook. To identify themes, codes were grouped together into categories, and participant comments were reviewed for repetition and emphasis on specific points. Finally, themes were mapped to Expert Recommendations for Implementing Change (ERIC) strategies to identify evidence-based opportunities to support video visit uptake in the VA.Interviewees were mostly female (57%, 16/28), with an average age of 49 years and with 2-20 years of experience working in the VA across 16 unique VA facilities. Most providers (82%, 23/28) worked in urban facilities. Many interviewees (78%, 22/28) had some experience with video visits prior to the COVID-19 pandemic, though a majority (61%, 17/28) had conducted fewer than 50 video visits in the quarter prior to recruitment. We identified four primary themes related to how providers adapt their practices to a web-based care setting: (1) peer-based learning and support improved providers' perceived value of and confidence in video visits, (2) providers developed new and refined existing communication and clinical skills to optimize video visits, (3) providers saw opportunities to revisit and refine team roles to optimize the value of video visits for their care teams, and (4) implementing and sustaining web-based care requires institutional and organizational support. We identified several ERIC implementation strategies to support the use of video visits across the individual-, clinic-, and system-levels that correspond to these themes: (1) individual-level strategies include the development of educational materials and conducting education meetings, (2) clinic-level strategies include identifying champions and revising workflows and professional roles, and (3) system-level strategies include altering incentive structures, preparing implementation blueprints, developing and implementing tools for quality monitoring, and involving executive leadership to encourage adoption.This work highlights strategies to support video visits that align with established ERIC implementation constructs, which can be used by health care systems to improve video visit implementation.

  View details for DOI 10.2196/43314

  View details for PubMedID 37093642

• Predictors of Incident HeartFailure Diagnosis Setting: Insights From the Veterans Affairs Healthcare System. JACC. Heart failure Tisdale, R. L., Fan, J., Calma, J., Cyr, K., Podchiyska, T., Stafford, R. S., Maron, D. J., Hernandez-Boussard, T., Ambrosy, A., Heidenreich, P. A., Sandhu, A. T. 2022

  Abstract

  BACKGROUND: Early recognition of heart failure (HF) can reduce morbidity, yet HF is often diagnosed only after symptoms require urgent treatment.OBJECTIVES: The authors sought to describe predictors of HF diagnosis in the acute care vs outpatient setting within the Veterans Health Administration (VHA).METHODS: The authors estimated whether incident HF diagnoses occurred in acute care (inpatient hospital or emergency department) vs outpatient settings within the VHA between 2014 and 2019. After excluding new-onset HF potentially caused by acute concurrent conditions, they identified sociodemographic and clinical variables associated with diagnosis setting and assessed variation across 130 VHA facilities using multivariable regression analysis.RESULTS: The authors identified 303,632 patients with new HF, with 160,454 (52.8%) diagnosed in acute care settings. In the prior year, 44% had HF symptoms and 11% had a natriuretic peptide tested, 88% of which were elevated. Patients with housing insecurity and high neighborhood social vulnerability had higher odds of acute care diagnosis (adjusted odds ratio: 1.22 [95%CI: 1.17-1.27] and 1.17 [95%CI: 1.14-1.21], respectively) adjusting for medical comorbidities. Better outpatient quality of care (blood pressure control and cholesterol and diabetes monitoring within the prior 2 years) predicted a lower odds of acute care diagnosis. Likelihood of acute care HF diagnosis varied from 41% to 68% across facilities after adjusting for patient-level risk factors.CONCLUSIONS: Many first HF diagnoses occur in the acute care setting, especially among socioeconomically vulnerable populations. Better outpatient care was associated with lower rates of an acute care diagnosis. These findings highlight opportunities for timelier HF diagnosis that may improve patient outcomes.

  View details for DOI 10.1016/j.jchf.2022.11.013

  View details for PubMedID 36881392

• Disparities in virtual cardiology visits among Veterans Health Administration patients during the COVID-19 pandemic. JAMIA open Tisdale, R. L., Ferguson, J., Van Campen, J., Greene, L., Sandhu, A. T., Heidenreich, P. A., Zulman, D. M. 2022; 5 (4): ooac103

  Abstract

  Objective: In response to the coronavirus disease 2019 (COVID-19) pandemic, the Veterans Health Administration (VA) rapidly expanded virtual care (defined as care delivered by video and phone), raising concerns about technology access disparities (ie, the digital divide). Virtual care was somewhat established in primary care and mental health care prepandemic, but video telehealth implementation was new for most subspecialties, including cardiology. We sought to identify patient characteristics of virtual and video-based care users in VA cardiology clinics nationally during the first year of the COVID-19 pandemic.Materials and Methods: Cohort study of Veteran patients across all VA facilities with a cardiology visit January 1, 2019-March 10, 2020, with follow-up January 1, 2019-March 10, 2021. Main measures included cardiology visits by visit type and likelihood of receiving cardiology-related virtual care, calculated with a repeated event survival model.Results: 416587 Veterans with 1689595 total cardiology visits were analyzed; average patient age was 69.6 years and 4.3% were female. Virtual cardiology care expanded dramatically early in the COVID-19 pandemic from 5% to 70% of encounters. Older, lower-income, and rural-dwelling Veterans and those experiencing homelessness were less likely to use video care (adjusted hazard ratio for ages 75 and older 0.80, 95% confidence interval (CI) 0.75-0.86; for highly rural residents 0.77, 95% CI 0.68-0.87; for low-income status 0.94, 95% CI 0.89-0.98; for homeless Veterans 0.85, 95% CI 0.80-0.92).Conclusion: The pandemic worsened the digital divide for cardiology care for many vulnerable patients to the extent that video visits represent added value over phone visits. Targeted interventions may be necessary for equity in COVID-19-era access to virtual cardiology care.

  View details for DOI 10.1093/jamiaopen/ooac103

  View details for PubMedID 36531138

• Disparities in Hospital Length of Stay Across Race and Ethnicity Among Patients With Heart Failure. Circulation. Heart failure Zheng, J., Tisdale, R. L., Heidenreich, P. A., Sandhu, A. T. 2022; 15 (11): e009362

  Abstract

  Reducing hospital length of stay (LOS) has been identified as an important lever for minimizing the burden of heart failure hospitalization, yet the impact of social and structural determinants of health on LOS has received little attention. We investigated disparities in LOS across race/ethnicity and their possible drivers.We analyzed patients hospitalized for heart failure from 2017 to 2020 using the Get With The Guidelines-Heart Failure registry. We characterized LOS differences across race/ethnicity by insurance and disposition, adjusting for demographics, comorbidities, and clinical severity. Effects of hospital-level clustering on LOS across race/ethnicity were assessed using hierarchical mixed-effects models. We evaluated the association between LOS and discharge rates of guideline-directed medical therapy.Three thousand three seven hundred thirty patients hospitalized for heart failure were identified. After excluding inpatient deaths, the adjusted LOS for Black (5.72 days [95% CI, 5.62-5.82]), Hispanic (5.94 days [95% CI, 5.79-6.08]), and Indigenous American/Pacific Islander (6.06 days [95% CI, 5.85-6.27]) patients remained significantly longer compared with non-Hispanic White patients (5.32 days [95% CI, 5.25-5.39]). This pattern was driven by LOS differences among patients discharged to hospice or nursing facilities. After accounting for variability between hospitals, associations of race/ethnicity with LOS either were attenuated or reversed in direction. Guideline-directed medical therapy rates on discharge did not differ significantly across race/ethnicity despite longer LOS for Black, Hispanic, and Indigenous American/Pacific Islander patients.Differences between hospitals drive LOS disparities across race/ethnicity. Longer LOS among Black, Hispanic, and Indigenous American/Pacific Islander patients was not associated with improved quality of care.

  View details for DOI 10.1161/CIRCHEARTFAILURE.121.009362

  View details for PubMedID 36378760

• Treatment Differences in Medical Therapy for Heart Failure With Reduced Ejection Fraction Between Sociodemographic Groups. JACC. Heart failure Witting, C., Zheng, J., Tisdale, R. L., Shannon, E., Kohsaka, S., Lewis, E. F., Heidenreich, P., Sandhu, A. 2022

  Abstract

  There are sociodemographic disparities in outcomes of heart failure with reduced ejection fraction (HFrEF), but disparities in guideline-directed medical therapy (GDMT) remain poorly characterized.This study aimed to analyze GDMT treatment rates in eligible patients with recently diagnosed HFrEF, and to determine how rates vary by sociodemographic characteristics.This retrospective cohort study included patients diagnosed with HFrEF at Veterans Affairs (VA) hospitals from 2013 to 2019. The authors analyzed GDMT treatment rates and doses, excluding patients with contraindications. Therapies of interest were evidence-based beta-blockers (BBs), renin-angiotensin system inhibitors (RASIs), angiotensin receptor-neprilysin inhibitors (ARNIs), and mineralocorticoid antagonists (MRAs). The authors compared adjusted treatment rates by race and ethnicity, neighborhood social vulnerability, rurality, distance to medical care, and sex.The cohort comprised 126,670 VA patients with recently diagnosed HFrEF. The study found that racial and ethnic minorities had similar or higher treatment rates than White patients. Patients residing in socially vulnerable neighborhoods had 3.4% lower ARNI (95% CI: 1.9%-5.0%) treatment rates. Patients residing farther from specialty care had similar rates of GDMT therapy overall, but were less likely to be taking at least 50% of the target doses of either BBs (4.0% less likely; 95% CI: 3.1%-5.0%) or RASIs (5.0% less likely; 95% CI: 4.1%-6.0%) compared with those closer to care.Among VA patients with recently diagnosed HFrEF, the authors did not find that racial and ethnic minority patients were less likely to receive GDMT. However, appropriate dose up-titration may occur less frequently in more remote patients.

  View details for DOI 10.1016/j.jchf.2022.08.023

  View details for PubMedID 36647925

• Medical therapy for patients with recent-onset heart failure with reduced ejection fraction during the COVID-19 pandemic: Insights from the Veteran's affairs healthcare system. American heart journal plus : cardiology research and practice Sandhu, A., Zheng, J., Tisdale, R., Kohsaka, S., Turakhia, M. P., Heidenreich, P. 2022: 100210

  Abstract

  This study aims to evaluate trends in guideline-directed medical therapy (GDMT) for patients with recent-onset heart failure with reduced ejection fraction (HFrEF) following the onset of the COVID-19 pandemic using an interrupted time series analysis in the Veteran's Affairs Healthcare System. Among 71,428 patients with recent-onset HFrEF between 1/1/2018 and 2/28/2021, we found the pandemic was not associated with differences in treatment rates for beta-blockers, renin-angiotensin-aldosterone system inhibitors, or mineralocorticoid receptor antagonists; there was a 2.6 % absolute decrease (95 % CI: 0.5 %-4.7 %) in ARNI rates in April 2020; which decreased over the pandemic. Despite the changes to healthcare delivery, the COVID-19 pandemic was associated with minimal changes in GDMT rates among patients with recent-onset HFrEF.

  View details for DOI 10.1016/j.ahjo.2022.100210

  View details for PubMedID 36156887

• A systematic review of healthcare provider-targeted mobile applications for non-communicable diseases in low- and middle-income countries. NPJ digital medicine Geldsetzer, P., Flores, S., Wang, G., Flores, B., Rogers, A. B., Bunker, A., Chang, A. Y., Tisdale, R. 2022; 5 (1): 99

  Abstract

  Mobile health (mHealth) interventions hold promise for addressing the epidemic of noncommunicable diseases (NCDs) in low- and middle-income countries (LMICs) by assisting healthcare providers managing these disorders in low-resource settings. We aimed to systematically identify and assess provider-facing mHealth applications used to screen for, diagnose, or monitor NCDs in LMICs. In this systematic review, we searched the indexing databases of PubMed, Web of Science, and Cochrane Central for studies published between January 2007 and October 2019. We included studies of technologies that were: (i) mobile phone- or tablet-based, (ii) able to screen for, diagnose, or monitor an NCD of public health importance in LMICs, and (iii) targeting health professionals as users. We extracted disease type, intervention purpose, target population, study population, sample size, study methodology, technology stage, country of development, operating system, and cost. Our initial search retrieved 13,262 studies, 315 of which met inclusion criteria and were analyzed. Cardiology was the most common clinical domain of the technologies evaluated, with 89 publications. mHealth innovations were predominantly developed using Apple's iOS operating system. Cost data were provided in only 50 studies, but most technologies for which this information was available cost less than 20 USD. Only 24 innovations targeted the ten NCDs responsible for the greatest number of disability-adjusted life years lost globally. Most publications evaluated products created in high-income countries. Reported mHealth technologies are well-developed, but their implementation in LMICs faces operating system incompatibility and a relative neglect of NCDs causing the greatest disease burden.

  View details for DOI 10.1038/s41746-022-00644-3

  View details for PubMedID 35853936

• A Retrospective Analysis of Medical Student Performance Evaluations, 2014-2020: Recommend with Reservations. Journal of general internal medicine Tisdale, R. L., Filsoof, A. R., Singhal, S., Caceres, W., Nallamshetty, S., Rogers, A. J., Verghese, A. C., Harrington, R. A., Witteles, R. M. 2022

  Abstract

  BACKGROUND: The Medical Student Performance Evaluations (MSPE) is a cornerstone of residency applications. Little is known regarding adherence to Association of American Medical Colleges (AAMC) MSPE recommendations and longitudinal changes in MSPE content.OBJECTIVES: Evaluate current MSPE quality and longitudinal changes in MSPE and grading practices.DESIGN: Retrospective analysis.PARTICIPANTS: Students from all Liaison Committee on Medical Education (LCME)-accredited medical schools from which the Stanford University Internal Medicine residency program received applications between 2014-2015 and 2019-2020.MAIN MEASURES: Inclusion of key words to describe applicant performance and metrics thereof, including distribution among students and key word assignment explanation; inclusion of clerkship grades, grade distributions, and grade composition; and evidence of grade inflation over time.KEY RESULTS: MSPE comprehensiveness varied substantially among the 149 schools analyzed. In total, 25% of schools provided complete information consistent with AAMC recommendations regarding key word/categorization of medical students and clerkship grades in 2019-2020. Seventy-seven distinct key word terms appeared across the 139 schools examined in 2019-2020. Grading practices markedly varied, with 2-83% of students receiving the top internal medicine clerkship grade depending on the year and school. Individual schools frequently changed key word and grading practices, with 33% and 18% of schools starting and/or stopping use of key words and grades, respectively. Significant grade inflation occurred over the 6-year study period, with an average 14% relative increase in the proportion of students receiving top clerkship grades.CONCLUSIONS: A minority of schools complies with AAMC MSPE guidelines, and MSPEs are inconsistent across time and schools. These practices may impair evaluation of students within and between schools.

  View details for DOI 10.1007/s11606-022-07502-8

  View details for PubMedID 35710660

• Cost-Effectiveness of Dapagliflozin for Non-diabetic Chronic Kidney Disease. Journal of general internal medicine Tisdale, R. L., Cusick, M. M., Aluri, K. Z., Handley, T. J., Joyner, A. K., Salomon, J. A., Chertow, G. M., Goldhaber-Fiebert, J. D., Owens, D. K. 2022

  Abstract

  BACKGROUND: In the USA, chronic kidney disease (CKD) affects 1 in 7 adults and costs $100 billion annually. The DAPA-CKD trial found dapagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, to be effective in reducing CKD progression and mortality in patients with diabetic and non-diabetic CKD. Currently, SGLT2 inhibitors are not considered standard of care for patients with non-diabetic CKD.OBJECTIVE: Determine the cost-effectiveness of adding dapagliflozin to standard management of patients with non-diabetic CKD.DESIGN: Markov model with lifetime time horizon and US healthcare sector perspective.PATIENTS: Patients with non-diabetic CKD INTERVENTION: Dapagliflozin plus standard care versus standard care only.MAIN MEASURES: Quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs), all discounted at 3% annually; total incidence of kidney failure on kidney replacement therapy; average years on kidney replacement therapy.KEY RESULTS: Adding dapagliflozin to standard care improved life expectancy by 2 years, increased discounted QALYS (from 6.75 to 8.06), and reduced the total incidence of kidney failure on kidney replacement therapy (KRT) (from 17.4 to 11.0%) and average years on KRT (from 0.77 to 0.43) over the lifetime of the cohort. Dapagliflozin plus standard care was more effective than standard care alone while increasing lifetime costs (from $245,900 to $324,8900, or $60,000 per QALY gained). Results were robust to variations in assumptions about dapagliflozin's efficacy over time and by CKD stage, added costs of kidney replacement therapy, and expected population annual CKD progression rates and sensitive to the cost of dapagliflozin. The net 1-year budgetary implication of treating all US patients with non-diabetic CKD could be up to $21 billion.CONCLUSIONS: Dapagliflozin improved life expectancy and reduced progression of CKD, the proportion of patients requiring kidney replacement therapy, and time on kidney replacement therapy in patients with non-diabetic CKD. Use of dapagliflozin meets conventional criteria for cost-effectiveness.

  View details for DOI 10.1007/s11606-021-07311-5

  View details for PubMedID 35137296

• Utilization of Generic Cardiovascular Drugs in Medicare's Part D Program. Circulation. Cardiovascular quality and outcomes Ma, I., Tisdale, R. L., Vail, D., Heidenreich, P. A., Sandhu, A. T. 2021: CIRCOUTCOMES120007559

  Abstract

  BACKGROUND: Generic medications cost less than brand-name medications and are similarly effective, but brand-name medications are still prescribed. We evaluated patterns in generic cardiovascular medication fills and estimated the potential cost savings with increased substitution of generic for brand-name medications.METHODS: This was a cross-sectional study of cardiovascular therapies using the Medicare Part D database of prescription medications in 2017. We evaluated drug fill patterns for therapies with available brand-name and generic options. We determined the generic substitution ratio and estimated the potential savings with increased generic substitution at the national, state, and clinician level. We compared states with laws related to mandatory pharmacist generic substitution and patient consent for substitution.RESULTS: Of $22.9 billion spent on cardiovascular drugs in Medicare Part D prescription programs in 2017, $11.0 billion was spent on medications with both brand-name and generic options. Although only 2.4% of medication fills were for the brand-name choice, they made up 21.2% of total spending. Accounting for estimated brand-name rebates, generic substitution for these medications would save $641 million, including $135 million in costs shouldered by patients. Furthermore, the minority of clinicians with the lowest generic utilization was responsible for a large proportion of the potential cost savings.CONCLUSIONS: There are substantial potential cost savings from substituting brand-name medications with generic medications. These savings would be primarily driven by lower use of brand-name therapies by the minority of clinicians who prescribe them at increased rates.

  View details for DOI 10.1161/CIRCOUTCOMES.120.007559

  View details for PubMedID 34879702

• Patient-Centered, Sustainable Hypertension Care: The Case for Adopting a Differentiated Service Delivery Model for Hypertension Services in Low- and Middle-Income Countries. Global heart Tisdale, R. L., Cazabon, D., Moran, A. E., Rabkin, M., Bygrave, H., Cohn, J. 2021; 16 (1): 59

  Abstract

  Expanding hypertension services in low- and middle-income countries requires efficient and effective service delivery approaches that meet the needs and expectations of people living with hypertension within the resource constraints of existing national health systems. Ideally, a hypertension program will extend treatment coverage while maintaining service quality, maximizing efficient resource utilization and improving clinical outcomes. In this article, we discuss lessons learned from HIV differentiated service delivery initiatives, and make the case that the same approach should be adopted for hypertension programs.

  View details for DOI 10.5334/gh.978

  View details for PubMedID 34692383

  View details for PubMedCentralID PMC8415184

• Disparity in the Setting of Incident Heart Failure Diagnosis. Circulation. Heart failure Sandhu, A. T., Tisdale, R. L., Rodriguez, F., Stafford, R. S., Maron, D. J., Hernandez-Boussard, T., Lewis, E., Heidenreich, P. A. 2021: CIRCHEARTFAILURE121008538

  Abstract

  BACKGROUND: Early heart failure (HF) recognition can reduce morbidity, yet HF is often initially diagnosed only after a patient clinically worsens. We sought to identify characteristics that predict diagnosis in the acute care setting versus the outpatient setting.METHODS: We estimated the proportion of incident HF diagnosed in the acute care setting (inpatient hospital or emergency department) versus outpatient setting based on diagnostic codes from a claims database covering commercial insurance and Medicare Advantage between 2003 and 2019. After excluding new-onset HF potentially caused by a concurrent acute cause (eg, acute myocardial infarction), we identified demographic, clinical, and socioeconomic predictors of diagnosis setting. Patients were linked to their primary care clinicians to evaluate diagnosis setting variation across clinicians.RESULTS: Of 959 438 patients with new HF, 38% were diagnosed in acute care. Of these, 46% had potential HF symptoms in the prior 6 months. Over time, the relative odds of acute care diagnosis increased by 3.2% annually after adjustment for patient characteristics (95% CI, 3.1%-3.3%). Acute care diagnosis setting was more likely for women compared with men (adjusted odds ratio, 1.11 [95% CI, 1.10-1.12]) and for Black patients compared with White patients (adjusted odds ratio, 1.18 [95% CI, 1.16-1.19]). The proportion of acute care diagnosis varied substantially (interquartile range: 24%-39%) among clinicians after adjusting for patient-level risk factors.CONCLUSIONS: A large proportion of first HF diagnoses occur in the acute care setting, particularly among women and Black patients, yet many had potential HF symptoms in the months before acute care visits. These results raise concerns that many HF diagnoses are missed in the outpatient setting. Earlier diagnosis could allow for timelier high-value interventions, addressing disparities and reducing the progression of HF.

  View details for DOI 10.1161/CIRCHEARTFAILURE.121.008538

  View details for PubMedID 34311559

• DISPARITIES IN VIRTUAL CARDIOLOGY VISITS AMONG VETERANS HEALTH ADMINISTRATION PATIENTS DURING THE COVID-19 PANDEMIC Tisdale, R. L., Ferguson, J. M., Van Campen, J., Greene, L., Sandhu, A., Heidenreich, P., Zulman, D. SPRINGER. 2021: S168

  View details for Web of Science ID 000679443300404

• Availability of Cost-effectiveness Studies for Drugs With High Medicare Part D Expenditures. JAMA network open Tisdale, R. L., Ma, I., Vail, D., Bhattacharya, J., Goldhaber-Fiebert, J. D., Heidenreich, P. A., Sandhu, A. T. 2021; 4 (6): e2113969

  Abstract

  Importance: Prescription drug spending in the US requires policy intervention to control costs and improve the value obtained from pharmaceutical spending. One such intervention is to apply cost-effectiveness evidence to decisions regarding drug coverage and pricing, but this intervention depends on the existence of such evidence to guide decisions.Objective: To characterize the availability and quality of cost-effectiveness studies for prescription drugs with the greatest Medicare Part D spending.Design, Setting, and Participants: In this national cross-sectional analysis, publicly available 2016 Medicare drug spending records were merged with 2016 US Food & Drug Administration Orange Book data and the Tufts Medical Center Cost-Effectiveness Analysis (CEA) Registry. All studies published through 2015 that evaluated the cost-effectiveness of the 250 drugs for which Medicare Part D spending was the greatest in US-based adult patient populations were included. Data were analyzed from September 2018 to June 2020.Main Outcomes and Measures: The presence and quality of published cost-effectiveness analyses for the 250 drugs for which Medicare Part D spending was greatest in 2016 were assessed based on the inclusion of key cost-effectiveness analysis elements and global ratings by independent reviewers for the Tufts CEA Registry.Results: Medicare Part D spending on the 250 drugs in the sample totaled $122.8 billion in 2016 (84.1% of total spending). Of these 250 drugs, 91 (36.4%) had a generic equivalent and 159 (63.6%) retained some patent exclusivity. There were 280 unique cost-effectiveness analyses for these drugs, representing data on 135 (54.0%) of the 250 drugs included and 67.0% of Part D spending on the top 250 drugs. The 115 drugs (46.0%) without cost-effectiveness studies accounted for 33.0% of Part D spending on the top 250 drugs. Of the 280 available studies, 128 (45.7%) were industry sponsored. A large proportion of the studies (250 [89.3%]) did not meet the minimum quality requirements.Conclusions and Relevance: In this cross-sectional study, a substantial proportion of 2016 Medicare Part D spending was for drugs with absent or low-quality cost-effectiveness analyses. The lack of quality analyses may present a challenge in efforts to develop policies addressing drug spending in terms of value.

  View details for DOI 10.1001/jamanetworkopen.2021.13969

  View details for PubMedID 34143189

• PREDICTORS OF SETTING OF HEART FAILURE DIAGNOSIS Tisdale, R., Stafford, R., Maron, D., Hernandez-Boussard, T., Rodriguez, F., Heidenreich, P., Sandhu, A. ELSEVIER SCIENCE INC. 2021: 676

  View details for Web of Science ID 000647487500675

• Patient-Centered, Sustainable Hypertension Care: The Case for Adopting a Differentiated Service Delivery Model for Hypertension Services in Low- and Middle-Income Countries GLOBAL HEART Tisdale, R. L., Cazabon, D., Moran, A. E., Rabkin, M., Bygrave, H., Cohn, J. 2021; 16 (1)

  View details for DOI 10.5334/gh.978

  View details for Web of Science ID 000693421100001

• Trends in Left Ventricular Ejection Fraction for Patients With a New Diagnosis of Heart Failure. Circulation. Heart failure Tisdale, R. L., Haddad, F., Kohsaka, S., Heidenreich, P. A. 2020: CIRCHEARTFAILURE119006743

  Abstract

  BACKGROUND: The left ventricular ejection fraction (LVEF) guides treatment of heart failure, yet this data has not been systematically collected in large data sets. We sought to characterize the epidemiology of incident heart failure using the initial LVEF.METHODS: We identified 219 537 patients in the Veterans Affairs system between 2011 and 2017 who had an LVEF documented within 365 days before and 30 days after the heart failure diagnosis date. LVEF was obtained from natural language processing from imaging and provider notes. In multivariate analysis, we assessed characteristics associated with having an initial LVEF <40%.RESULTS: Most patients were male and White; a plurality were within the 60 to 69 year age decile. A majority of patients had ischemic heart disease and a high burden of co-morbidities. Over time, presentation with an LVEF <40% became slightly less common, with a nadir in 2015. Presentation with an initial LVEF <40% was more common in younger patients, men, Black and Hispanic patients, an inpatient presentation, lower systolic blood pressure, lower pulse pressure, and higher heart rate. Ischemic heart disease, alcohol use disorder, peripheral arterial disease, and ventricular arrhythmias were associated with an initial LVEF <40%, while most other comorbid conditions (eg, atrial fibrillation, chronic obstructive pulmonary disease, malignancy) were more strongly associated with an initial LVEF >50%.CONCLUSIONS: For patients with heart failure, particularly at the extremes of age, an initial preserved LVEF is common. In addition to clinical characteristics, certain races (Black and Hispanic) were more likely to present with a reduced LVEF. Further studies are needed to determine if racial differences are due to patient or health systems issues such as access to care.

  View details for DOI 10.1161/CIRCHEARTFAILURE.119.006743

  View details for PubMedID 32867526

• Association Between Neighborhood Social Risk and Hospital Readmission Reduction Penalties Under the New Stratified Approach: Is Dual Eligibility Adjustment Enough? Circulation. Cardiovascular quality and outcomes Sandhu, A. T., Tisdale, R., Joynt Maddox, K. E., Heidenreich, P. A. 2020: CIRCOUTCOMES119006353

  View details for DOI 10.1161/CIRCOUTCOMES.119.006353

  View details for PubMedID 32600063

• Novel Graduate Medical Education in the Era of a Novel Virus Journal of Graduate Medical Education Tisdale, R., Filsoof, A., Singhal, S. 2020
• How Much Time are Physicians and Nurses Spending Together at the Patient Bedside? Journal of hospital medicine Sang, A. X., Tisdale, R. L., Nielsen, D., Loica-Mersa, S., Miller, T., Chong, I., Shieh, L. 2019; 14: E1–E6

  Abstract

  BACKGROUND: Bedside rounding involving both nurses and physicians has numerous benefits for patients and staff. However, precise quantitative data on the current extent of physician-nurse (MD-RN) overlap at the patient bedside are lacking.OBJECTIVE: This study aimed to examine the frequency of nurse and physician overlap at the patient beside and what factors affect this frequency.DESIGN: This is a prospective, observational study of time-motion data generated from wearable radio frequency identification (RFID)-based locator technology.SETTING: Single-institution academic hospital.MEASUREMENTS: The length of physician rounds, frequency of rounds that include nurses simultaneously at the bedside, and length of MD-RN overlap were measured and analyzed by ward, day of week, and distance between patient room and nursing station.RESULTS: A total of 739 MD rounding events were captured over 90 consecutive days. Of these events, 267 took place in single-bed patient rooms. The frequency of MD-RN overlap was 30.0%, and there was no statistical difference between the three wards studied. Overall, the average length of all MD rounds was 7.31 ± 0.58 minutes, but rounding involving a bedside nurse lasted longer than rounds with MDs alone (9.56 vs 5.68 minutes, P < .05). There was no difference in either the length of rounds or the frequency of MD-RN overlap between weekdays and weekends. Finally, patient rooms located farther away from the nursing station had a lower likelihood of MD-RN overlap (Pearson's r = -0.67, P < .05).CONCLUSION: RFID-based technology provides precise, automated, and high-throughput time-motion data to capture nurse and physician activity. At our institution, 30.0% of rounds involve a bedside nurse, highlighting a potential barrier to bedside interdisciplinary rounding.

  View details for DOI 10.12788/jhm.3204

  View details for PubMedID 31112496

• What's in a Name? Factors That Influence the Usage of Generic Versus Trade Names for Cardiac Medications Among Healthcare Providers CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Ouyang, D., Tisdale, R., Cheng, P., Chi, J., Chen, J. H., Ashley, E. 2018; 11 (8)

  View details for DOI 10.1161/CIRCOUTCOMES.118.004704

  View details for Web of Science ID 000442242700009

• What's in a Name? Factors That Influence the Usage of Generic Versus Trade Names for Cardiac Medications Among Healthcare Providers. Circulation. Cardiovascular quality and outcomes Ouyang, D., Tisdale, R., Cheng, P., Chi, J., Chen, J. H., Ashley, E. 2018; 11 (8): e004704

  View details for DOI 10.1161/CIRCOUTCOMES.118.004704

  View details for PubMedID 30354370

• Acetaminophen or Tylenol? A Retrospective Analysis of Medication Digital Communication Practices. Journal of general internal medicine Ouyang, D., Tisdale, R., Ashley, E., Chi, J., Chen, J. H. 2018

  View details for PubMedID 29717410

• APPLYING NATURAL LANGUAGE PROCESSING OF ECHOCARDIOGRAPHY REPORTS TO DESCRIBE EPIDEMIOLOGY OF HEART FAILURE Tisdale, R., Heidenreich, P. ELSEVIER SCIENCE INC. 2018: 712

  View details for DOI 10.1016/S0735-1097(18)31253-1

  View details for Web of Science ID 000429659701562

• MEDICATION COMMUNICATION PRACTICES BETWEEN PROVIDERS IN CARDIOLOGY Tisdale, R., Ouyang, D., Cheng, P., Chi, J., Chen, J., Ashley, E. ELSEVIER SCIENCE INC. 2018: 2644

  View details for DOI 10.1016/S0735-1097(18)33185-1

  View details for Web of Science ID 000429659705094

• EMR-based handoff tool improves completeness of internal medicine residents' handoffs. BMJ open quality Tisdale, R. L., Eggers, Z., Shieh, L. 2018; 7 (3): e000188

  Abstract

  Background: The majority of adverse events in healthcare involve communication breakdown. Physician-to-physician handoffs are particularly prone to communication errors, yet have been shown to be more complete when systematised according to a standardised bundle. Interventions that improve thoroughness of handoffs have not been widely studied.Aim: To measure the effect of an electronic medical record (EMR)-based handoff tool on handoff completeness.Intervention: This EMR-based handoff tool included a radio button prompting users to classify patients as stable, a 'watcher' or unstable. It automatically pulled in EMR data on the patient's 24-hour vitals, common lab tests and code status. Finally, it provided text boxes labelled 'Active Issues', 'Action List (To-Dos)' and 'If/Then' to fill in.Implementation and evaluation: Written handoffs from general and specialty (haematology, oncology, cardiology) Internal Medicine resident-run inpatient wards were evaluated on a randomly chosen representative sample of days in April and May 2015 at Stanford University Medical Center, focusing on a predefined set of content elements. The intervention was then implemented in June 2015 with postintervention data collected in an identical fashion in August to September 2016.Results: Handoff completeness improved significantly (p<0.0001). Improvement in inclusion of illness severity was notable for its magnitude and its importance in establishing a consistent mental model of a patient. Elements that automatically pulled in data and those prompting users to actively fill in data both improved.Conclusion: A simple EMR-based handoff tool providing a mix of frameworks for completion and automatic pull-in of objective data improved handoff completeness. This suggests that EMR-based interventions may be effective at improving handoffs, possibly leading to fewer medical errors and better patient care.

  View details for DOI 10.1136/bmjoq-2017-000188

  View details for PubMedID 30019013

• Stress and Anxiety Scores in First and Repeat IVF Cycles: A Pilot Study. PloS one Turner, K., Reynolds-May, M. F., Zitek, E. M., Tisdale, R. L., Carlisle, A. B., Westphal, L. M. 2013; 8 (5)

  View details for DOI 10.1371/journal.pone.0063743

  View details for PubMedID 23717472