2018 — 2021 |
Chang, Bernard P. |
R01Activity Code Description: To support a discrete, specified, circumscribed project to be performed by the named investigator(s) in an area representing his or her specific interest and competencies. |
Testing a Rapid Outpatient Management Strategy On Ptsd, Cardiovascular and Rehospitalization Risk in Tia and Minor Stroke Survivors Evaluated in the Emergency Department @ Columbia University Health Sciences
Recent research suggests that exposure to stressful aspects of emergency department (ED) and inpatient care may increase risk for subsequent posttraumatic stress disorder (PTSD) and recurrent cardiovascular events in patients who present to the ED with transient ischemic attacks and minor strokes (TIAMS). There are currently no established clinical guidelines for emergency department (ED) management of TIAMS after the initial evaluation and safety determination. This study will compare psychological and long-term cardiovascular outcomes associated with the two most widely employed strategies for managing TIAMS patients in US EDs. We will use an observational design to compare TIAMS-induced PTSD symptoms, 30-day rehospitalization, and 1-year cardiovascular disease (CVD)/mortality outcomes in TIAMS patients managed according to (1) ED evaluation followed by inpatient admission strategy, versus (2) rapid ED evaluation and discharge with a scheduled next-day outpatient neurology follow-up. Further, we will assess autonomic nervous system (ANS) reactivity to the 2 strategies using ambulatory ECG. This study design is possible because of a newly established Rapid Access Vascular Evaluation- Neurology (RAVEN) TIAMS care pathway, which will be available for 2 weeks per month (on alternating weeks) at Columbia University Medical Center. We hypothesize that patients treated during RAVEN weeks will have lower PTSD symptoms, reduced 30d rehospitalization, and lower 1- year CVD/mortality risk relative to those treated during the inpatient admission strategy weeks. We will explore whether ANS markers of stress (ambulatory heart rate (HR) and heart rate variability (HRV) in the 3 days after ED presentation) explain any group differences in study outcomes. Nearly 1 in 5 TIA/MS survivors screen positive for PTSD in the month after the event, and research in other CVD patients suggests that PTSD may increase risk for recurrent CVD events. To date, research linking ED/inpatient exposure with subsequent PTSD has been unable to disentangle the stress that results from the medical event itself from stress resulting from the hectic ED/inpatient stay. If our hypothesis is correct -- that rapid ED discharge and outpatient follow-up reduces PTSD symptoms and improves clinical outcomes in TIAMS survivors-- the results of our study will impact clinical guidelines immediately. Furthermore, the study will have broader implications for the clinical calculus of ED care versus outpatient follow-up for many other diseases, such as acute coronary syndrome, traditionally managed with prolonged ED observation and inpatient care.
|
0.957 |
2020 — 2021 |
Chang, Bernard P. Shechter, Ari |
R01Activity Code Description: To support a discrete, specified, circumscribed project to be performed by the named investigator(s) in an area representing his or her specific interest and competencies. |
The Identification of Modifiable Emergency Department and Sleep Factors Contributing to Psychological and Cardiovascular Risk in Clinicians @ Columbia University Health Sciences
Emergency department (ED) overcrowding was declared a ?crisis? by the Institute of Medicine 10 years ago, and EDs have become more crowded since. Patients treated in overcrowded EDs are at increased risk for subsequent cardiovascular disease (CVD) and psychiatric disorder, largely due to increases in patients? psychological stress during their acute care stay. While the association of ED stressors with patient CVD and psychological outcomes is established, little work has explored the impact of ED environmental factors on the nurses and doctors who spend years exposed to stressful and frequently overcrowded EDs?often after poor sleep due to shift-work. This study will test whether modifiable ED factors and/or short sleep increase ambulatory blood pressure (ABP) and psychological risk in ED clinicians Whereas 45% of the 1 million physicians in the U.S. report symptoms of burnout, an astonishing 70% of ED providers report burnout symptoms (i.e., emotional exhaustion, depersonalization, and reduced personal accomplishment). There is evidence that aspects of acute care work (crowding, acute and chronic stress, shift work) may contribute to burnout risk, which is related to worse patient care and more medical errors, and is also an independent risk factor for CVD. Burnout is associated with 37% increased risk for coronary heart disease (CHD) events, independent of age, body mass index, smoking, and lipid levels. Proposed physiological mechanisms for the association of burnout with CVD include autonomic dysregulation and increased blood pressure. Similarly, recent meta-analyses have shown short sleep (<6 hours) is associated with incident CHD risk (RR=1.26), likely through similar pathways. Circadian misalignment, another consequence of shift work common in ED providers, also increases CVD risk. We will test the influence of ED factors, sleep, and circadian misalignment on ABP (a primary marker of CVD risk) and burnout in an innovative study design, leveraging our expertise in ED research, behavioral cardiology, and sleep. We will prospectively follow a cohort of ED physicians and nurses for 3 years, testing the hypothesis that ED work factors (e.g. ED overcrowding, short sleep, and circadian misalignment due to shift work), increase burnout and contribute to increased ABP. We will continually capture ED data on patient volume, acuity, and staffing. Annually, participants will complete a 2-week burst, monitoring sleep duration, circadian misalignment, and work-related stress. During each burst, we will assess burnout, job strain, and 24-hour ABP. This design will allow us to: 1) evaluate the short-term contribution of ED crowding, circadian misalignment, and short sleep to acute changes in ABP and psychological risk 2) characterize the relationship of cumulative ED stress exposures and sleep impairment to 3-year progression of CVD and psychological risk.
|
0.957 |