This career development award will establish Dr. Oanh Nguyen as a clinician-investigator focused on designing, implementing, and evaluating transitional care interventions to improve health outcomes for vulnerable patients with cardiovascular illness. This award will provide support needed to develop her expertise in: 1) advanced methods in patient-centered outcomes research (PCOR); 2) social determinants of health; and 3) intervention development, implementation, and evaluation in real-world health settings. To achieve these goals, Dr. Nguyen has assembled an expert mentorship team. Her primary mentor, Ethan Halm, MD, MPH, has extensive experience in health services research, PCOR, predictive modeling, intervention development, and training and mentoring faculty. Her co-mentor, Simon Lee, PhD is a medical anthropologist with expertise in qualitative methods, PCOR, and implementation science. Additional scientific advisors include Song Zhang, PhD, an expert in advanced biostatistics and predictive modeling techniques; and Sandeep Das, MD, an expert in implementation and evaluation of evidence-based cardiovascular care delivery interventions. Readmission within 30 days of hospitalization occurs in up to 1 in 5 adults, and patients with congestive heart failure (CHF) and ischemic heart disease (IHD) are among those at highest risk. Despite federal financial `readmissions penalties' for cardiovascular and other conditions, the most effective strategy to prevent readmissions remains unknown. Current interventions focus on improving medical care processes, but do not address deeper social vulnerabilities such as food and housing insecurity or behavioral health needs associated with higher readmission risk. Informed by her clinical experience and preliminary studies, Dr. Nguyen will conduct a series of studies to: 1) develop predictive models to identify hospitalized patients with CHF and IHD at high risk for readmission, and to stratify individuals by medical severity and social vulnerabilities (Aim 1); 2) conduct qualitative interviews of high-risk patients to understand patient perspectives on how social vulnerabilities affect medical recovery from CHF and IHD, and on the acceptability of community- based interventions to address these vulnerabilities (Aim 2); and 3) develop, pilot, and assess the feasibility of a transitional care intervention enhanced to address social vulnerabilities in addition to traditional medical needs (Aim 3), incorporating an innovative social-health information exchange (Dallas Information Exchange Portal). This research plan leverages existing institutional resources, including Dr. Halm's AHRQ-funded UT Southwestern (UTSW) Center for PCOR; the UTSW CTSA; and novel information technology. This training and research will form the basis for an R01 application for a fully powered randomized controlled trial to assess the impact of a risk-stratified readmission prevention strategy that addresses both social and medical vulnerabilities to prevent readmissions and improve health outcomes in CHF and IHD.

Public Health Relevance

Readmission within 30 days of hospitalization occurs in up to 1 in 5 adults, and patients with congestive heart failure and ischemic heart disease are among those at the highest risk for readmission. Social vulnerabilities such as housing, food, and economic insecurity, and social isolation, are associated with higher readmission risk but health systems are currently poorly equipped to recognize or address these vulnerabilities. This project focuses on: 1) developing an automated, computerized approach to identifying individuals at high risk for readmission due to social vulnerabilities; 2) understanding patient perceptions on the impact of social vulnerabilities on readmissions and cardiovascular disease, and the acceptability of community-based interventions to address these vulnerabilities; and 3) implementing and evaluating an enhanced evidence-based transitional care strategy for high risk patients that leverages existing community- based resources via a novel social-health information exchange to address social vulnerabilities and improve care for adults with cardiovascular illness.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Mentored Patient-Oriented Research Career Development Award (K23)
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NHLBI Mentored Patient-Oriented Research Review Committee (MPOR)
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Campo, Rebecca A
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University of California San Francisco
Internal Medicine/Medicine
Schools of Medicine
San Francisco
United States
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Makam, Anil N; Nguyen, Oanh Kieu; Xuan, Lei et al. (2018) Long-Term Acute Care Hospital Use of Non-Mechanically Ventilated Hospitalized Older Adults. J Am Geriatr Soc 66:2112-2119
Smith, Lauren N; Makam, Anil N; Darden, Douglas et al. (2018) Acute Myocardial Infarction Readmission Risk Prediction Models: A Systematic Review of Model Performance. Circ Cardiovasc Qual Outcomes 11:e003885