Psychosocial evaluation predicts readmission risk for LVAD patients

A tool designed to assess the psychosocial status of heart transplant candidates may also be able to predict which left ventricular assist device (LVAD) recipients are at the highest risk of being readmitted to the hospital, Cleveland Clinic researchers reported Jan. 9 in Circulation: Heart Failure.

Guidelines recommend a psychosocial assessment of patients being considered for advanced cardiac therapies including transplantation and LVAD implantation as part of a larger, multidisciplinary examination. But individual institutions are left to their own discretion in terms of exactly how to evaluate a candidate’s psychosocial status.

Brett W. Sperry, MD, and colleagues sought to test the utility of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) in a cohort of LVAD patients. The SIPAT had previously been associated with negative outcomes after transplantation in patients receiving a new heart, but hadn’t been evaluated in LVAD candidates.

The study included 128 patients implanted with a first LVAD at Cleveland Clinic from 2013 to 2017 who were evaluated with the SIPAT before their operation. Higher SIPAT scores weren’t significantly associated with mortality or the time to a patient’s first rehospitalization, but each 10-point increase in the SIPAT score was linked to a 31 percent jump in adverse events including death, device exchange or hospitalization.

Most of these adverse events (291 out of 319) came in the form of readmission, with each patient averaging 2.5 events over a median follow-up of 349 days. Candidates deemed at marginal or high psychosocial risk based on their SIPAT results averaged about seven readmissions per patient at two years post-implantation, while good or excellent candidates averaged a shade above four readmissions at two years.

“These data suggest that a quantitative assessment with the SIPAT score may be helpful to clinicians to identify patients at high risk for adverse cardiac events after LVAD implantation,” Sperry et al. wrote. “The SIPAT scoring system may be useful to enhance psychosocial care in high-risk patients and mitigate potential barriers to a successful post-LVAD outcome.”

The SIPAT score features 20 components related to four specific areas, which were adapted to be related to LVADs instead of transplants when questions explicitly mentioned transplantation. Score ranges then indicate whether a patient should be considered an excellent candidate, a good candidate, a minimally acceptable candidate or a high-risk candidate for the therapy.

When adapted to LVAD suitability, the score is designed to quantify each patient’s:

  1. Readiness for an LVAD—includes understanding of the illness and the device, along with a willingness to be treated and comply with the therapy.
  2. Social support system—includes the availability and functionality of a patient’s support system, along with the appropriateness of their physical living space.
  3. Psychological stability and psychopathology—evaluates the risk or presence of psychopathology, assesses anxiety and depression and examines personality traits or disorders, along with signs of truthful versus deceptive behavior.
  4. Lifestyle and effect of substance abuse—assesses a patient’s use, abuse or dependence on alcohol, nicotine and other substances, along with the risk of relapse.

The researchers said the SIPAT is now built into their electronic medical record and takes a trained staff member about five minutes to complete. They advocated for repeat assessments with the tool, particularly when changes are noticed within patients.

“It is our institutional practice to repeat a SIPAT score when there has been a change in psychosocial status,” Sperry and colleagues wrote. “A positive change may be identification of additional supports, abstinence from drugs or alcohol, or completion of a substance abuse program. Negative changes may be resuming substance abuse, missed appointments, or medication noncompliance.”

In a related editorial, Eric D. Adler, MD, noted LVAD patients and their caretakers must be especially vigilant in monitoring their devices and drug regimens, which makes their psychosocial status even more important in determining the benefits of the therapy. He predicted further tailoring the SIPAT score to LVAD patients rather than transplant candidates could lead to it being more predictive of adverse events.

“There are fundamental differences in psychosocial requirements for LVAD patients and transplant patients,” wrote Adler, with the University of California, San Diego. “For example, it seems likely that a modified score including an objective assessment of the patient and caregiver’s comprehension of the LVAD would improve the ability of the test to predict readmissions.”

On an individual patient basis, both Sperry et al. and Adler suggested the SIPAT be used simply as one tool in psychosocial assessment. Other contextual factors are also necessary to determine a patient’s suitability for advanced heart treatments.

“Ultimately, the best use of the SIPAT may be as a quality metric for a program to gauge globally the degree of psychosocial risk they are taking,” Adler wrote.