Value of psychosocial evaluation for left ventricular assist device candidates

Abstract

Objective: Left ventricular assist devices require a psychosocial assessment to determine candidacy despite limited data correlating with outcome. Our objective is to determine whether the Stanford Integrated Psychosocial Assessment for Transplant, a tool validated for transplant and widely used by left ventricular assist device programs, predicts left ventricular assist device program hospital readmissions and death.

Methods: We performed a retrospective analysis of adults at the Cleveland Clinic with Stanford Integrated Psychosocial Assessment for Transplant scores before primary left ventricular assist device program implantation from April 1, 2013, to December 31, 2018. The primary outcome was unplanned hospital readmissions censored at death, transplantation, and transfer of care. The secondary outcome was death.

Results: There were 263 patients in the left ventricular assist device program with a median (Q1, Q3) Stanford Integrated Psychosocial Assessment for Transplant score of 16 (8, 28). During a median follow-up 1.2 years, 56 died, 65 underwent transplantation, and 21 had transferred care. There were 640 unplanned hospital readmissions among 250 patients with at least 1 outpatient visit at our center. In a multivariable analysis, Stanford Integrated Psychosocial Assessment for Transplant components but not total Stanford Integrated Psychosocial Assessment for Transplant score was associated with readmissions. Psychopathology (Stanford Integrated Psychosocial Assessment for Transplant C-IX) was associated with hemocompatibility (coefficient 0.21 ± standard error 0.11, P = .040) and cardiac (0.15 ± 0.065, P = .02) readmissions. Patient readiness was associated with noncardiac (Stanford Integrated Psychosocial Assessment for Transplant A-III, 0.24 ± 0.099, P = .016) and cardiac (Stanford Integrated Psychosocial Assessment for Transplant A-low total, 0.037 ± 0.014, P = .007) readmissions. Poor living environment (Stanford Integrated Psychosocial Assessment for Transplant B-VIII) was associated with device-related readmissions (0.83 ± 0.34, P = .014). Death was associated with organic psychopathology or neurocognitive impairment (Stanford Integrated Psychosocial Assessment for Transplant C-X, 0.59 ± 0.21, P = .006).

Conclusions: Total Stanford Integrated Psychosocial Assessment for Transplant score was not associated with left ventricular assist device program readmission or mortality. However, we identified certain Stanford Integrated Psychosocial Assessment for Transplant components that were associated with outcome and could be used to create a left ventricular assist device program specific psychosocial tool.

Keywords: SIPAT; heart transplantation; hospital readmissions; mechanical circulatory support; outcome assessment.

FIGURE E1.

SIPAT availability. SIPAT, Stanford Integrated Psychosocial Assessment for Transplant.

FIGURE E2.

Cohort. MCS, Mechanical circulatory support; SIPAT, Stanford Integrated Psychosocial Assessment for Transplant; TAH, total artificial heart;LVAD, left ventricular assist device.

FIGURE E3.

SIPAT, LVAD, and unplanned readmissions among SIPAT cohort and those excluded due to no SIPAT score. Cumulative number of unplanned readmissions. Each dot represents an event positioned on the vertical axis by Nelson estimator. Vertical lines are asymmetric 68% confidence limits. SIPAT, Stanford Integrated Psychosocial Assessment for Transplant.

FIGURE E4.

Competing risks. Nonparametric estimates for transplant, transfer, and death on after LVAD implant. Each symbol represents an outcome, and the vertical lines are 68% confidence limits. Table below shows patients still at risk and alive on LVAD. LVAD, Left ventricular assist device.

FIGURE E5.

Risk of death. There were 2 phases of mortality: early perioperative phase and constant phase. LVAD, Left ventricular assist device.

FIGURE 1.

SIPAT domains and scores. Each SIPAT item is listed with point range and grouped by domain. Items with greater point values were found by SIPAT developers to incur greater risk. Patients receive a score for each individual item, which are then summed to calculate the overall score for each patient. Lower scores indicate lower-risk candidates. SIPAT, Stanford Integrated Psychosocial Assessment for Transplant; LVAD, left ventricular assist device.

FIGURE 2.

Unplanned hospital readmissions. Nonparametric estimates: cumulative number of cardiac-related, device-related, noncardiac, and hemocompatibility readmissions. Each dot represents an event positioned on the vertical axis by Nelson estimator, and vertical lines are asymmetric 68% confidence limits. Table below is patient at risk of readmission.

FIGURE 3.

Risk of unplanned readmissions. Instantaneous risk of cardiac-, device-related, noncardiac, and hemocompatibility readmission (solid line).

FIGURE 4.

Value of SIPAT domains for LVAD candidates. The SIPAT, a psychosocial tool validated for transplantation, is widely used to evaluate LVAD patients but has not been shown to predict outcome. We included 263 adult patients who had a SIPAT score before implantation of a primary durable LVAD and found that SIPAT components predicted unplanned hospital readmissions, making it useful for patients with advanced heart failure. SIPAT, Stanford Integrated Psychosocial Assessment for Transplant; LVAD, left ventricular assist device; MCS, mechanical circulatory support; TAH, total artificial heart.