Current Issue
September 2023
Vol 16, Issue 9
Vol 16, Issue 9
Author
- Krumholz, Harlan M87
- Spertus, John A66
- Nallamothu, Brahmajee K54
- Fonarow, Gregg C53
- Peterson, Eric D52
- Cohen, David J32
- Chan, Paul S30
- Ho, P Michael29
- Yeh, Robert W28
- Hernandez, Adrian F27
- Bhatt, Deepak L25
- Masoudi, Frederick A25
- Wang, Tracy Y25
- Heidenreich, Paul A24
- Schwamm, Lee H24
- Arnold, Suzanne V22
- Normand, Sharon-Lise T22
- Bradley, Steven M20
- Maddox, Thomas M20
- Wasfy, Jason H20
- Jones, Philip G19
- Ko, Dennis T19
- Reeves, Mathew J18
- Rumsfeld, John S18
- Xian, Ying18
Export Citation
-
Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach
- Kori S. Zachrison,
- Renee Y. Hsia,
- Lee H. Schwamm,
- Zhiyu Yan,
- Margaret E. Samuels-Kalow,
- Mathew J. Reeves,
- Carlos A. Camargo and
- Jukka-Pekka Onnela
AbstractPDF/EPUBAbstract
Background:Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer.Methods:This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center.Results:Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22–0.26] and 0.59 [95% CI, 0.50–0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23–0.29] and odds ratio, 0.49 [95% CI, 0.38–0.62], uninsured odds ratio, 0.75 [95% CI, 0.63–0.89], and 0.72 [95% CI, 0.6–0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer.Conclusions:Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster. -
Psychosocial Stressors at Work and Coronary Heart Disease Risk in Men and Women: 18-Year Prospective Cohort Study of Combined Exposures
- Mathilde Lavigne-Robichaud,
- Xavier Trudel,
- Denis Talbot,
- Alain Milot,
- Mahée Gilbert-Ouimet,
- Michel Vézina,
- Danielle Laurin,
- Clermont E. Dionne,
- Neil Pearce,
- Gilles R. Dagenais and
- Chantal Brisson
AbstractPDF/EPUBAbstract
Background.Psychosocial stressors at work, like job strain and effort-reward imbalance (ERI), can increase coronary heart disease (CHD) risk. ERI indicates an imbalance between the effort and received rewards. Evidence about the adverse effect of combined exposure to these work stressors on CHD risk is scarce. This study examines the separate and combined effect of job strain and ERI exposure on CHD incidence in a prospective cohort of white-collar workers in Quebec, Canada.Methods.Six thousand four hundred sixty-five white-collar workers without cardiovascular disease (mean age, 45.3±6.7) were followed for 18 years (from 2000 to 2018). Job strain and ERI were measured with validated questionnaires. CHD events were retrieved from medico-administrative databases using validated algorithms. Marginal Cox models were used to calculate hazard ratios (HR) stratified by sex. Multiple imputation and inverse probability weights were applied to minimize potential threats to internal validity.Results.Among 3118 men, 571 had a first CHD event. Exposure to either job strain or ERI was associated with an adjusted 49% CHD risk increase (HR, 1.49 [95% CI, 1.07–2.09]). Combined exposure to job strain and ERI was associated with an adjusted 103% CHD risk increase (HR, 2.03 [95% CI, 1.38–2.97]). Exclusion of early CHD cases and censoring at retirement did not alter these associations. Among 3347 women, 265 had a first CHD event. Findings were inconclusive (passive job HR, 1.24 [95% CI, 0.80–1.91]; active job HR, 1.16 [95% CI, 0.70–1.94]; job strain HR, 1.08 [95% CI, 0.66–1.77]; ERI HR, 1.02 [95% CI, 0.72–1.45]).Conclusions.In this prospective cohort study, men exposed to job strain or ERI, separately and in combination, were at increased risk of CHD. Early interventions on these psychosocial stressors at work in men may be effective prevention strategies to reduce CHD burden. Among women, further investigation is required. -
Determinants and Outcomes Associated With Skilled Nursing Facility Use After Coronary Artery Bypass Grafting: A Statewide Experience
- Michael P. Thompson,
- James W. Stewart,
- Hechuan Hou,
- Hari Nathan,
- Francis D. Pagani,
- Alphonse DeLucia,
- Patricia F. Theurer,
- Richard L. Prager,
- Robert B. Hawkins and
- Donald S. Likosky
AbstractPDF/EPUBAbstract
BACKGROUND:Skilled nursing facility (SNF) care is frequently used after cardiac surgery, but the patterns and determinants of use have not been well understood. The objective of this study was to evaluate determinants and outcomes associated with SNF use after isolated coronary artery bypass grafting.METHODS:A retrospective analysis of Medicare Fee-For-Service claims linked to the Society of Thoracic Surgeons clinical data was conducted on isolated coronary artery bypass grafting patients without prior SNF use in Michigan between 2011 and 2019. Descriptive analysis evaluated the frequency, trends, and variation in SNF use across 33 Michigan hospitals. Multivariable mixed-effects regression was used to evaluate patient-level demographic and clinical determinants of SNF use and its effect on short- and long-term outcomes.RESULTS:In our sample of 8614 patients, the average age was 73.3 years, 70.5% were male, and 7.7% were listed as non-White race. An SNF was utilized by 1920 (22.3%) patients within 90 days of discharge and varied from 3.2% to 58.3% across the 33 hospitals. Patients using SNFs were more likely to be female, older, non-White, with more comorbidities, worse cardiovascular function, a perioperative morbidity, and longer hospital lengths of stay. Outcomes were significantly worse for SNF users, including more frequent 90-day readmissions and emergency department visits and less use of home health and rehabilitation services. SNF users had higher risk-adjusted hazard of mortality (hazard ratio, 1.41 [95% CI, 1.26–1.57]; P<0.001) compared with non-SNF users and had 2.7-percentage point higher 5-year mortality rate in a propensity-matched cohort of patients (18.1% versus 15.4%; P<0.001).CONCLUSIONS:The use of SNF care after isolated coronary artery bypass grafting was frequent and variable across Michigan hospitals and associated with worse risk-adjusted outcomes. Standardization of criteria for SNF use may reduce variability among hospitals and ensure appropriateness of use. -
Global Cardio Oncology Registry (G-COR): Registry Design, Primary Objectives, and Future Perspectives of a Multicenter Global Initiative
- Arco J. Teske,
- Rohit Moudgil,
- Teresa López-Fernández,
- Ana Barac,
- Sherry Ann Brown,
- Anita Deswal,
- Tomas G. Neilan,
- Sarju Ganatra,
- Husam Abdel Qadir,
- Venu Menon,
- Aaron L. Sverdlov,
- Richard K. Cheng,
- Silvia Makhoul,
- Arjun K. Ghosh,
- Sebastian Szmit,
- Vlad Zaha,
- Daniel Addison,
- Lili Zhang,
- Joerg Herrmann,
- Jun H. Chong,
- Vivek Agarwala,
- Zaza Iakobishvili,
- Patricia Guerrero,
- Eric H. Yang,
- Monika Leja,
- Nausheen Akhter,
- Avirup Guha,
- Tochukwu M. Okwuosa,
- Carolina Carvalho Silva,
- Patrick Collier,
- Jeanne DeCara,
- Brenton Bauer,
- Carrie E. Lenneman and
- Diego Sadler
AbstractPDF/EPUBAbstract
BACKGROUND:Global collaboration in cardio-oncology is needed to understand the prevalence of cancer therapy-related cardiovascular toxicity in different risk groups, practice settings, and geographic locations. There are limited data on the socioeconomic and racial/ethnic disparities that may impact access to care and outcomes. To address these gaps, we established the Global Cardio-Oncology Registry, a multinational, multicenter prospective registry.METHODS:We assembled cardiologists and oncologists from academic and community settings to collaborate in the first Global Cardio-Oncology Registry. Subsequently, a survey for site resources, demographics, and intention to participate was conducted. We designed an online data platform to facilitate this global initiative.RESULTS:A total of 119 sites responded to an online questionnaire on their practices and main goals of the registry: 49 US sites from 23 states and 70 international sites from 5 continents indicated a willingness to participate in the Global Cardio-Oncology Registry. Sites were more commonly led by cardiologists (85/119; 72%) and were more often university/teaching (81/119; 68%) than community based (38/119; 32%). The average number of cardio-oncology patients treated per month was 80 per site. The top 3 Global Cardio-Oncology Registry priorities in cardio-oncology care were breast cancer, hematologic malignancies, and patients treated with immune checkpoint inhibitors. Executive and scientific committees and specific committees were established. A pilot phase for breast cancer using Research Electronic Data Capture Cloud platform recently started patient enrollment.CONCLUSIONS:We present the structure for a global collaboration. Information derived from the Global Cardio-Oncology Registry will help understand the risk factors impacting cancer therapy-related cardiovascular toxicity in different geographic locations and therefore contribute to reduce access gaps in cardio-oncology care. Risk calculators will be prospectively derived and validated. -
Impact of Produce Prescriptions on Diet, Food Security, and Cardiometabolic Health Outcomes: A Multisite Evaluation of 9 Produce Prescription Programs in the United States
- Kurt Hager,
- Mengxi Du,
- Zhongyu Li,
- Dariush Mozaffarian,
- Kenneth Chui,
- Peilin Shi,
- Brent Ling,
- Sean B. Cash,
- Sara C. Folta and
- Fang Fang Zhang
AbstractPDF/EPUBAbstract
BACKGROUND:Produce prescriptions may improve cardiometabolic health by increasing fruit and vegetable (F&V) consumption and food insecurity yet impacts on clinical outcomes and health status have not been evaluated in large, multisite evaluations.METHODS:This multisite, pre- and post-evaluation used individual-level data from 22 produce prescription locations in 12 US states from 2014 to 2020. No programs were previously evaluated. The study included 3881 individuals (2064 adults aged 18+ years and 1817 children aged 2–17 years) with, or at risk for, poor cardiometabolic health recruited from clinics serving low-income neighborhoods. Programs provided financial incentives to purchase F&V at grocery stores or farmers markets (median, $63/months; duration, 4–10 months). Surveys assessed F&V intake, food security, and self-reported health; glycated hemoglobin, blood pressure, body mass index (BMI), and BMI z-score were measured at clinics. Adjusted, multilevel mixed models accounted for clustering by program.RESULTS:After a median participation of 6.0 months, F&V intake increased by 0.85 (95% CI, 0.68–1.02) and 0.26 (95% CI, 0.06–0.45) cups per day among adults and children, respectively. The odds of being food insecure dropped by one-third (odds ratio, 0.63 [0.52–0.76]) and odds of improving 1 level in self-reported health status increased for adults (odds ratio, 1.62 [1.30–2.02]) and children (odds ratio, 2.37 [1.70–3.31]). Among adults with glycated hemoglobin ≥6.5%, glycated hemoglobin declined by −0.29% age points (−0.42 to −0.16); among adults with hypertension, systolic and diastolic blood pressures declined by −8.38 mm Hg (−10.13 to −6.62) and −4.94 mm Hg (−5.96 to −3.92); and among adults with overweight or obesity, BMI decreased by −0.36 kg/m2 (−0.64 to −0.09). Child BMI z-score did not change −0.01 (−0.06 to 0.04).CONCLUSIONS:In this large, multisite evaluation, produce prescriptions were associated with significant improvements in F&V intake, food security, and health status for adults and children, and clinically relevant improvements in glycated hemoglobin, blood pressure, and BMI for adults with poor cardiometabolic health. -
Toward a Roadmap for Best Practices in Pediatric Preventive Cardiology: A Science Advisory From the American Heart Association
- Amanda M. Perak,
- Carissa Baker-Smith,
- Laura L. Hayman,
- Michael Khoury,
- Amy L. Peterson,
- Adam L. Ware,
- Justin P. Zachariah,
- Geetha Raghuveer and
- on behalf of the American Heart Association Council on Hypertension; Council on Cardiovascular and Stroke Nursing; Council on Lifelong Congenital Heart Disease and Heart Health in the Young
AbstractPDF/EPUBAbstract
Cardiovascular disease risk factors are highly prevalent among youth in the United States and Canada. Pediatric preventive cardiology programs have independently developed and proliferated to address cardiovascular risk factors in youth, but there is a general lack of clarity on best practices to optimize and sustain desired outcomes. We conducted surveys of pediatric cardiology division directors and pediatric preventive cardiology clinicians across the United States and Canada to describe the current landscape and perspectives on future directions for the field. We summarize the data and conclude with a call to action for various audiences who seek to improve cardiovascular health in youth, reduce the burden of premature cardiovascular disease, and increase healthy longevity. We call on heart centers, hospitals, payers, and policymakers to invest resources in the important work of pediatric preventive cardiology programs. We urge professional societies to advocate for pediatric preventive cardiology and provide opportunities for training and cross-pollination across programs. We encourage researchers to close evidence gaps. Last, we invite pediatric preventive cardiology clinicians to collaborate and innovate to advance the practice of pediatric preventive cardiology. -
Association Between Prenatal Diagnosis and Age at Surgery for Noncritical and Critical Congenital Heart Defects
- Joyce L. Woo,
- Christina Laternser,
- Brett R. Anderson,
- William A. Grobman,
- Michael C. Monge and
- Matthew M. Davis
AbstractPDF/EPUBAbstract
BACKGROUND:The relationship between the prenatal diagnosis of congenital heart defects (CHDs) and age at CHD surgery is poorly understood, despite the known relationships between age at surgery and long-term outcomes. The objective of this study was to determine the associations between prenatal diagnosis of CHD and age at surgery, and whether these associations differ for critical and noncritical CHDs.METHODS:This is a cohort analysis of patients aged 0 to 9 years who received their initial cardiac surgery at Ann & Robert H. Lurie Children’s Hospital of Chicago between 2015 and 2021 with prenatal diagnosis as the exposure variable. All data were obtained from the locally maintained Society of Thoracic Surgeons Congenital Heart Surgery Database at Lurie Children’s Hospital. We used multivariable fixed effects regression models to estimate the strength of the association of prenatal diagnosis with age at surgery among patients with critical (surgery ≤60 days) and noncritical (surgery >60 days) CHDs.RESULTS:Of 1131 individuals who met inclusion criteria, 532 (47%) had a prenatal diagnosis, 428 (38%) had critical CHDs, 533 (47%) were female, and the median age at surgery was 119 days (interquartile range, 11–309 days). After controlling for demographics, comorbidities, and surgical complexity, the mean age at surgery was significantly younger in those with prenatally versus postnatally diagnosed critical CHD (7.1 days sooner, P<0.001) and noncritical CHDs (atrial septal defects [12.4 months sooner, P=0.037], ventricular septal defects [6.0 months sooner, P<0.003], and noncritical coarctation of the aorta [1.8 months sooner, P=0.010]).CONCLUSIONS:Younger age at CHD surgery, which is associated with postsurgical neurodevelopmental and physical outcomes, is significantly associated with prenatal CHD diagnosis. This relationship was identified for both critical and noncritical CHDs. -
Family Engagement in the Adult Cardiac Intensive Care Unit: A Survey of Family Engagement Practices in the Cardiac Critical Care Trials Network
- Michael Goldfarb,
- Carlos Alviar,
- David Berg,
- Jason Katz,
- Ran Lee,
- Shuangbo Liu,
- Theresa Maitz,
- Mitchell Padkins,
- Rajnish Prasad,
- Robert Roswell,
- Kevin Shah,
- Andrea Thompson,
- Sean van Diepen,
- Sammy Zakaria and
- David Morrow
AbstractPDF/EPUBAbstract
BACKGROUND:Cardiovascular and critical care professional societies recommend incorporating family engagement practices into routine clinical care. However, little is known about current family engagement practices in contemporary cardiac intensive care units (CICUs).METHODS:We implemented a validated 12-item family engagement practice survey among site investigators participating in the Critical Care Cardiology Trials Network, a collaborative network of CICUs in North America. The survey includes 9 items assessing specific engagement practices, 1 item about other family-centered care practices, and 2 open-ended questions on strategies and barriers concerning family engagement practice. We developed an engagement practice score by assigning 1 point for each family engagement practice partially or fully adopted at each site (max score 9). We assessed for relationships between the engagement practice score and CICU demographics.RESULTS:All sites (N=39; 100%) completed the survey. The most common family engagement practices were open visitation (95%), information and support to families (85%), structured care conferences (n=82%), and family participation in rounds (77%). The median engagement practice score was 5 (interquartile range, 4). There were no differences in engagement practice scores by geographic region or CICU type. The most commonly used strategies to promote family engagement were family presence during rounds (41%), communication (28%), and family meetings (28%). The most common barriers to family engagement were COVID-related visitation policies (38%) and resource limitations (13%).CONCLUSIONS:Family engagement practices are routinely performed in many CICUs; however, considerable variability exists. There is a need for strategies to address the variability of family engagement practices in CICUs. -
2023 AHA/ACC Clinical Performance and Quality Measures for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Performance Measures
-
Implementation of an Atrial Fibrillation Decision Aid Care Pathway in the Emergency Department Reduces Atrial Fibrillation Hospitalizations
- Anil K. Gehi,
- Tiffany Armbruster,
- Jennifer Walker,
- Lindsey Rosman,
- Jeffrey Laux,
- Ari Becker,
- Oludamilola Aladesanmi,
- Anthony J. Mazzella,
- Zachariah Deyo and
- Kevin Biese
AbstractPDF/EPUBAbstract
BACKGROUND:A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied.METHODS:A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level.RESULTS:Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71–0.97]; P=0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26–2.31]; P<0.001).CONCLUSIONS:We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations. -
Patients’ Perspectives Regarding Generator Exchanges of Implantable Cardioverter Defibrillators
- Sarah C. Montembeau,
- Faisal M. Merchant,
- Candace Speight,
- Daniel B. Kramer,
- Daniel D. Matlock,
- Michal Horný,
- Neal W. Dickert and
- Birju R. Rao
AbstractPDF/EPUBAbstract
BACKGROUND:Shared decision-making is mandated for patients receiving primary prevention implantable cardioverter defibrillators (ICDs). Less attention has been paid to generator exchange decisions, although at the time of generator exchange, patients’ risk of sudden cardiac death, risk of procedural complications, quality of life, or prognosis may have changed. This study was designed to explore how patients make ICD generator exchange decisions.METHODS:Emory Healthcare patients with primary prevention ICDs implanted from 2013 to 2021 were recruited to complete in-depth interviews exploring perspectives regarding generator exchanges. Interviews were conducted in 2021. Transcribed interviews were qualitatively coded using multilevel template analytic methods. To investigate benefit thresholds for pursuing generator exchanges, patients were presented standard-gamble type hypothetical scenarios where their ICD battery was depleted but their 5-year risk of sudden cardiac death at that time varied (10%, 5%, and 1%).RESULTS:Fifty patients were interviewed; 18 had a prior generator exchange, 16 had received ICD therapy, and 17 had improved left ventricular ejection fraction. As sudden cardiac death risk decreased from 10% to 5% to 1%, the number of participants willing to undergo a generator exchange decreased from 48 to 42 to 33, respectively. Responses suggest that doctor’s recommendations are likely to substantially impact patients’ decision-making. Other drivers of decision-making included past experiences with ICD therapy and device implantation, as well as risk aversion. Therapeutic inertia and misconceptions about ICD therapy were common and represent substantive barriers to effective shared decision-making in this context.CONCLUSIONS:Strong defaults may exist to continue therapy and exchange ICD generators. Updated risk stratification may facilitate shared decision-making and reduce generator exchanges in very low-risk patients, especially if these interventions are directed toward clinicians. Interventions targeting phenomena such as therapeutic inertia may be more impactful and warrant exploration in randomized trials. -
Comparison of Hospital Performance in Acute Ischemic Stroke Based on Mortality and Functional Outcome in South Korea
- Bosco Seong Kyu Yang,
- Minuk Jang,
- Keon-Joo Lee,
- Beom Joon Kim,
- Moon-Ku Han,
- Joon-Tae Kim,
- Kang-Ho Choi,
- Jae-Kwan Cha,
- Dae-Hyun Kim,
- Dong-Eog Kim,
- Wi-Sun Ryu,
- Jong-Moo Park,
- Kyusik Kang,
- Soo Joo Lee,
- Jae Guk Kim,
- Mi-Sun Oh,
- Kyung-Ho Yu,
- Byung-Chul Lee,
- Keun-Sik Hong,
- Yong-Jin Cho,
- Jay Chol Choi,
- Tai Hwan Park,
- Kyung Bok Lee,
- Jee-Hyun Kwon,
- Wook-Joo Kim,
- Sung Il Sohn,
- Jeong-Ho Hong,
- Jun Lee,
- Sang-Hwa Lee,
- Ji Sung Lee,
- Juneyoung Lee,
- Philip B. Gorelick,
- Hee-Joon Bae and
- on the behalf of the CRCS-K (Clinical Research Collaboration for Stroke in Korea) investigators*
AbstractPDF/EPUBAbstract
BACKGROUND:Recent evidence suggests a correlation between modified Rankin Scale-based measures, an outcome measure commonly used in acute stroke trials, and mortality-based measures used by health agencies in the evaluation of hospital performance. We aimed to examine whether the 2 types of measures are interchangeable in relation to evaluation of hospital performance in acute ischemic stroke.METHODS:Five outcome measures, unfavorable functional outcome (3-month modified Rankin Scale score ≥2), death or dependency (3-month modified Rankin Scale score ≥3), 1-month mortality, 3-month mortality, and 1-year mortality, were collected for 8292 individuals who were hospitalized for acute ischemic stroke between January 2014 and May 2015 in 14 hospitals participating in the Clinical Research Collaboration for Stroke in Korea – National Institute of Health registry. Hierarchical regression models were used to calculate per-hospital risk-adjusted outcome rates for each measure. Hospitals were ranked and grouped based on the risk-adjusted outcome rates, and the correlations between the modified Rankin Scale-based and mortality-based ranking and their intermeasure reliability in categorizing hospital performance were analyzed.RESULTS:The comparison between the ranking based on the unfavorable functional outcome and that based on 1-year mortality resulted in a Spearman correlation coefficient of −0.29 and Kendall rank coefficient of −0.23, and the comparison of grouping based on these 2 types of ranks resulted in a weighted kappa of 0.123 for the grouping in the top 33%/middle 33%/bottom 33% and 0.25 for the grouping in the top 20%/middle 60%/bottom 20%, respectively. No significant correlation or similarity in grouping capacities were found between the rankings based on the functional outcome measures and those based on the mortality measures.CONCLUSIONS:This study shows that regardless of clinical correlation at an individual patient level, functional outcome-based measures and mortality-based measures are not interchangeable in the evaluation of hospital performance in acute ischemic stroke. -
Relationship Between In-Hospital Adverse Events and Hospital Performance on 30-Day All-cause Mortality and Readmission for Patients With Heart Failure
- Yun Wang,
- Noel Eldridge,
- Mark L. Metersky,
- David Rodrick,
- Sheila Eckenrode,
- Jasie Mathew,
- Deron H. Galusha,
- Andrea A. Peterson,
- David Hunt,
- Sharon-Lise T. Normand and
- Harlan M. Krumholz
AbstractPDF/EPUBAbstract
BACKGROUND:Hospitals with high mortality and readmission rates for patients with heart failure (HF) might also perform poorly in other quality concepts. We sought to evaluate the association between hospital performance on mortality and readmission with hospital performance rates of safety adverse events.METHODS:This cross-sectional study linked the 2009 to 2019 patient-level adverse events data from the Medicare Patient Safety Monitoring System, a randomly selected medical records-abstracted patient safety database, to the 2005 to 2016 hospital-level HF-specific 30-day all-cause mortality and readmissions data from the United States Centers for Medicare & Medicaid Services. Hospitals were classified to one of 3 performance categories based on their risk-standardized 30-day all-cause mortality and readmission rates: better (both in <25th percentile), worse (both >75th percentile), and average (otherwise). Our main outcome was the occurrence (yes/no) of one or more adverse events during hospitalization. A mixed-effect model was fit to assess the relationship between a patient's risk of having adverse events and hospital performance categories, adjusted for patient and hospital characteristics.RESULTS:The study included 39 597 patients with HF from 3108 hospitals, of which 252 hospitals (8.1%) and 215 (6.9%) were in the better and worse categories, respectively. The rate of patients with one or more adverse events during a hospitalization was 12.5% (95% CI, 12.1–12.8). Compared with patients admitted to better hospitals, patients admitted to worse hospitals had a higher risk of one or more hospital-acquired adverse events (adjusted risk ratio, 1.24 [95% CI, 1.06–1.44]).CONCLUSIONS:Patients admitted with HF to hospitals with high 30-day all-cause mortality and readmission rates had a higher risk of in-hospital adverse events. There may be common quality issues among these 3 measure concepts in these hospitals that produce poor performance for patients with HF. -
Disparities in 1-Year-Mortality in Infants With Cyanotic Congenital Heart Disease: Insights From Contemporary National Data
- Martina A. Steurer,
- Charles McCulloch,
- Stephanie Santana,
- James W. Collins,
- Tonia Branche,
- John M. Costello and
- Shabnam Peyvandi
AbstractPDF/EPUBAbstract
BACKGROUND:Racial inequities in congenital heart disease (CHD) outcomes are well documented, but contributing factors warrant further investigation. We examined the interplay between race, socioeconomic position, and neonatal variables (prematurity and small for gestational age) on 1-year death in infants with CHD. We hypothesize that socioeconomic position mediates a significant part of observed racial disparities in CHD outcomes.METHODS:Linked birth/death files from the Natality database for all liveborn neonates in the United States were examined from 2014 to 2018. Infants with cyanotic CHD were identified. Non-Hispanic Black (NHB) and Hispanic infants were compared with non-Hispanic White (NHW) infants. The primary outcome was 1-year death. Socioeconomic position was defined as maternal education and insurance status. Variables included as mediators were prematurity, small for gestational age, and socioeconomic position. Structural equation modeling was used to calculate the contribution of each mediator to the disparity in 1-year death.RESULTS:We identified 7167 NHW, 1393 NHB, and 1920 Hispanic infants with cyanotic CHD. NHB race and Hispanic ethnicity were associated with increased 1-year death compared to NHW (OR, 1.43 [95% CI, 1.25–1.64] and 1.17 [95% CI, 1.03–1.33], respectively). The effect of socioeconomic position explained 28.2% (CI, 15.1–54.8) of the death disparity between NHB and NHW race and 100% (CI, 42.0–368) of the disparity between Hispanic and NHW. This was mainly driven by maternal education (21.3% [CI, 12.1–43.3] and 82.8% [CI, 33.1–317.8], respectively) while insurance status alone did not explain a significant percentage. The direct effect of race or ethnicity became nonsignificant: NHB versus NHW 43.1% (CI, −0.3 to 63.6) and Hispanic versus NHW −19.0% (CI, −329.4 to 45.3).CONCLUSIONS:Less privileged socioeconomic position, especially lower maternal education, explains a large portion of the 1-year death disparity in Black and Hispanic infants with CHD. These findings identify targets for social interventions to decrease racial disparities. -
Impact of Neighborhood Social Deprivation on Health Care Costs Associated With TAVR
- Hasrit Sidhu,
- Feng Qiu,
- Ragavie Manoragavan,
- Dennis T. Ko,
- Mamas A Mamas,
- Maneesh Sud,
- Derrick Y. Tam and
- Harindra C. Wijeysundera
AbstractPDF/EPUBAbstract
BACKGROUND:Cumulative costs of transcatheter aortic valve replacement (TAVR) differ in the referral, procedural and postprocedural phases depending on patient comorbidities, type of procedure, and procedural complications. Our goal was to determine the association between neighborhood measures of social deprivation and TAVR costs in each of the 3 phases.METHODS:Demographics, patient comorbidities, procedural details, in-hospital complications, and costs for adults undergoing TAVR between 2017 and 2020 in Ontario, Canada were obtained from administrative databases and linked to social deprivation data using the Ontario Marginalization Index. The 3 dimensions of social deprivation assessed were (1) material deprivation, (2) residential instability, and (3) ethnic concentration. Hierarchical generalized linear models were used to determine the association between neighborhood social deprivation and cumulative TAVR costs, reported in 2018 Canadian dollars.RESULTS:We identified a total of 7617 TAVR referrals with 3784 patients undergoing TAVR within our study period. Cumulative mean costs in the referral, procedural and postprocedural phases were $8116±$11 374, $32 790±$17 766, and $18 901±$32 490, respectively. After adjustment for clinical and demographic variables, higher factor scores in residential instability were associated with greater cumulative costs in the postprocedural phase, whereas higher factor scores in the other 2 dimensions of marginalization were not significantly associated with higher costs in any of the 3 phases.CONCLUSIONS:This analysis shows that residential instability is associated with higher cumulative costs in the postprocedural phase of TAVR. This lays the foundation for future studies to understand the mechanism of this finding and identify potential mitigation policies. -
Impact of a Prior Cancer Diagnosis on Quality of Care and Survival Following Acute Myocardial Infarction: Retrospective Population-Based Cohort Study in England
- Lucy Teece,
- Michael J. Sweeting,
- Marlous Hall,
- Briana Coles,
- Clare Oliver-Williams,
- Cathy A. Welch,
- Mark A. de Belder,
- John Deanfield,
- Clive Weston,
- Mark J. Rutherford,
- Lizz Paley,
- Umesh T. Kadam,
- Paul C. Lambert,
- Michael D. Peake,
- Chris P. Gale,
- David Adlam and
- on behalf of the VICORI Collaborative
AbstractPDF/EPUBAbstract
Background:An increasing proportion of patients with cancer experience acute myocardial infarction (AMI). We investigated differences in quality of AMI care and survival between patients with and without previous cancer diagnoses.Methods:A retrospective cohort study using Virtual Cardio-Oncology Research Initiative data. Patients aged 40+ years hospitalized in England with AMI between January 2010 and March 2018 were assessed, ascertaining previous cancers diagnosed within 15 years. Multivariable regression was used to assess effects of cancer diagnosis, time, stage, and site on international quality indicators and mortality.Results:Of 512 388 patients with AMI (mean age, 69.3 years; 33.5% women), 42 187 (8.2%) had previous cancers. Patients with cancer had significantly lower use of ACE (angiotensin-converting enzyme) inhibitors/angiotensin receptor blockers (mean percentage point decrease [mppd], 2.6% [95% CI, 1.8–3.4]) and lower overall composite care (mppd, 1.2% [95% CI, 0.9–1.6]). Poorer quality indicator attainment was observed in patients with cancer diagnosed in the last year (mppd, 1.4% [95% CI, 1.8–1.0]), with later stage disease (mppd, 2.5% [95% CI, 3.3–1.4]), and with lung cancer (mppd, 2.2% [95% CI, 3.0–1.3]). Twelve-month all-cause survival was 90.5% in noncancer controls and 86.3% in adjusted counterfactual controls. Differences in post-AMI survival were driven by cancer-related deaths. Modeling improving quality indicator attainment to noncancer patient levels showed modest 12-month survival benefits (lung cancer, 0.6%; other cancers, 0.3%).Conclusions:Measures of quality of AMI care are poorer in patients with cancer, with lower use of secondary prevention medications. Findings are primarily driven by differences in age and comorbidities between cancer and noncancer populations and attenuated after adjustment. The largest impact was observed in recent cancer diagnoses (<1 year) and lung cancer. Further investigation will determine whether differences reflect appropriate management according to cancer prognosis or whether opportunities to improve AMI outcomes in patients with cancer exist. -
Trends of Concomitant Diabetes and Peripheral Artery Disease and Lower Extremity Amputation in US Medicare Patients, 2007 to 2019
- Xavier P. Fowler,
- Mark A. Eid,
- J. Aaron Barnes,
- Barbara Gladders,
- Andrea M. Austin,
- Eric J. Goodney,
- Kayla O. Moore,
- Stephen Kearing,
- Mark W. Feinberg,
- Marc P. Bonaca,
- Mark A. Creager and
- Philip P. Goodney
AbstractPDF/EPUBAbstract
Background:Previous studies demonstrate geographic and racial/ethnic variation in diagnosis and complications of diabetes and peripheral artery disease (PAD). However, recent trends for patients diagnosed with both PAD and diabetes are lacking. We assessed the period prevalence of concurrent diabetes and PAD across the United States from 2007 to 2019 and regional and racial/ethnic variation in amputations among Medicare patients.Methods:Using Medicare claims from 2007 to 2019, we identified patients with both diabetes and PAD. We calculated period prevalence of concomitant diabetes and PAD and incident cases of diabetes and PAD for every year. Patients were followed to identify amputations, and results were stratified by race/ethnicity and hospital referral region.Results:9 410 785 patients with diabetes and PAD were identified (mean age, 72.8 [SD, 10.94] years; 58.6% women, 74.7% White, 13.2% Black, 7.3% Hispanic, 2.8% Asian/API, and 0.6% Native American). Period prevalence of diabetes and PAD was 23 per 1000 beneficiaries. We observed a 33% relative decrease in annual new diagnoses throughout the study. All racial/ethnic groups experienced a similar decline in new diagnoses. Black and Hispanic patients had on average a 50% greater rate of disease compared with White patients. One- and 5-year amputation rates remained stable at ≈1.5% and 3%, respectively. Native American, Black, and Hispanic patients were at greater risk of amputation compared with White patients at 1- and 5-year time points (5-year rate ratio range, 1.22–3.17). Across US regions, we observed differential amputation rates, with an inverse relationship between the prevalence of concomitant diabetes and PAD and overall amputation rates.Conclusions:Significant regional and racial/ethnic variation exists in the incidence of concomitant diabetes and PAD among Medicare patients. Black patients in areas with the lowest rates of PAD and diabetes are at disproportionally higher risk for amputation. Furthermore, areas with higher prevalence of PAD and diabetes have the lowest rates of amputation.
