Comparative Effectiveness of Implantable Defibrillators for Asymptomatic Brugada Syndrome: A Decision-Analytic Model

Background

Optimal management of asymptomatic Brugada syndrome (BrS) with spontaneous type I electrocardiographic pattern is uncertain.

Methods and Results

We developed an individual‐level simulation comprising 2 000 000 average‐risk individuals with asymptomatic BrS and spontaneous type I electrocardiographic pattern. We compared (1) observation, (2) electrophysiologic study (EPS)‐guided implantable cardioverter‐defibrillator (ICD), and (3) upfront ICD, each using either subcutaneous or transvenous ICD, resulting in 6 strategies tested. The primary outcome was quality‐adjusted life years (QALYs), with cardiac deaths (arrest or procedural‐related) as a secondary outcome. We varied BrS diagnosis age and underlying arrest rate. We assessed cost‐effectiveness at $100 000/QALY. Compared with observation, EPS‐guided subcutaneous ICD resulted in 0.35 QALY gain/individual and 4130 cardiac deaths avoided/100 000 individuals, and EPS‐guided transvenous ICD resulted in 0.26 QALY gain and 3390 cardiac deaths avoided. Compared with observation, upfront ICD reduced cardiac deaths by a greater margin (subcutaneous ICD, 8950; transvenous ICD, 6050), but only subcutaneous ICD improved QALYs (subcutaneous ICD, 0.25 QALY gain; transvenous ICD, 0.01 QALY loss), and complications were higher. ICD‐based strategies were more effective at younger ages and higher arrest rates (eg, using subcutaneous devices, upfront ICD was the most effective strategy at ages 20–39.4 years and arrest rates >1.37%/year; EPS‐guided ICD was the most effective strategy at ages 39.5–51.3 years and arrest rates 0.47%–1.37%/year, and observation was the most effective strategy at ages >51.3 years and arrest rates <0.47%/year). EPS‐guided subcutaneous ICD was cost‐effective ($80 508/QALY).

Conclusions

Device‐based approaches (with or without EPS risk stratification) can be more effective than observation among selected patients with asymptomatic BrS. BrS management should be tailored to patient characteristics.

Prevalence of Angina Among Primary Care Patients With Coronary Artery Disease

IMPORTANCE

Angina pectoris is associated with morbidity and mortality. Angina prevalence and frequency among contemporary US populations with coronary artery disease (CAD) remain incompletely defined.

OBJECTIVE

To ascertain the angina prevalence and frequency among stable outpatients with CAD.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study involved telephone-based administration of the Seattle Angina Questionnaire-7 (SAQ-7) between February 1, 2017, and July 31, 2017, to a nonconvenience sample of adults with established CAD who receive primary care through a large US integrated primary care network. Data analysis was performed from August 2017 to August 2019.

EXPOSURE

SAQ-7 administration.

MAIN OUTCOMES AND MEASURES

Angina prevalence and frequency were assessed using SAQ-7 question 2. Covariates associated with angina were assessed in univariable and multivariable regression.

RESULTS

Of 4139 eligible patients, 1612 responded to the survey (response rate, 38.9%). The mean (SD) age of the respondents was 71.8 (11.0) years, 577 (35.8%) were women, 1447 (89.8%) spoke English, 147 (9.1%) spoke Spanish, 1336 (82.8%) were White, 76 (4.7%) were Black, 92 (5.7%) were Hispanic, 974 (60.4%) had Medicare, and 83 (5.2%) had Medicaid. Among respondents, 342 (21.2%) reported experiencing angina at least once monthly; among those, 201 (12.5%) reported daily or weekly angina, and 141 respondents (8.7%) reported monthly angina. The mean (SD) SAQ-7 score was 93.7 (13.7). After multivariable adjustment, speaking a language other than Spanish or English (odds ratio [OR], 5.07; 95% CI, 1.39-18.50), Black race (OR, 2.01; 95% CI, 1.08-3.75), current smoking (OR, 1.88; 95% CI, 1.27-2.78), former smoking (OR, 1.69; 95% CI, 1.13-2.51), atrial fibrillation (OR, 1.52; 95% CI, 1.02-2.26), and chronic obstructive pulmonary disease (OR, 1.61; 95% CI, 1.18-2.18) were associated with more frequent angina. Male sex (OR, 0.63; 95% CI, 0.47-0.86), peripheral artery disease (OR, 0.63; 95% CI, 0.44-0.90), and novel oral anticoagulant use (OR, 0.19; 95% CI, 0.08-0.48) were associated with less frequent angina.

CONCLUSIONS AND RELEVANCE

Among stable outpatients with CAD receiving primary care through an integrated primary care network, 21.2% of surveyed patients reported experiencing angina at least once monthly. Several objective demographic and clinical characteristics were associated with angina frequency. Proactive assessment of angina symptoms using validated assessment tools and estimation of patients at higher risk of suboptimally controlled angina may be associated with reduced morbidity.

Hospital Variation in 30-Day Readmissions Following Transcatheter Aortic Valve Replacement

Background Data on hospital variation in 30-day readmission rates after transcatheter aortic valve replacement (TAVR) are limited. Further, whether such variation is explained by differences in hospital characteristics and hospital practice patterns remains unknown. Methods and Results We used the 2017 Nationwide Readmissions Database to identify hospitals that performed at least 5 TAVRs. Hierarchical logistic regression models were used to examine between-hospital variation in 30-day all-cause risk-standardized readmission rate (RSRR) after TAVR and to explore reasons underlying hospital variation in 30-day RSRR. The study included 27 091 index TAVRs performed across 325 hospitals. The median (interquartile range) hospital-level 30-day RSRR was 11.9% (11.1%-12.8%) ranging from 8.8% to 16.5%. After adjusting for differences in patient characteristics, there was significant between-hospital variation in 30-day RSRR (hospital odds ratio, 1.59; 95% CI, 1.39-1.77). Differences in length of stay and discharge disposition accounted for 15% of the between-hospital variance in RSRRs. There was no significant association between hospital characteristics and 30-day readmission rates after TAVR. There was statistically significant but weak correlation between 30-day RSRR after TAVR and that after surgical aortic valve replacement, percutaneous coronary intervention, acute myocardial infarction, heart failure, and pneumonia (r=0.132-0.298; P<0.001 for all). Causes of 30-day readmission varied across hospitals, with noncardiac readmissions being more common at the bottom 5% hospitals (ie, those with the highest RSRRs). Conclusions There is significant variation in 30-day RSRR after TAVR across hospitals that is not entirely explained by differences in patient or hospital characteristics as well as hospital-wide practice patterns. Noncardiac readmissions are more common in hospitals with the highest RSRRs.

Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation

BACKGROUND

Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value.

OBJECTIVES

This study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events.

METHODS

Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services.

RESULTS

Following hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient-visits; 95% CI: -6.5 to -5.3), and percutaneous coronary intervention (PCI) (-0.65 per 100 patient-visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5% to 2.6%), or be hospitalized (-5.8%; 95% CI: -7.7% to -3.8%). Patients with chest pain had lower net mean length of stay (-0.24 days; 95% CI: -0.32 to -0.16) but no net change in spending.

CONCLUSIONS

Hs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.

Association between hospital cardiovascular procedural volumes and transcatheter mitral valve repair outcomes

BACKGROUND

Cardiovascular procedural volumes can serve as metrics of hospital infrastructure and quality, and are the basis for thresholds for initiating transcatheter mitral valve repair (TMVr) programs. Whether hospital volumes of TMVr, surgical mitral valve replacement or repair (SMVRr), and percutaneous coronary intervention (PCI) are indicators of TMVr quality of care is not known.

METHODS

We used the 2017 Nationwide Readmissions Database to identify hospitals that performed at least 5 TMVr procedures. Hospitals were divided into quartiles of TMVr volume. Associations of hospital TMVr, SMVRr, and PCI volumes, as well as SMVRr and PCI outcomes with TMVr outcomes were examined. Outcomes studied were risk-standardized in-hospital mortality rate (RSMR) and 30-day readmission rate (RSRR).

RESULTS

The study included 3404 TMVr procedures performed across 150 hospitals in the US. The median hospital TMVr volume was 17 (IQR 10, 28). The mean hospital-level RSMR and RSRR for TMVr were 3.0% (95% CI 2.5%, 3.4%) and 14.8% (95% CI 14.5%, 15.0%), respectively. There was no significant association between hospital TMVr volume (as quartiles or as a continuous variable) and TMVr RSMR or RSRR (P > 0.05). Similarly, there was weak or no correlation between hospital SMVRr and PCI volumes and outcomes with TMVr RSMR or RSRR (Pearson correlation coefficients, r = -0.199 to 0.269).

CONCLUSION

In this study, we found no relationship between hospital TMVr, SMVRr, and PCI volume and TMVr outcomes. Further studies are needed to determine more appropriate structure and process measures to assess the performance of established and new TMVr centers.

The essential role of population health during and beyond COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.

An Analysis of Ambulance Transport and Out-of-Network Emergency Department Utilization in an Accountable Care Organization

For hospital-affiliated accountable care organizations (ACOs), emergency care represents a unique challenge for coordination of care and a major source of ACO leakage. The authors analyzed emergency department (ED) visits among ACO members to assess the potential impact of ambulance transport on the use of in-network versus out-of-network EDs. To better understand factors influencing the use of in-network versus out-of-network EDs, 2018 claims data from members of a regional subset of a large ACO in the greater Boston area were analyzed. Within this population, multivariable logistic regression was used to assess the relationship between ambulance transport as well as demographic factors, insurance type, and hospital distance on the use of in-network versus out-of-network EDs. Arrival to an ED via ambulance was found to be significantly associated with reduced odds of presenting to an in-network ED compared to arriving by private transportation (odds ratio 0.70, 95% confidence interval: 0.58-0.85). Age older than 65 years, commercial insurance (relative to Medicare), proximity to an in-network ED, and distance from an out-of-network ED also were significantly associated with use of in-network EDs relative to out-of-network EDs. Given the central role of the ED as a primary source of hospital admissions in the United States, emergency care represents a key potential target for interventions aimed at reducing patient leakage. Future efforts should aim to identify and evaluate new ways that emergency medical services can be leveraged to promote effective care coordination.

Patient Characteristics and Clinical Outcomes of Type 1 Versus Type 2 Myocardial Infarction

BACKGROUND

Type 2 myocardial infarction (MI) patients may have different characteristics and outcomes when compared with type 1 MI.

OBJECTIVES

The purpose of this study was to compare patients with type 1 MI to those with type 2 MI in the United States.

METHODS

Using the Nationwide Readmissions Database, MI patients were categorized over the 3 months following the introduction of an International Classification of Diseases-10th Revision code specific for type 2 MI. Baseline characteristics and inpatient and post-discharge outcomes among both cohorts were compared.

RESULTS

There were 216,657 patients with type 1 MI, 37,765 patients with type 2 MI, and 1,525 patients with both type 1 and 2 MI. Patients with type 2 MI were older (71 years vs. 69 years; p < 0.001), were more likely to be women (47.3% vs. 40%; p < 0.001), and had higher prevalence of heart failure (27.9% vs. 10.9%; p < 0.001), kidney disease (35.7% vs. 25.7%; p < 0.001), and atrial fibrillation (31% vs. 21%; p < 0.001). Rates of coronary angiography (10.9% vs. 57.3%; p < 0.001), percutaneous coronary intervention (1.7% vs. 38.5%; p < 0.001), and coronary artery bypass grafting (0.4% vs. 7.8%; p < 0.001) were lower among type 2 MI patients. Patients with type 2 MI had lower risk of in-hospital mortality (adjusted odds ratio: 0.57 [95% confidence interval: 0.54 to 0.60]) and 30-day MI readmission (adjusted odds ratio: 0.46 [95% confidence interval: 0.35 to 0.59]). There was no difference in risk of 30-day all-cause or heart failure readmission.

CONCLUSIONS

Patients with type 2 MI have a unique cardiovascular phenotype when compared with type 1 MI, and are managed in a heterogenous manner. Validated management strategies for type 2 MI are needed.

Practice pattern of use of high sensitivity troponin in the outpatient settings

Background

High‐sensitivity troponin assays (hs‐Tn) detect lower serum concentrations than prior‐generation assays and help guide acute coronary syndrome (ACS) evaluation in emergency departments. Outpatient hs‐Tn utilization is not well described.

Hypothesis

Outpatient providers use hs‐TnT to triage patients with suspected ACS.

Methods

We compared the volume of outpatient prior‐generation troponin tests in the pre‐hsTn implementation period (January 2015‐March 2018) with outpatient hs‐TnT volume in the post‐implementation period (April 2018‐January 2020). Triage patterns were compared between patients with hs‐TnT≥99th vs <99th percentile, using two‐sample t tests. In patients triaged home, adverse events were compared between patients with hs‐TnT≥99th vs <99th percentile, using log‐rank tests.

Results

Across a large tertiary healthcare system, a mean of 80 prior‐generation tests/month were ordered during the pre‐hsTn implementation period compared with 12 hs‐TnT tests/month in the post‐implementation period. Prior‐generation orders rose by 1.72 tests/month during pre‐implementation, vs a decline of 2.74 hs‐TnT tests/month during post‐implementation (P < .001). Among 129 hs‐TnT orders, most were placed by cardiologists (54%) and primary care providers (32%). Patient symptoms at the time of troponin ordering included dyspnea (34%) and chest pain (33%), although 25% were asymptomatic. Among symptomatic patients (n = 74), those with hs‐TnT > 99th percentile were more likely to be sent to the ED (RR, 3.36; 95% CI, 1.22‐9.25; P = .002). Among patients sent home (n = 66), those with hs‐TnT > 99th percentile had more adverse events by 6 months (3.3% vs 22.2% RR, 6.67; 95% CI, 1.04‐42.9; P = .026).

Conclusions

In this healthcare system, outpatient troponin utilization significantly declined since hs‐TnT implementation. Some providers use hs‐TnT to triage patients with suspected ACS to the ED; others test asymptomatic patients and some send patients home despite high hs‐TnT values.

Trends in Diagnosis Related Groups for Inpatient Admissions and Associated Changes in Payment From 2012 to 2016

IMPORTANCE

Hospitals are reimbursed based on Diagnosis Related Groups (DRGs), which are defined, in part, by patients having 1 or more complications or comorbidities within a given DRG family. Hospitals have made substantial investment in efforts to document these complications and comorbidities.

OBJECTIVE

To examine temporal trends in DRGs with a major complication or comorbidity, compare these findings with 2 alternative measures of disease severity, and estimate associated changes in payment.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from the all-payer National Inpatient Sample for admissions assigned to 1 of the top 20 reimbursed DRG families at US acute care hospitals from January 1, 2012, to December 31, 2016. Data were analyzed from July 10, 2018, to May 29, 2019.

EXPOSURES

Quarter year of hospitalization.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of DRGs with a major complication or comorbidity. Secondary outcomes were comorbidity scores, risk-adjusted mortality rates, and estimated payment. Changes in assigned DRGs, comorbidity scores, and risk-adjusted mortality rates were analyzed by linear regression. Payment changes were estimated for each DRG by calculating the Centers for Medicare & Medicaid Services weighted payment using 2012 and 2016 case mix and hospitalization counts.

RESULTS

Between 2012 and 2016, there were 62 167 976 hospitalizations for the 20 highest-reimbursed DRG families; the sample was 32.9% male and 66.8% White, with a median age of 57 years (interquartile range, 31-73 years). Within 15 of these DRG families (75%), the proportion of DRGs with a major complication or comorbidity increased significantly over time. Over the same period, comorbidity scores were largely stable, with a decrease in 6 DRG families (30%), no change in 10 (50%), and an increase in 4 (20%). Among 19 DRG families with a calculable mortality rate, the risk-adjusted mortality rate significantly decreased in 8 (42%), did not change in 9 (47%), and increased in 2 (11%). The observed DRG shifts were associated with at least $1.2 billion in increased payment.

CONCLUSIONS AND RELEVANCE

In this cohort study, between 2012 and 2016, the proportion of admissions assigned to a DRG with major complication or comorbidity increased for 15 of the top 20 reimbursed DRG families. This change was not accompanied by commensurate increases in disease severity but was associated with increased payment.

Changes in hospital admissions for urgent conditions during COVID-19 pandemic

OBJECTIVES

To determine whether patients are deferring necessary care for urgent conditions during the coronavirus disease 2019 (COVID-19) pandemic and, if so, to what extent.

STUDY DESIGN

Cross-sectional study.

METHODS

Using billing data from 8 acute care hospitals, we identified 9 principal medical diagnoses from International Classification of Diseases, Tenth Revision codes across 4 medical specialties (cardiology, gastroenterology, neurology, and urology). In addition, we defined a combined obstetrical falsification end point. We compared daily admission rates during the pandemic period (3/1/2020-4/30/2020) with the same dates in 2019 (3/1/2019-4/30/2019). As a reference, we also compared a prepandemic period in the same years (1/1/2019-2/28/2019 and 1/1/2020-2/29/2020). We compared admission rates between years using t tests.

RESULTS

There were 3219 admissions for the conditions of interest during the study period in 2019 and 2661 in 2020. There was no difference in prepandemic daily admission rates in 2020 compared with 2019 (29.04 vs 27.63 admissions per day; -4.9%; P = .50). During the pandemic period, there was a 33.7% decrease in admission rates for all conditions combined in 2020 compared with 2019 (24.68 vs 16.37; -33.7%; P = .03). By specialty, the combined gastroenterology (10.22 vs 7.20; -29.6%; P = .02) and cardiovascular (2.34 vs 1.29; -44.7%; P = .05) end points demonstrated reduction in daily admission rates.

CONCLUSIONS

Daily admission rates during the COVID-19 pandemic were lower for these acute medical conditions. Public awareness campaigns are urgently needed to reassure the public about the safety of presenting for care.

Patient Readmission Rates For All Insurance Types After Implementation Of The Hospital Readmissions Reduction Program

Since the implementation of the Hospital Readmissions Reduction Program (HRRP), readmissions have declined for Medicare patients with conditions targeted by the policy (acute myocardial infarction, heart failure, and pneumonia). To understand whether HRRP implementation was associated with a readmission decline for patients across all insurance types (Medicare, Medicaid, and private), we conducted a difference-in-differences analysis using information from the Nationwide Readmissions Database. We compared how quarterly readmissions for target conditions changed before (2010-12) and after (2012-14) HRRP implementation, using nontarget conditions as the control. Our results demonstrate that readmissions declined at a significantly faster rate after HRRP implementation not just for Medicare patients but also for those with Medicaid, both in the aggregate and for individual target conditions. However, composite Medicaid readmission rates remained higher than those for Medicare. Throughout the study period privately insured patients had the lowest aggregate readmission rates, which declined at a similar rate compared to nontarget conditions. The HRRP was associated with nationwide readmission reductions beyond the Medicare patients originally targeted by the policy. Further research is needed to understand the specific mechanisms by which hospitals have achieved reductions in readmissions.

Early clinical and sociodemographic experience with patients hospitalized with COVID-19 at a large American healthcare system

BACKGROUND

Despite over 4 million cases of novel coronavirus disease 2019 (COVID-19) in the United States, limited data exist including socioeconomic background and post-discharge outcomes for patients hospitalized with this disease.

METHODS

In this case series, we identified patients with COVID-19 admitted to 3 Partners Healthcare hospitals in Boston, Massachusetts between March 7th, 2020, and March 30th, 2020. Patient characteristics, treatment strategies, and outcomes were determined.

FINDINGS

A total of 247 patients hospitalized with COVID-19 were identified; the median age was 61 (interquartile range [IQR]: 50-76 years), 58% were men, 30% of Hispanic ethnicity, 21% enrolled in Medicaid, and 12% dual-enrolled Medicare/Medicaid. The median estimated household income was $66,701 [IQR: $50,336-$86,601]. Most patients were treated with hydroxychloroquine (72%), and statins (76%; newly initiated in 34%). During their admission, 103 patients (42%) required intensive care. At the end of the data collection period (June 24, 2020), 213 patients (86.2%) were discharged alive, 2 patients (0.8%) remain admitted, and 32 patients (13%) have died. Among those discharged alive (n = 213), 70 (32.9%) were discharged to a post-acute facility, 31 (14.6%) newly required supplemental oxygen, 19 (8.9%) newly required tube feeding, and 34 (16%) required new prescriptions for antipsychotics, benzodiazepines, methadone, or opioids. Over a median post-discharge follow-up of 80 days (IQR, 68-84), 22 patients (10.3%) were readmitted.

INTERPRETATION

Patients hospitalized with COVID-19 are frequently of vulnerable socioeconomic status and often require intensive care. Patients who survive COVID-19 hospitalization have substantial need for post-acute services.

Misclassification of Myocardial Injury as Myocardial Infarction: Implications for Assessing Outcomes in Value-Based Programs

Importance

Similar to other patients with acute myocardial infarction, patients with type 2 myocardial infarction (T2MI) are included in several value-based programs, including the Hospital Readmissions Reduction Program and the Hospital Value-Based Purchasing Program. To our knowledge, whether nonischemic myocardial injury is being misclassified as T2MI is unknown and may have implications for these programs.

Objective

To determine whether patients with nonischemic myocardial injury are being miscoded as having T2MI and if this has implications for 30-day readmission and mortality rates.

Design, Settings, and Participants

Using the new International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code, we identified patients who were coded as having T2MI between October 2017 and May 2018 at Massachusetts General Hospital. Strict adjudication using the fourth universal definition of MI was then applied.

Main outcome and Measures

Clinical adjudication of T2MI and 30-day readmission and mortality rates as a function of T2MI or nonischemic myocardial injury.

Results

Of 633 patients, 369 (58.3%) were men and 514 (81.2%) were white. After strict adjudication, 359 (56.7%) had T2MI, 265 (41.9%) had myocardial injury, 6 (0.9%) had type 1 MI, and 3 (0.5%) had unstable angina. Patients with T2MI had a higher prevalence of cardiovascular comorbidities than those with myocardial injury. Patients with T2MI and myocardial injury had high in-hospital mortality rates (10.6% and 8.7%, respectively; P = .50). Of those discharged alive (563 [88.9%]), 30-day readmission rates (22.7% vs 21.1%; P = .68) and mortality rates (4.4% vs 7.4%; P = .14) were comparable among patients with T2MI and myocardial injury.

Conclusions and Relevance

A substantial percentage of patients coded as having T2MI actually have myocardial injury. Both conditions have high 30-day readmission and mortality rates. Including patients with high-risk myocardial injury may have substantial implications for value-based programs.

Utility, Appropriateness, and Content of Electronic Consultations Across Medical Subspecialties

BACKGROUND

Electronic consultations (e-consults) can facilitate patient access to specialists, minimize travel, and reduce unnecessary in-person visits. However, metrics to enable study of e-consults and their effect on processes and patient care are lacking.

OBJECTIVE

To assess novel metrics of e-consult appropriateness and utility.

DESIGN

Retrospective cohort study.

SETTING

Primary and specialty care practices at 2 large academic and 2 community hospitals of an integrated health system.

PARTICIPANTS

Patients with e-consult requests to 5 specialties-hematology, infectious disease, dermatology, rheumatology, and psychiatry-between October 2017 and November 2018.

MEASUREMENTS

The appropriateness of e-consult inquiries was assessed by review of medical records and defined as meeting the following 4 criteria: not answerable by reviewing evidence-based summary sources ("point-of-care resource test"), not merely requesting logistic information, having appropriate clinical urgency, and having appropriate patient complexity. Interrater agreement in assessments of e-consult appropriateness was assessed by the κ statistic. Utility of e-consults was assessed by the rate of avoided visits (AVs), defined by the absence of an in-person visit to the same specialty within 120 days.

RESULTS

Overall, 6512 eligible e-consults were made by 1096 referring providers to 121 specialist consultants. Inquiries were characterized as diagnostic, therapeutic, for provider education, or at the request of the patient. Most consultations were answered within 1 day, with variation across specialties (73.1% for psychiatry to 87.8% for infectious disease). Overall, 70.2% of e-consults met all 4 criteria for appropriateness; the frequency of unmet criteria varied among specialties. Raters agreed on the appropriateness of 94% of e-consults (κ = 0.57 [95% CI, 0.36 to 0.79]), indicating moderate agreement. The overall rate of AVs across the 5 specialties was 81.2%; the highest rate was in psychiatry (92.6%) and the lowest in dermatology (61.9%).

LIMITATION

Generalizability is unknown outside a single integrated health system, where requesting and consulting providers share a common electronic health record.

CONCLUSION

Novel metrics to assess the appropriateness and utility of e-consults provide meaningful insight into practice, provide a rubric for comparison in future studies in additional settings, and suggest areas to improve resource use and patient care.

PRIMARY FUNDING SOURCE

None.

Association of an Acute Myocardial Infarction Readmission-Reduction Program With Mortality and Readmission

BACKGROUND

Reducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated.

METHODS AND RESULTS

We started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119).

CONCLUSIONS

An AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.

Home-Time After Discharge Among Patients With Type 2 Myocardial Infarction

Background Home-time, defined as the time spent alive outside of a healthcare institution, has emerged as a patient-centered health outcome. The discharge locations and distribution of home-time after a type 2 myocardial infarction are unknown. Methods and Results Patients with a type 2 myocardial infarction between October 2017 and May 2018 at Massachusetts General Hospital were included. Patients discharged to hospice or without follow-up data were excluded. Our primary outcome was home-time defined as the number of days lived outside of a hospital, long-term acute care facility, skilled nursing facility, or rehabilitation facility. We identified 359 patients with type 2 myocardial infarction over the study period. Of those discharged alive (N=321), 62.9% were discharged home, and the remainder went to a facility or hospice. Among those with available follow-up data (N=289), the median home-time was 30 (interquartile range [IQR], 16-30) days at 30 days, 171 (IQR, 133-180) days at 180 days, and 347 (IQR, 203-362) days at 365 days. At 1 year, 29 patients (10%) with type 2 myocardial infarction had spent no time at home and only 57 patients (19.7%) spent the entire year alive and at home. At 1 year, postdischarge all-cause mortality was 23.2%, all-cause readmission was 69.2%, and major adverse cardiovascular events (composite of all-cause mortality, recurrent myocardial infarction, or stroke) was 34.9%. Home-time through 1 year correlated strongly with time-to-event all-cause mortality (τ=0.54, P<0.001) and major adverse cardiovascular events (τ=0.52, P<0.001) and modestly with a composite of all-cause mortality or readmission (τ=0.44, P<0.001). Conclusions Home-time is low after a hospitalization for type 2 myocardial infarction and correlates strongly with mortality and major adverse cardiovascular events.

Abstract 240: Assessing the Lack of Appropriate Anticoagulation in Patients With Atrial Fibrillation - Implications for Cardiology Registry-Based Care

Intro: Anticoagulation is indicated for many patients with atrial fibrillation (AF) for prevention of cardioembolic stroke, although national proportions of eligible patients receiving anticoagulation remain suboptimal. Automated and semi-automated quality improvement techniques including registries and population health coordinators may help identify and increase eligible patients to receive anticoagulation.

Methods: We queried our electronic health record to identify patients without anticoagulation but with atrial fibrillation (as identified as either paroxysmal atrial fibrillation, persistent atrial fibrillation, chronic atrial fibrillation, typical atrial flutter, atypical atrial flutter, or unspecified atrial flutter) either on the problem list or as billed administrative claims between September 2016 - September 2019 in MGH outpatient cardiology clinics. All patients were participating in MGH cardiology, with their primary care based either within MGH or outside of MGH. Then, we conducted detailed chart review to calculate thromboembolic risk with respective CHADS-VASC score and confirmed that the patient was not receiving anticoagulation. A typology was developed as charts were reviewed to categorize reasons for lacking anticoagulation. These categories were grouped into broader categories representing a (1) potential quality problem or (2) appropriate lack of anticoagulation.

Results: Of 100 patients, 59 were deemed to have a potential quality problem and 41 were deemed to have appropriate lack of anticoagulation. Of the patients with a potential quality problem, 11 have a CHADS VASC score of 1, 18 have a CHADS VASC score of 2, 6 have a CHADS VASC score of 3, 10 have a CHADS VASC score of 4, and 8 have a CHADS of 5, and 6 have a CHADS VASC of 6 or above. Additionally, 3 patients have been lost to follow up, 12 patients had presented with current symptoms of AF within the last year, and 44 patients exhibited acute history of AF symptoms. 41 patients did not present concern for multiple reasons including: CHADS VASC=0, deceased, patients declined medication, followed by outside cardiologist, technology and medication discrepancies, inaccurate administrative data for AF, and prior major bleeding.

Conclusions: We found that most un-anticoagulated AF patients identified by administrative claims and EHR problem lists are likely eligible for anticoagulation. Of those, most have a history of paroxysmal AF. As such, registry-based strategies based on queries of past AF may improve rates of anticoagulation in this population. Since automated queries still detect many patients with contraindications such as bleeding or inaccurate administrative data, manual review of administrative queries is likely to be important in quality efforts for AF.