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Mentias A, Keshvani N, Sumarsono A, Desai R, Khan MS, Menon V, Hsich E, Bress AP, Jacobs J, Vasan RS, Fonarow GC, Pandey A. Patterns, Prognostic Implications, and Rural-Urban Disparities in Optimal GDMT Following HFrEF Diagnosis Among Medicare Beneficiaries. JACC. HEART FAILURE 2024; 12:1044-1055. [PMID: 37943222 DOI: 10.1016/j.jchf.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Patterns and disparities in guideline-directed medical therapy (GDMT) uptake for heart failure with reduced ejection fraction (HFrEF) across rural vs urban regions are not well described. OBJECTIVES This study aims to evaluate patterns, prognostic implications, and rural-urban differences in GDMT use among Medicare beneficiaries following new-onset HFrEF. METHODS Patients with a diagnosis of new-onset HFrEF in a 5% Medicare sample with available data for Part D medication use were identified from January 2015 through December 2020. The primary exposure was residence in rural vs urban zip codes. Optimal triple GDMT was defined as ≥50% of the target daily dose of beta-blockers, ≥50% of the target daily dose of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker or any dose of sacubitril/valsartan, and any dose of mineralocorticoid receptor antagonist. The association between the achievement of optimal GDMT over time following new-onset HFrEF diagnosis and risk of all-cause mortality and subsequent HF hospitalization was also evaluated using adjusted Cox models. The association between living in rural vs urban location and time to optimal GDMT achievement over a 12-month follow-up was assessed using cumulative incidence curves and adjusted Fine-Gray subdistribution hazard models. RESULTS A total of 41,296 patients (age: 76.7 years; 15.0% Black; 27.6% rural) were included. Optimal GDMT use over the 12-month follow-up was low, with 22.5% initiated on any dose of triple GDMT and 9.1% on optimal GDMT doses. Optimal GDMT on follow-up was significantly associated with a lower risk of death (HR: 0.89 [95% CI: 0.85-0.94]; P < 0.001) and subsequent HF hospitalization (HR: 0.93 [95% CI: 0.87-0.98]; P = 0.02). Optimal GDMT use at 12 months was significantly lower among patients living in rural (vs urban) areas (8.4% vs 9.3%; P = 0.02). In adjusted analysis, living in rural (vs urban) locations was associated with a significantly lower probability of achieving optimal GDMT (HR: 0.92 [95% CI: 0.86-0.98]; P = 0.01 Differences in optimal GDMT use following HFrEF diagnosis accounted for 16% of excess mortality risk among patients living in rural (vs urban) areas. CONCLUSIONS Use of optimal GDMT following new-onset HFrEF diagnosis is low, with substantially lower use noted among patients living in rural vs urban locations. Suboptimal GDMT use following new-onset HFrEF was associated with an increased risk of mortality and subsequent HF hospitalization.
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Affiliation(s)
- Amgad Mentias
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew Sumarsono
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | - Venu Menon
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eileen Hsich
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adam P Bress
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joshua Jacobs
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Ramachandran S Vasan
- School of Public Health, Department of Population Health, and Division of Cardiology, Long School of Medicine, University of Texas San Antonio, San Antonio, Texas, USA
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Gupta A, Tisdale RL, Calma J, Stafford RS, Maron DJ, Hernandez-Boussard T, Ambrosy AP, Heidenreich PA, Sandhu AT. Equity in the Setting of Heart Failure Diagnosis: An Analysis of Differences Between and Within Clinician Practices. Circ Heart Fail 2024; 17:e010718. [PMID: 38847082 DOI: 10.1161/circheartfailure.123.010718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/28/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Timely heart failure (HF) diagnosis can lead to earlier intervention and reduced morbidity. Among historically marginalized patients, new-onset HF diagnosis is more likely to occur in acute care settings (emergency department or inpatient hospitalization) than outpatient settings. Whether inequity within outpatient clinician practices affects diagnosis settings is unknown. METHODS We determined the setting of incident HF diagnosis among Medicare fee-for-service beneficiaries between 2013 and 2017. We identified sociodemographic and medical characteristics associated with HF diagnosis in the acute care setting. Within each outpatient clinician practice, we compared acute care diagnosis rates across sociodemographic characteristics: female versus male sex, non-Hispanic White versus other racial and ethnic groups, and dual Medicare-Medicaid eligible (a surrogate for low income) versus nondual-eligible patients. Based on within-practice differences in acute diagnosis rates, we stratified clinician practices by equity (high, intermediate, and low) and compared clinician practice characteristics. RESULTS Among 315 439 Medicare patients with incident HF, 173 121 (54.9%) were first diagnosed in acute care settings. Higher adjusted acute care diagnosis rates were associated with female sex (6.4% [95% CI, 6.1%-6.8%]), American Indian (3.6% [95% CI, 1.1%-6.1%]) race, and dual eligibility (4.1% [95% CI, 3.7%-4.5%]). These differences persisted within clinician practices. With clinician practice adjustment, dual-eligible patients had a 4.9% (95% CI, 4.5%-5.4%) greater acute care diagnosis rate than nondual-eligible patients. Clinician practices with greater equity across dual eligibility also had greater equity across sex and race and ethnicity and were more likely to be composed of predominantly primary care clinicians. CONCLUSIONS Differences in HF diagnosis rates in the acute care setting between and within clinician practices highlight an opportunity to improve equity in diagnosing historically marginalized patients.
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Affiliation(s)
- Anshal Gupta
- Stanford University School of Medicine, Palo Alto, CA (A.G.)
| | - Rebecca L Tisdale
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA (R.L.T., P.A.H., A.T.S.)
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (R.L.T.)
| | - Jamie Calma
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (J.C., D.J.M., P.A.H., A.T.S.)
| | - Randall S Stafford
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (R.S.S., D.J.M., A.T.S.)
| | - David J Maron
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (J.C., D.J.M., P.A.H., A.T.S.)
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (R.S.S., D.J.M., A.T.S.)
| | | | - Andrew P Ambrosy
- Division of Research, Kaiser Permanente Northern California, Oakland (A.P.A.)
| | - Paul A Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA (R.L.T., P.A.H., A.T.S.)
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (J.C., D.J.M., P.A.H., A.T.S.)
| | - Alexander T Sandhu
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA (R.L.T., P.A.H., A.T.S.)
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (J.C., D.J.M., P.A.H., A.T.S.)
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (R.S.S., D.J.M., A.T.S.)
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Jain S, Murphy TE, Falvey JR, Leo-Summers L, O’Leary JR, Zang E, Gill TM, Krumholz HM, Ferrante LE. Social Determinants of Health and Delivery of Rehabilitation to Older Adults During ICU Hospitalization. JAMA Netw Open 2024; 7:e2410713. [PMID: 38728030 PMCID: PMC11087837 DOI: 10.1001/jamanetworkopen.2024.10713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/09/2024] [Indexed: 05/13/2024] Open
Abstract
Importance Older adults with socioeconomic disadvantage develop a greater burden of disability after critical illness than those without socioeconomic disadvantage. The delivery of in-hospital rehabilitation that can mitigate functional decline may be influenced by social determinants of health (SDOH). Whether rehabilitation delivery differs by SDOH during critical illness hospitalization is not known. Objective To evaluate whether SDOH are associated with the delivery of skilled rehabilitation during critical illness hospitalization among older adults. Design, Setting, and Participants This cohort study used data from the National Health and Aging Trends Study linked with Medicare claims (2011-2018). Participants included older adults hospitalized with a stay in the intensive care unit (ICU). Data were analyzed from August 2022 to September 2023. Exposures Dual eligibility for Medicare and Medicaid, education, income, limited English proficiency (LEP), and rural residence. Main Outcome and Measures The primary outcome was delivery of physical therapy (PT) and/or occupational therapy (OT) during ICU hospitalization, characterized as any in-hospital PT or OT and rate of in-hospital PT or OT, calculated as total number of units divided by length of stay. Results In the sample of 1618 ICU hospitalizations (median [IQR] patient age, 81.0 [75.0-86.0] years; 842 [52.0%] female), 371 hospitalizations (22.9%) were among patients with dual Medicare and Medicaid eligibility, 523 hospitalizations (32.6%) were among patients with less than high school education, 320 hospitalizations (19.8%) were for patients with rural residence, and 56 hospitalizations (3.5%) were among patients with LEP. A total of 1076 hospitalized patients (68.5%) received any PT or OT, with a mean rate of 0.94 (95% CI, 0.86-1.02) units/d. After adjustment for age, sex, prehospitalization disability, mechanical ventilation, and organ dysfunction, factors associated with lower odds of receipt of PT or OT included dual Medicare and Medicaid eligibility (adjusted odds ratio, 0.70 [95% CI, 0.50-0.97]) and rural residence (adjusted odds ratio, 0.65 [95% CI, 0.48-0.87]). LEP was associated with a lower rate of PT or OT (adjusted rate ratio, 0.55 [95% CI, 0.32-0.94]). Conclusions and Relevance These findings highlight the need to consider SDOH in efforts to promote rehabilitation delivery during ICU hospitalization and to investigate factors underlying inequities in this practice.
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Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terrence E. Murphy
- Department of Public Health Sciences, Pennsylvania State University, State College
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore
| | | | - John R. O’Leary
- Program on Aging, Yale School of Medicine, New Haven, Connecticut
| | - Emma Zang
- Department of Sociology, Yale University, New Haven, Connecticut
| | - Thomas M. Gill
- Program on Aging, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Nikpour J, Brom H, Mason A, Chittams J, Poghosyan L, Carthon MB. Better Nurse Practitioner Primary Care Practice Environments Reduce Hospitalization Disparities Among Dually-Enrolled Patients. Med Care 2024; 62:217-224. [PMID: 38036459 PMCID: PMC10949042 DOI: 10.1097/mlr.0000000000001951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
BACKGROUND Over 12 million Americans are dually enrolled in Medicare and Medicaid. These individuals experience over twice as many hospitalizations for chronic diseases such as coronary artery disease and diabetes compared with Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address the care needs of dually-enrolled patients, yet NPs often work in unsupportive clinical practice environments. The purpose of this study was to examine the association between the NP primary care practice environment and hospitalization disparities between dually-enrolled and Medicare-only patients with chronic diseases. METHODS Using secondary cross-sectional data from the Nurse Practitioner Primary Care Organizational Climate Questionnaire and Medicare claims files, we examined 135,648 patients with coronary artery disease and/or diabetes (20.0% dually-eligible, 80.0% Medicare-only), cared for in 450 practices employing NPs across 4 states (PA, NJ, CA, FL) in 2015. We compared dually-enrolled patients' odds of being hospitalized when cared for in practice environments characterized as poor, mixed, and good based on practice-level Nurse Practitioner Primary Care Organizational Climate Questionnaire scores. RESULTS After adjusting for patient and practice characteristics, dually-enrolled patients in poor practice environments had the highest odds of being hospitalized compared with their Medicare-only counterparts [odds ratio (OR): 1.48, CI: 1.37, 1.60]. In mixed environments, dually-enrolled patients had 27% higher odds of a hospitalization (OR: 1.27, CI: 1.12, 1.45). However, in the best practice environments, hospitalization differences were nonsignificant (OR: 1.02, CI: 0.85, 1.23). CONCLUSIONS As policymakers look to improve outcomes for dually-enrolled patients, addressing a modifiable aspect of care delivery in NPs' clinical practice environment is a key opportunity to reduce hospitalization disparities.
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Affiliation(s)
- Jacqueline Nikpour
- Center for Health Outcomes and Policy Research, University
of Pennsylvania School of Nursing, Philadelphia, PA
| | - Heather Brom
- Center for Health Outcomes and Policy Research, University
of Pennsylvania School of Nursing, Philadelphia, PA
| | - Aleigha Mason
- Center for Health Outcomes and Policy Research, University
of Pennsylvania School of Nursing, Philadelphia, PA
| | - Jesse Chittams
- Center for Health Outcomes and Policy Research, University
of Pennsylvania School of Nursing, Philadelphia, PA
| | - Lusine Poghosyan
- Center for Healthcare Delivery Research & Innovations,
Columbia School of Nursing, New York, NY
| | - Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, University
of Pennsylvania School of Nursing, Philadelphia, PA
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Duncan FC, Al Nasrallah N, Nephew L, Han Y, Killion A, Liu H, Al-Hader A, Sears CR. Racial disparities in staging, treatment, and mortality in non-small cell lung cancer. Transl Lung Cancer Res 2024; 13:76-94. [PMID: 38405005 PMCID: PMC10891396 DOI: 10.21037/tlcr-23-407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 01/12/2024] [Indexed: 02/27/2024]
Abstract
Background Black race is associated with advanced stage at diagnosis and increased mortality in non-small cell lung cancer (NSCLC). Most studies focus on race alone, without accounting for social determinants of health (SDOH). We explored the hypothesis that racial disparities in stage at diagnosis and outcomes are associated with SDOH and influence treatment decisions by patients and providers. Methods Patients with NSCLC newly diagnosed at Indiana University Simon Comprehensive Cancer Center (IUSCCC) from January 1, 2000 to May 31, 2015 were studied. Multivariable regression analyses were conducted to examine the impact of SDOH (race, gender, insurance status, and marital status) on diagnosis stage, time to treatment, receipt of and reasons for not receiving guideline concordant treatment, and 5-year overall survival (OS) based on Kaplan-Meier curves. Results A total of 3,349 subjects were included in the study, 12.2% of Black race. Those diagnosed with advanced-stage NSCLC had a significantly higher odds of being male, uninsured, and Black. Five-year OS was lower in those of Black race, male, single, uninsured, Medicare/Medicaid insurance, and advanced stage. Adjusted for multiple variables, individuals with Medicare, Medicare/Medicaid, uninsured, widowed, and advanced stage at diagnosis, were associated with significantly lower OS time. Black, single, widowed, and uninsured individuals were less likely to receive stage appropriate treatment for advanced disease. Those uninsured [odds ratio (OR): 3.876, P<0.001], Medicaid insurance (OR: 3.039, P=0.0017), and of Black race (OR: 1.779, P=0.0377) were less likely to receive curative-intent surgery for early-stage NSCLC because it was not a recommended treatment. Conclusions We found racial, gender, and socioeconomic disparities in NSCLC diagnosis stage, receipt of stage-appropriate treatment, and reasons for guideline discordance in receipt of curative intent surgery for early-stage NSCLC. While insurance type and marital status were associated with worse OS, race alone was not. This suggests racial differences in outcomes may not be associated with race alone, but rather worse SDOH disproportionately affecting Black individuals. Efforts to understand advanced diagnosis and reasons for failure to receive stage-appropriate treatment by vulnerable populations is needed to ensure equitable NSCLC care.
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Affiliation(s)
- Francesca C. Duncan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nawar Al Nasrallah
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yan Han
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrew Killion
- Indiana Clinical and Translational Science Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hao Liu
- Department of Biostatistics and Epidemiology, Rutgers Cancer Institute of New Jersey, Rutgers School of Public Health, New Brunswick, NJ, USA
| | - Ahmad Al-Hader
- Division of Hematology and Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Catherine R. Sears
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Division of Pulmonary Medicine, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA
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Park YS, Joo HJ, Jang YS, Jeon H, Park EC, Shin J. Socioeconomic Status and Dementia Risk Among Intensive Care Unit Survivors: Using National Health Insurance Cohort in Korea. J Alzheimers Dis 2024; 97:273-281. [PMID: 38143351 DOI: 10.3233/jad-230715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND In aging populations, more elderly patients are going to the intensive care unit (ICU) and surviving. However, the specific factors influencing the occurrence of post-intensive care syndrome in the elderly remain uncertain. OBJECTIVE To investigate the association between socioeconomic status (SES) and risk of developing dementia within two years following critical care. METHODS This study included participants from the Korean National Health Insurance Service Cohort Database who had not been diagnosed with dementia and had been hospitalized in the ICU from 2003 to 2019. Dementia was determined using specific diagnostic codes (G30, G31) and prescription of certain medications (rivastigmine, galantamine, memantine, or donepezil). SES was categorized into low (medical aid beneficiaries) and non-low (National Health Insurance) groups. Through a 1:3 propensity score matching based on sex, age, Charlson comorbidity index, and primary diagnosis, the study included 16,780 patients. We used Cox proportional hazard models to estimate adjusted hazard ratios (HR) of dementia. RESULTS Patients with low SES were higher risk of developing dementia within 2 years after receiving critical care than those who were in non-low SES (HR: 1.23, 95% CI: 1.04-1.46). Specifically, patients with low SES and those in the high-income group exhibited the highest incidence rates of developing dementia within two years after receiving critical care, with rates of 3.61 (95% CI: 3.13-4.17) for low SES and 2.58 (95% CI: 2.20-3.03) for high income, respectively. CONCLUSIONS After discharge from critical care, compared to the non-low SES group, the low SES group was associated with an increased risk of developing dementia.
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Affiliation(s)
- Yu Shin Park
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Hye Jin Joo
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Gachon University College of Medicine, Seoul, Republic of Korea
| | - Yun Seo Jang
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Hajae Jeon
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaeyong Shin
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Jing Z, Zhang J, Ding J, Xue Z. The prognostic value of systemic vascular resistance in heart failure patients with permanent atrial fibrillation: a retrospective study. Heart Vessels 2023; 38:1431-1441. [PMID: 37743357 PMCID: PMC10603009 DOI: 10.1007/s00380-023-02314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
Heart failure (HF) and permanent atrial fibrillation (AF) interact mutually, exacerbating hemodynamic effects and causing adverse outcomes and increased healthcare costs. Monitoring hemodynamic indicators in patients with these comorbidities is crucial for effective clinical management. Transthoracic impedance cardiography (ICG) has been widely employed in assessing hemodynamic status in clinical settings. Given the limited research on the prognostic significance of ICG parameters in HF with permanent AF, we undertook this study. A total of 66 HF patients with permanent AF were included in this retrospective study, and the primary outcome was rehospitalization due to worsening HF within 180-day post-discharge. Cox regression analysis was performed to explore the connection between ICG-evaluated parameters and the outcome risk. Receiver operating characteristic (ROC) curve analysis determined the optimal cutoff values of risk factors, subsequently applied in plotting Kaplan Meier (KM) survival curves. Multivariate Cox regression analysis revealed that systemic vascular resistance (SVR) both on admission and at discharge independently predicted rehospitalization for worsening HF. ROC analysis established optimal SVR cutoff values: 320.89 (kPa s/L) on admission and 169.94 (kPa s/L) at discharge (sensitivity 70%, specificity 94.4%, area under the curve (AUC) 0.831, respectively, sensitivity 90%, specificity 55.6%, AUC 0.742). KM survival curves analysis showed that patients with SVR > 320.89 (kPa s/L) on admission had an 8.14-fold (P < 0.001) increased risk of the end-point event compared with those with SVR ≤ 320.89 (kPa s/L). Similarly, patients with SVR > 169.94 (kPa s/L) at discharge faced a risk elevated by 6.57 times (P = 0.002) relative to those with SVR ≤ 169.94 (kPa s/L). In HF patients with permanent AF, SVR measured by ICG emerges as an independent risk factor and clinical predictor for HF deterioration-related readmission within 180 days after discharge. Higher SVR levels, both upon admission and at discharge, correlate with an incremental rehospitalization risk.
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Affiliation(s)
- Zongpeng Jing
- Department of Cardiology, Aoyang Hospital Affiliated to Jiangsu University, Zhangjiagang, 215600, China
| | - Jingjing Zhang
- Department of Cardiology, Aoyang Hospital Affiliated to Jiangsu University, Zhangjiagang, 215600, China
| | - Jijun Ding
- Department of Cardiology, Aoyang Hospital Affiliated to Jiangsu University, Zhangjiagang, 215600, China
| | - Zongqian Xue
- Department of Cardiology, Aoyang Hospital Affiliated to Jiangsu University, Zhangjiagang, 215600, China.
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Siriwardhana C, Carrazana E, Liow K, Chen JJ. Racial/Ethnic Disparities in the Alzheimer's Disease Link with Cardio and Cerebrovascular Diseases, Based on Hawaii Medicare Data. J Alzheimers Dis Rep 2023; 7:1103-1120. [PMID: 37849625 PMCID: PMC10578323 DOI: 10.3233/adr-230003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 08/22/2023] [Indexed: 10/19/2023] Open
Abstract
Background There is an expanding body of literature implicating heart disease and stroke as risk factors for Alzheimer's disease (AD). Hawaii is one of the six majority-minority states in the United States and has significant racial health disparities. The Native-Hawaiians/Pacific-Islander (NHPI) population is well-known as a high-risk group for a variety of disease conditions. Objective We explored the association of cardiovascular disease with AD development based on the Hawaii Medicare data, focusing on racial disparities. Methods We utilized nine years of Hawaii Medicare data to identify subjects who developed heart failure (HF), ischemic heart disease (IHD), atrial fibrillation (AF), acute myocardial infarction (AMI), stroke, and progressed to AD, using multistate models. Propensity score-matched controls without cardiovascular disease were identified to compare the risk of AD after heart disease and stroke. Racial/Ethnic differences in progression to AD were evaluated, accounting for other risk factors. Results We found increased risks of AD for AF, HF, IHD, and stroke. Socioeconomic (SE) status was found to be critical to AD risk. Among the low SE group, increased AD risks were found in NHPIs compared to Asians for all conditions selected and compared to whites for HF, IHD, and stroke. Interestingly, these observations were found reversed in the higher SE group, showing reduced AD risks for NHPIs compared to whites for AF, HF, and IHD, and to Asians for HF and IHD. Conclusions NHPIs with poor SE status seems to be mostly disadvantaged by the heart/stroke and AD association compared to corresponding whites and Asians.
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Affiliation(s)
- Chathura Siriwardhana
- Department of Quantitative Health Sciences, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | - Enrique Carrazana
- Department of Medicine, University of Hawaii John Burns School of Medicine, Honolulu, HI, USA
| | - Kore Liow
- Department of Quantitative Health Sciences, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
- Department of Medicine, University of Hawaii John Burns School of Medicine, Honolulu, HI, USA
- Memory Disorders Center, Stroke & Neurologic Restoration Center, Hawaii Pacific Neuroscience, Honolulu, HI, USA
| | - John J. Chen
- Department of Quantitative Health Sciences, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
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9
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Pierce JB, Ikeaba U, Peters AE, DeVore AD, Chiswell K, Allen LA, Albert NM, Yancy CW, Fonarow GC, Greene SJ. Quality of Care and Outcomes Among Patients Hospitalized for Heart Failure in Rural vs Urban US Hospitals: The Get With The Guidelines-Heart Failure Registry. JAMA Cardiol 2023; 8:376-385. [PMID: 36806447 PMCID: PMC9941973 DOI: 10.1001/jamacardio.2023.0241] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/30/2023] [Indexed: 02/22/2023]
Abstract
Importance Prior studies have suggested patients with heart failure (HF) from rural areas have worse clinical outcomes. Contemporary differences between rural and urban hospitals in quality of care and clinical outcomes for patients hospitalized for HF remain poorly understood. Objective To assess quality of care and clinical outcomes for US patients hospitalized for HF at rural vs urban hospitals. Design, Setting, and Participants This retrospective cohort study analyzed 774 419 patients hospitalized for HF across 569 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry between January 1, 2014, and September 30, 2021. Postdischarge outcomes were assessed in a subset of 161 996 patients linked to Medicare claims. Data were analyzed from August 2022 to January 2023. Main Outcomes and Measures GWTG-HF quality measures, in-hospital mortality, length of stay, and 30-day mortality and readmission outcomes. Results This study included 19 832 patients (2.6%) and 754 587 patients (97.4%) hospitalized at 49 rural hospitals (8.6%) and 520 urban hospitals (91.4%), respectively. Of 774 419 included patients, 366 161 (47.3%) were female, and the median (IQR) age was 73 (62-83) years. Compared with patients at urban hospitals, patients at rural hospitals were older (median [IQR] age, 74 [64-84] years vs 73 [61-83] years; standardized difference, 10.63) and more likely to be non-Hispanic White (14 572 [73.5%] vs 498 950 [66.1%]; standardized difference, 34.47). In adjusted models, patients at rural hospitals were less likely to be prescribed cardiac resynchronization therapy (adjusted risk difference [aRD], -13.5%; adjusted odds ratio [aOR], 0.44; 95% CI, 0.22-0.92), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (aRD, -3.7%; aOR, 0.71; 95% CI, 0.53-0.96), and an angiotensin receptor-neprilysin inhibitor (aRD, -5.0%; aOR, 0.68; 95% CI, 0.47-0.98) at discharge. In-hospital mortality was similar between rural and urban hospitals (460 of 19 832 [2.3%] vs 20 529 of 754 587 [2.7%]; aOR, 0.86; 95% CI, 0.70-1.07). Patients at rural hospitals were less likely to have a length of stay of 4 or more days (aOR, 0.75; 95% CI, 0.67-0.85). Among Medicare beneficiaries, there were no significant differences between rural and urban hospitals in 30-day HF readmission (adjusted hazard ratio [aHR], 1.03; 95% CI, 0.90-1.19), all-cause readmission (aHR, 0.97; 95% CI, 0.91-1.04), and all-cause mortality (aHR, 1.05; 95% CI, 0.91-1.21). Conclusions and Relevance In this large contemporary cohort of US patients hospitalized for HF, care at rural hospitals was independently associated with lower use of some guideline-recommended therapies at discharge and shorter length of stay. In-hospital mortality and 30-day postdischarge outcomes were similar at rural and urban hospitals.
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Affiliation(s)
- Jacob B. Pierce
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Anthony E. Peters
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Adam D. DeVore
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina
| | - Larry A. Allen
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Nancy M. Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Deputy Editor, JAMA Cardiology
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles
- Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH.
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11
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Marano PJ, Steverson AB, Chen C, Ma Y, Stern RJ, Davis J, Hsue PY, Zier LS. Effect of a Novel, Evidence-Based, Standardized Discharge Checklist on 30-Day All-Cause Readmissions in Patients Hospitalized for Heart Failure in an Urban Safety Net Hospital. Am J Cardiol 2022; 182:40-45. [PMID: 36028389 DOI: 10.1016/j.amjcard.2022.06.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022]
Abstract
Safety net hospitals frequently incur financial penalties for high readmission rates. Heart failure (HF) is a common driver of readmissions, but effectively lowering readmission rates in patients with HF has proved challenging. There are few evidence-based interventions validated within safety net systems. Between October 2018 and April 2019, we implemented an evidence-based discharge checklist. We evaluated the hypothesis that it would reduce 30-day all-cause readmissions in patients admitted for HF at an urban safety net hospital. We retrospectively compared all-cause 30-day readmission rates between the cohort discharged using the checklist and historical controls. Demographics were similar between the intervention (n = 103) and control (n = 187) groups and reflected the diverse and vulnerable population cared for in the safety net. The mean age was 60 years, 71% were male, 42% were Black, 22% were Hispanic/Latinx, 28% were not housed, 35% used illicit stimulants, and 73% had a left ventricular ejection fraction ≤40%. Use of the checklist was associated with a 12.4% absolute reduction in the 30-day readmission rate (29.9% vs 17.5%, p = 0.02). The intervention group was more likely to be discharged on appropriate guideline-directed medical therapy for reduced systolic function, including β blockers (93% vs 73%, p = 0.0004), angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (92% vs 66%, p <0.0001) and mineralocorticoid receptor antagonists (50% vs 27%, p = 0.0007). Multivariable analysis demonstrated that using the discharge checklist was associated with a lower risk of 30-day all-cause readmission (risk ratio 0.54, 0.33 to 0.90). Therefore, a low-cost, novel, evidence-based discharge checklist significantly reduced 30-day all-cause readmission rates in patients hospitalized for HF at a safety net hospital.
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Affiliation(s)
- Paul J Marano
- Division of Cardiology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California.
| | - Alexandra B Steverson
- Division of Cardiology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California
| | - Caren Chen
- Division of Cardiology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California; San Francisco Department of Public Health, San Francisco, California
| | - Yifei Ma
- Division of Cardiology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California
| | - Rachel J Stern
- Division of Cardiology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California; Ventura County Healthcare Agency, Ventura, California
| | - Jonathan Davis
- Division of Cardiology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California
| | - Priscilla Y Hsue
- Division of Cardiology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California
| | - Lucas S Zier
- Division of Cardiology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California
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12
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Wenger NK, Lloyd-Jones DM, Elkind MSV, Fonarow GC, Warner JJ, Alger HM, Cheng S, Kinzy C, Hall JL, Roger VL. Call to Action for Cardiovascular Disease in Women: Epidemiology, Awareness, Access, and Delivery of Equitable Health Care: A Presidential Advisory From the American Heart Association. Circulation 2022; 145:e1059-e1071. [PMID: 35531777 PMCID: PMC10162504 DOI: 10.1161/cir.0000000000001071] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Addressing the pervasive gaps in knowledge and care delivery to reduce sex-based disparities and achieve equity is fundamental to the American Heart Association's commitment to advancing cardiovascular health for all by 2024. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders around the globe to identify and remove barriers to health care access and quality for women. A concise and current summary of existing data across the areas of risk and prevention, access and delivery of equitable care, and awareness and education provides a framework to consider knowledge gaps and research needs critical toward achieving significant progress for the health and well-being of all women.
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13
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DeVore AD, Bosworth HB, Granger BB. Improving implementation of evidence-based therapies for heart failure. Clin Cardiol 2022; 45 Suppl 1:S52-S59. [PMID: 35789019 PMCID: PMC9254671 DOI: 10.1002/clc.23845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 12/11/2022] Open
Abstract
Treatment options for patients with heart failure have improved rapidly over the last few decades. Data from large scale clinical trials demonstrate that medical and device therapies can improve quality of life, reduce hospitalizations for acute heart failure, and reduce mortality. However, the use of many of these therapies in routine practice is remarkably low. There are many reasons for suboptimal implementation of evidence-based therapies for heart failure, and we believe addressing the large gap between what can be accomplished in clinical trials versus routine practice is a critical and urgent public health issue. In this review, we outline reasons for this implementation gap and review recent studies attempting to address this issue. We also provide recommendations for future interventions and areas of clinical investigation to improve implementation for patients with heart failure.
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Affiliation(s)
- Adam D. DeVore
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
- Department of MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Hayden B. Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of MedicineDivision of General Internal Medicine, Duke University Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
- Duke University School of Nursing, Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Bradi B. Granger
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
- Duke University School of Nursing, Duke University School of MedicineDurhamNorth CarolinaUSA
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14
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Jain S, Murphy TE, O’Leary JR, Leo-Summers L, Ferrante LE. Association Between Socioeconomic Disadvantage and Decline in Function, Cognition, and Mental Health After Critical Illness Among Older Adults : A Cohort Study. Ann Intern Med 2022; 175:644-655. [PMID: 35254879 PMCID: PMC9316386 DOI: 10.7326/m21-3086] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Older adults admitted to an intensive care unit (ICU) are at risk for developing impairments in function, cognition, and mental health. It is not known whether socioeconomically disadvantaged older persons are at greater risk for these impairments than their less vulnerable counterparts. OBJECTIVE To evaluate the association between socioeconomic disadvantage and decline in function, cognition, and mental health among older survivors of an ICU hospitalization. DESIGN Retrospective analysis of a longitudinal cohort study. SETTING Community-dwelling older adults in the National Health and Aging Trends Study (NHATS). PARTICIPANTS Participants with ICU hospitalizations between 2011 and 2017. MEASUREMENTS Socioeconomic disadvantage was assessed as dual-eligible Medicare-Medicaid status. The outcome of function was defined as the count of disabilities in 7 activities of daily living and mobility tasks, the cognitive outcome as the transition from no or possible to probable dementia, and the mental health outcome as the Patient Health Questionnaire-4 score in the NHATS interview after ICU hospitalization. The analytic sample included 641 ICU hospitalizations for function, 458 for cognition, and 519 for mental health. RESULTS After accounting for sociodemographic and clinical characteristics, dual eligibility was associated with a 28% increase in disability after ICU hospitalization (incidence rate ratio, 1.28; 95% CI, 1.00 to 1.64); and nearly 10-fold greater odds of transitioning to probable dementia (odds ratio, 9.79; 95% CI, 3.46 to 27.65). Dual eligibility was not associated with symptoms of depression and anxiety after ICU hospitalization (incidence rate ratio, 1.33; 95% CI, 0.99 to 1.79). LIMITATION Administrative data, variability in timing of baseline and outcome assessments, proxy selection. CONCLUSION Dual-eligible older persons are at greater risk for decline in function and cognition after an ICU hospitalization than their more advantaged counterparts. This finding highlights the need to prioritize low-income seniors in rehabilitation and recovery efforts after critical illness and warrants investigation into factors leading to this disparity. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Terrence E. Murphy
- Program on Aging, Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - John R. O’Leary
- Program on Aging, Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Linda Leo-Summers
- Program on Aging, Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
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15
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Taylor K, Diaz A, Nuliyalu U, Ibrahim A, Nathan H. Association of Dual Medicare and Medicaid Eligibility With Outcomes and Spending for Cancer Surgery in High-Quality Hospitals. JAMA Surg 2022; 157:e217586. [PMID: 35195684 PMCID: PMC8867385 DOI: 10.1001/jamasurg.2021.7586] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Although dual eligibility (DE) status for Medicare and Medicaid has been used for social risk stratification in value-based payment programs, little is known about the interplay between hospital quality and disparities in outcomes and spending by social risk. OBJECTIVE To assess whether treatment at high-quality hospitals mitigates DE-associated disparities in outcomes and spending for cancer surgery. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study from January 1, 2014, to December 31, 2018, evaluating inpatient surgery at acute care hospitals. A total of 119 757 Medicare beneficiaries aged 65 years or older who underwent colectomy, rectal resection, lung resection, or pancreatectomy were evaluated. Data were analyzed between November 1, 2020, and April 30, 2021. EXPOSURES Medicare and Medicaid DE status and hospital quality. MAIN OUTCOMES AND MEASURES Postoperative complications, readmission, and mortality by DE status and hospital quality. RESULTS Overall, 119 757 Medicare beneficiaries underwent colectomy, rectal resection, lung resection, or pancreatectomy. The mean (SD) age was 75.3 (6.7) years, 61 617 (51.5%) were women, 7677 (6.4%) were Black, 106 099 (88.6%) were White, and 5981 (5.0%) identified as another race or ethnicity; 11.3% had DE status. Dually eligible patients were more likely to be discharged to a facility (colectomy, 15.0% [95% CI, 14.7%-15.3%] vs 23.9% [95% CI, 22.9%-24.9%]; proctectomy, 18.7% [95% CI, 18.0%-19.3%] vs 26.9% [95% CI, 24.9%-28.9%]; lung resection, 11.0% [95% CI, 10.7%-11.3%] vs 17.9% [95% CI, 16.8%-18.9%]; pancreatectomy, 23.5% [95% CI, 22.5%-24.4%] vs 30.0% [95% CI, 26.5%-33.5%]). Differences in postacute care use persisted even after accounting for postoperative complications and contributed to variation in spending. Compared with the lowest-quality hospitals, DE patients had improved rates of discharge to a facility (22.7% vs 19.3%) and spending ($22 577 vs $20 100) but rates remained increased compared with Medicare patients even at the highest-quality hospitals. CONCLUSIONS AND RELEVANCE The findings of this study indicate that, even among the highest-quality hospitals, DE patients had poorer outcomes and higher spending. Dually eligible patients were more likely to be discharged to a facility and therefore incurred higher postacute care costs. Although treatment at high-quality hospitals is associated with reduced differences in outcomes, DE patients remain at high risk for adverse postoperative outcomes and increased readmissions and postacute care use.
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Affiliation(s)
- Kathryn Taylor
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor,Department of Surgery, Stanford University, Stanford, California,Department of Surgery, University of Michigan, Ann Arbor
| | - Adrian Diaz
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor,Department of Surgery, The Ohio State University, Columbus
| | - Usha Nuliyalu
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor,Department of Surgery, University of Michigan, Ann Arbor
| | - Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor,Department of Surgery, University of Michigan, Ann Arbor
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16
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Silvestri D, Goutos D, Lloren A, Zhou S, Zhou G, Farietta T, Charania S, Herrin J, Peltz A, Lin Z, Bernheim S. Factors Associated With Disparities in Hospital Readmission Rates Among US Adults Dually Eligible for Medicare and Medicaid. JAMA HEALTH FORUM 2022; 3:e214611. [PMID: 35977231 PMCID: PMC8903116 DOI: 10.1001/jamahealthforum.2021.4611] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/02/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Low-income older adults who are dually eligible (DE) for Medicare and Medicaid often experience worse outcomes following hospitalization. Among other federal policies aimed at improving health for DE patients, Medicare has recently begun reporting disparities in within-hospital readmissions. The degree to which disparities for DE patients are owing to differences in community-level factors or, conversely, are amenable to hospital quality improvement, remains heavily debated. Objective To examine the extent to which within-hospital disparities in 30-day readmission rates for DE patients are ameliorated by state- and community-level factors. Design Setting and Participants In this retrospective cohort study, Centers for Medicare & Medicaid Services (CMS) Disparity Methods were used to calculate within-hospital disparities in 30-day risk-adjusted readmission rates for DE vs non-DE patients in US hospitals participating in Medicare. All analyses were performed in February and March 2019. The study included Medicare patients (aged ≥65 years) hospitalized for acute myocardial infarction (AMI), heart failure (HF), or pneumonia in 2014 to 2017. Main Outcomes and Measures Within-hospital disparities, as measured by the rate difference (RD) in 30-day readmission between DE vs non-DE patients following admission for AMI, HF, or pneumonia; variance across hospitals; and correlation of hospital RDs with and without adjustment for state Medicaid eligibility policies and community-level factors. Results The final sample included 475 444 patients admitted for AMI, 898 395 for HF, and 1 214 282 for pneumonia, of whom 13.2%, 17.4%, and 23.0% were DE patients, respectively. Dually eligible patients had higher 30-day readmission rates relative to non-DE patients (RD >0) in 99.0% (AMI), 99.4% (HF), and 97.5% (pneumonia) of US hospitals. Across hospitals, the mean (IQR) RD between DE vs non-DE was 1.00% (0.87%-1.10%) for AMI, 0.82% (0.73%-0.96%) for HF, and 0.53% (0.37%-0.71%) for pneumonia. The mean (IQR) RD after adjustment for community-level factors was 0.87% (0.73%-0.97%) for AMI, 0.67% (0.57%-0.80%) for HF, and 0.42% (0.29%-0.57%) for pneumonia. Relative hospital rankings of corresponding within-hospital disparities before and after community-level adjustment were highly correlated (Pearson coefficient, 0.98). Conclusions and Relevance In this cohort study, within-hospital disparities in 30-day readmission for DE patients were modestly associated with differences in state Medicaid policies and community-level factors. This suggests that remaining variation in these disparities should be the focus of hospital efforts to improve the quality of care transitions at discharge for DE patients in efforts to advance equity.
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Affiliation(s)
- David Silvestri
- National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Demetri Goutos
- The Yale Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut
| | - Anouk Lloren
- Mathematica Policy Research, Cambridge, Massachusetts
| | - Sheng Zhou
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut,The Yale Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut
| | - Guohai Zhou
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Sana Charania
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut,Flying Buttress Associates, Charlottesville, Virginia
| | - Alon Peltz
- The Yale Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut,Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Zhenqiu Lin
- The Yale Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Susannah Bernheim
- National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut,The Yale Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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17
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Piña IL, Allen LA, Desai NR. Policy and Payment Challenges in the Postpandemic Treatment of Heart Failure: Value-Based Care and Telehealth. J Card Fail 2021; 28:835-844. [PMID: 34520854 PMCID: PMC8434774 DOI: 10.1016/j.cardfail.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/13/2022]
Abstract
Increasing patient and therapeutic complexity have created both challenges and opportunities for heart failure care. Within this background, the coronavirus disease-2019 pandemic has disrupted care as usual, accelerating the need for transition from volume-based to value-based care, and demanding a rapid expansion of telehealth and remote care for heart failure. Patients, clinicians, health systems, and payors have by necessity become more invested in these issues. Herein we review recent changes in health care policy related to the movement from volume to value-based payment and from in-person to remote care delivery.
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Affiliation(s)
- Ileana L Piña
- Central Michigan University, Mount Pleasant, Michigan.
| | - Larry A Allen
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Nihar R Desai
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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