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Weight N, Moledina S, Volgman AS, Bagur R, Wijeysundera HC, Sun LY, Chadi Alraies M, Rashid M, Kontopantelis E, Mamas MA. Socioeconomic disparities in the management and outcomes of acute myocardial infarction. Heart 2023; 110:122-131. [PMID: 37558395 DOI: 10.1136/heartjnl-2023-322601] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/21/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Patients from lower socioeconomic status areas have poorer outcomes following acute myocardial infarction (AMI); however, how ethnicity modifies such socioeconomic disparities is unclear. METHODS Using the UK Myocardial Ischaemia National Audit Project (MINAP) registry, we divided 370 064 patients with AMI into quintiles based on Index of Multiple Deprivation (IMD) score, comprising seven domains including income, health, employment and education. We compared white and 'ethnic-minority' patients, comprising Black, Asian and mixed ethnicity patients (as recorded in MINAP); further analyses compared the constituents of the ethnic-minority group. Logistic regression models examined the role of the IMD, ethnicity and their interaction on the odds of in-hospital mortality. RESULTS More patients from the most deprived quintile (Q5) were from ethnic-minority backgrounds (Q5; 15% vs Q1; 4%). In-hospital mortality (OR 1.10, 95% CI 1.01 to 1.19, p=0.025) and major adverse cardiovascular event (MACE) (OR 1.07, 95% CI 1.00 to 1.15, p=0.048) were more likely in Q5, and MACE was more likely in ethnic-minority patients (OR 1.40, 95% CI 1.00 to 1.95, p=0.048) versus white (OR 1.05, 95% CI 0.98 to 1.13, p=0.027) in Q5. In subgroup analyses, Black patients had the highest in-hospital mortality within the most affluent quintile (Q1) (Black: 0.079, 95% CI 0.046 to 0.112, p<0.001; White: 0.062, 95% CI 0.059 to 0.066, p<0.001), but not in Q5 (Black: 0.065, 95% CI 0.054 to 0.077, p<0.001; White: 0.065, 95% CI 0.061 to 0.069, p<0.001). CONCLUSION Patients with a higher deprivation score were more often from an ethnic-minority background, more likely to suffer in-hospital mortality or MACE when compared with the most affluent quintile, and this relationship was stronger in ethnic minorities compared with White patients.
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Affiliation(s)
- Nicholas Weight
- Keele Cardiovascular Research Group, Keele University Faculty of Medicine & Health Sciences, Keele, UK
| | - Saadiq Moledina
- Keele Cardiovascular Research Group, Keele University Faculty of Medicine & Health Sciences, Keele, UK
| | | | - Rodrigo Bagur
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | | | - Louise Y Sun
- Division of Cardiac Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - M Chadi Alraies
- Cardiovascular Institute, Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Keele University Faculty of Medicine & Health Sciences, Keele, UK
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, Greater Manchester, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University Faculty of Medicine & Health Sciences, Keele, UK
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Ohm J, Kuja-Halkola R, Warnqvist A, Häbel H, Skoglund PH, Sundström J, Hambraeus K, Jernberg T, Svensson P. Socioeconomic Disparities and Mediators for Recurrent Atherosclerotic Cardiovascular Disease Events After a First Myocardial Infarction. Circulation 2023; 148:256-267. [PMID: 37459408 PMCID: PMC10348618 DOI: 10.1161/circulationaha.123.064440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/13/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Low socioeconomic status is associated with worse secondary prevention use and prognosis after myocardial infarction (MI). Actions for health equity improvements warrant identification of risk mediators. Therefore, we assessed mediators of the association between socioeconomic status and first recurrent atherosclerotic cardiovascular disease event (rASCVD) after MI. METHODS In this cohort study on 1-year survivors of first-ever MI with Swedish universal health coverage ages 18 to 76 years, individual-level data from SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) and linked national registries was collected from 2006 through 2020. Exposure was socioeconomic status by disposable income quintile (principal proxy), educational level, and marital status. The primary outcome was rASCVD and secondary outcomes were cardiovascular and all-cause mortality. We initially assessed the incremental attenuation of hazard ratios with 95% CIs in sequential multivariable models adding groups of potential mediators (ie, previous risk factors, acute presentation and infarct severity, initial therapies, and secondary prevention). Thereafter, the proportion of excess rASCVD associated with a low income mediated through nonparticipation in cardiac rehabilitation, suboptimal statin management, a cardiometabolic risk profile, persistent smoking, and blood pressure above target after MI were calculated using causal mediation analysis. RESULTS Among 68 775 participants (73.8% men), 7064 rASCVD occurred during a mean 5.7-year follow-up. Income, adjusted for age, sex, and calendar year, was associated with rASCVD (hazard ratio, 1.63 [95% CI, 1.51-1.76] in the lowest versus highest income quintile). Risk attenuated most by adjustment for previous risk factors and by adding secondary prevention variables for a final model (hazard ratio, 1.38 [95% CI, 1.26-1.51]) in the lowest versus highest income quintile. The proportions of the excess 15-year rASCVD risk in the lowest income quintile mediated through nonparticipation in cardiac rehabilitation, cardiometabolic risk profile, persistent smoking, and poor blood pressure control were 3.3% (95% CI 2.1-4.8), 3.9% (95% CI, 2.9-5.5), 15.2% (95% 9.1-25.7), and 1.0% (95% CI 0.6-1.5), respectively. Risk mediation through optimal statin management was negligible. CONCLUSIONS Nonparticipation in cardiac rehabilitation, a cardiometabolic risk profile, and persistent smoking mediate income-dependent prognosis after MI. In the absence of randomized trials, this causal inference approach may guide decisions to improve health equity.
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Affiliation(s)
- Joel Ohm
- Department of Emergency Medicine Solna (J.O.), Karolinska University Hospital, Stockholm, Sweden
- Coagulation Unit, Department of Hematology (J.O.), Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Solna (J.O., P.H.S.), Karolinska Institutet, Stockholm, Sweden
| | - Ralf Kuja-Halkola
- Department of Medical Epidemiology and Biostatistics (R.K.-H.), Karolinska Institutet, Stockholm, Sweden
| | - Anna Warnqvist
- Institute of Environmental Medicine, Division of Biostatistics (A.W., H.H.), Karolinska Institutet, Stockholm, Sweden
| | - Henrike Häbel
- Institute of Environmental Medicine, Division of Biostatistics (A.W., H.H.), Karolinska Institutet, Stockholm, Sweden
| | - Per H. Skoglund
- Department of Medicine Solna (J.O., P.H.S.), Karolinska Institutet, Stockholm, Sweden
- Center for Palliative Care, Stiftelsen Stockholms Sjukhem, Stockholm, Sweden (P.H.S.)
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Sweden (J.S.)
| | | | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital (T.J.), Karolinska Institutet, Stockholm, Sweden
| | - Per Svensson
- Department of Clinical Science and Education, Södersjukhuset (P.S.), Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden (P.S.)
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3
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Goitia JJ, Onwuzurike J, Chen A, Wu YL, Shen AYJ, Lee MS. Association between vehicle ownership and disparities in mortality after myocardial infarction. Am J Prev Cardiol 2023; 14:100500. [PMID: 37181802 PMCID: PMC10173400 DOI: 10.1016/j.ajpc.2023.100500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 04/12/2023] [Accepted: 04/23/2023] [Indexed: 05/16/2023] Open
Abstract
Background Access to reliable transportation is fundamental in the management of chronic disease. The purpose of this study was to investigate the association between vehicle ownership at the neighborhood-level and long-term mortality after myocardial infarction (MI). Methods This is a retrospective observational study evaluating adult patients admitted for MI between January 1st, 2006, and December 31st, 2016. Neighborhoods were defined by census tract and household vehicle ownership data was obtained from the American Community Survey courtesy of the University of California, Los Angeles Center for Neighborhood Knowledge. Patients were divided into 2 groups: those living in neighborhoods with higher vehicle ownership, and those living in neighborhoods with lower vehicle ownership. The cutoff of 4.34% of households reporting not owning a vehicle was used to define a neighborhood as one with "higher" vs "lower" vehicle ownership as this was the median value for the cohort. The association between vehicle ownership and all-cause mortality after MI was assessed using Cox proportional hazards regression models. Results A total of 30,126 patients were included (age 68.1 +/- 13.5 years, 63.2% male). After adjusting for age, sex, race/ethnicity, and medical comorbidities, lower vehicle ownership was associated with increased all-cause mortality after MI (hazard ratio [HR] 1.10; 95% confidence interval [CI] 1.06-1.14; p<0.001). This finding remained significant after adjusting for median household income (HR 1.06; 95% CI 1.02-1.10; p = 0.007). Upon comparison of White and Black patients living in neighborhoods with lower vehicle ownership; Black patients were found to have an increased all-cause mortality after MI (HR 1.21, 95% CI 1.13-1.30, p<0.001), a difference which remained significant after adjusting for income (HR 1.20; 95% CI 1.12-1.29; p<0.001). There was no significant difference in mortality between White and Black patients living in neighborhoods with higher vehicle ownership. Conclusion Lower vehicle ownership was associated with increased mortality after MI. Black patients living in neighborhoods with lower vehicle ownership had a higher mortality after MI than White patients living in similar neighborhoods but Black patients living in neighborhoods with higher vehicle ownership had no worse mortality than their White counterparts. This study highlights the importance of transportation in determining health status after MI.
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Affiliation(s)
- Jesse J Goitia
- Division of Cardiology, University of California, Irvine
- Corresponding author at: Division of Cardiology, University of California, Irvine, 333 City Blvd W, Ste 400, Orange, CA 92868, USA.
| | - James Onwuzurike
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Aiyu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Yi-Lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Albert Yuh-Jer Shen
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
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Anand VV, Zhe ELC, Chin YH, Goh RSJ, Lin C, Kueh MTW, Chong B, Kong G, Tay PWL, Dalakoti M, Muthiah M, Dimitriadis GK, Wang JW, Mehta A, Foo R, Tse G, Figtree GA, Loh PH, Chan MY, Mamas MA, Chew NWS. Socioeconomic deprivation and prognostic outcomes in acute coronary syndrome: A meta-analysis using multidimensional socioeconomic status indices. Int J Cardiol 2023:S0167-5273(23)00597-1. [PMID: 37116760 DOI: 10.1016/j.ijcard.2023.04.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/26/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Low socioeconomic status (SES) is an important prognosticator amongst patients with acute coronary syndrome (ACS). This paper analysed the effects of SES on ACS outcomes. METHODS Medline and Embase were searched for articles reporting outcomes of ACS patients stratified by SES using a multidimensional index, comprising at least 2 of the following components: Income, Education and Employment. A comparative meta-analysis was conducted using random-effects models to estimate the risk ratio of all-cause mortality in low SES vs high SES populations, stratified according to geographical region, study year, follow-up duration and SES index. RESULTS A total of 29 studies comprising of 301,340 individuals were included, of whom 43.7% were classified as low SES. While patients of both SES groups had similar cardiovascular risk profiles, ACS patients of low SES had significantly higher risk of all-cause mortality (adjusted HR:1.19, 95%CI: 1.10-1.1.29, p < 0.001) compared to patients of high SES, with higher 1-year mortality (RR:1.08, 95%CI:1.03-1.13, p = 0.0057) but not 30-day mortality (RR:1.07, 95%CI:0.98-1.16, p = 0.1003). Despite having similar rates of ST-elevation myocardial infarction and non-ST-elevation ACS, individuals with low SES had lower rates of coronary revascularisation (RR:0.95, 95%CI:0.91-0.99, p = 0.0115) and had higher cerebrovascular accident risk (RR:1.25, 95%CI:1.01-1.55, p = 0.0469). Excess mortality risk was independent of region (p = 0.2636), study year (p = 0.7271) and duration of follow-up (p = 0.0604) but was dependent on the SES index used (p < 0.0001). CONCLUSION Low SES is associated with increased mortality post-ACS, with suboptimal coronary revascularisation rates compared to those of high SES. Concerted efforts are needed to address the global ACS-related socioeconomic inequity. REGISTRATION AND PROTOCOL The current study was registered with PROSPERO, ID: CRD42022334482.
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Affiliation(s)
- Vickram Vijay Anand
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ethan Lee Cheng Zhe
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Yip Han Chin
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Rachel Sze Jen Goh
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Chaoxing Lin
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Martin Tze Wah Kueh
- Royal College of Surgeons in Ireland and University College Dublin Malaysia Campus, Malaysia
| | - Bryan Chong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Gwyneth Kong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Phoebe Wen Lin Tay
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Mayank Dalakoti
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Georgios K Dimitriadis
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK; Department of Endocrinology ASO/EASO COM, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Jiong-Wei Wang
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Surgery, Cardiovascular Research Institute (CVRI), National University of Singapore, Singapore; Nanomedicine Translational Research Programme, Centre for NanoMedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anurag Mehta
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University Pauley Heart Centre, Richmond, VA, USA
| | - Roger Foo
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; Kent and Medway Medical School, Kent, Canterbury CT2 7NT, UK
| | - Gemma A Figtree
- Northern Clinical School, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Poay Huan Loh
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Mark Y Chan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, UK; Institute of Population Health, University of Manchester, UK
| | - Nicholas W S Chew
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore.
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Minhas AMK, Jain V, Li M, Ariss RW, Fudim M, Michos ED, Virani SS, Sperling L, Mehta A. Family income and cardiovascular disease risk in American adults. Sci Rep 2023; 13:279. [PMID: 36609674 PMCID: PMC9822929 DOI: 10.1038/s41598-023-27474-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
Socioeconomic status is an overlooked risk factor for cardiovascular disease (CVD). Low family income is a measure of socioeconomic status and may portend greater CVD risk. Therefore, we assessed the association of family income with cardiovascular risk factor and disease burden in American adults. This retrospective analysis included data from participants aged ≥ 20 years from the National Health and Nutrition Examination Survey (NHANES) cycles between 2005 and 2018. Family income to poverty ratio (PIR) was calculated by dividing family (or individual) income by poverty guidelines specific to the survey year and used as a measure of socioeconomic status. The association of PIR with the presence of cardiovascular risk factors and CVD as well as cardiac mortality and all-cause mortality was examined. We included 35,932 unweighted participants corresponding to 207,073,472 weighted, nationally representative participants. Participants with lower PIR were often female and more likely to belong to race/ethnic minorities (non-Hispanic Black, Mexican American, other Hispanic). In addition, they were less likely to be married/living with a partner, to attain college graduation or higher, or to have health insurance. In adjusted analyses, the prevalence odds of diabetes mellitus, hypertension, coronary artery disease (CAD), congestive heart failure (CHF), and stroke largely decreased in a step-wise manner from highest (≥ 5) to lowest PIR (< 1). In adjusted analysis, we also noted a mostly dose-dependent association of PIR with the risk of all-cause and cardiac mortality during a mean 5.7 and 5.8 years of follow up, respectively. Our study demonstrates a largely dose-dependent association of PIR with hypertension, diabetes mellitus, CHF, CAD and stroke prevalence as well as incident all-cause mortality and cardiac mortality in a nationally representative sample of American adults. Public policy efforts should be directed to alleviate these disparities to help improve cardiovascular outcomes in vulnerable groups with low family income.
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Affiliation(s)
- Abdul Mannan Khan Minhas
- grid.414961.f0000 0004 0426 4740Department of Medicine, Forrest General Hospital, Hattiesburg, MS USA
| | - Vardhmaan Jain
- grid.189967.80000 0001 0941 6502Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA USA
| | - Monica Li
- grid.189967.80000 0001 0941 6502Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Robert W. Ariss
- grid.62560.370000 0004 0378 8294Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Marat Fudim
- grid.189509.c0000000100241216Division of Cardiology, Duke University Medical Center, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Duke Clinical Research Institute, Durham, NC USA
| | - Erin D. Michos
- grid.21107.350000 0001 2171 9311Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Salim S. Virani
- grid.39382.330000 0001 2160 926XMichael E. DeBakey Veterans Affair Medical Center and Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Laurence Sperling
- grid.189967.80000 0001 0941 6502Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA USA
| | - Anurag Mehta
- VCU Health Pauley Heart Center, Virginia Commonwealth University School of Medicine, 1200 East Broad Street, PO Box 980036, Richmond, VA, 23298, USA.
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Averill RF, Mills RE. Impact of Socioeconomic Status on Delivery System Effectiveness. J Ambul Care Manage 2023; 46:54-62. [PMID: 36102831 PMCID: PMC9722366 DOI: 10.1097/jac.0000000000000438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The socioeconomic status (SES) component of the Social Vulnerability Index ranks US counties based on the SES of county residents and was used to evaluate the impact of SES on the performance of the health care delivery system. Using Medicare fee-for-service data, the performance of the health care delivery system was evaluated based on population measures such as per capita hospital admissions, quality of care measures such as surgical mortality, postacute care measures such as readmissions, and service volume measures such as posthospitalization nursing home and rehabilitation admissions. Substantial differences in delivery system performance across SES populations were observed.
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Affiliation(s)
- Richard F. Averill
- The Hesperium Group, Seymour, Connecticut (Mr Averill); and RREntanglements, Florence, Oregon (Dr Mills)
| | - Ronald E. Mills
- The Hesperium Group, Seymour, Connecticut (Mr Averill); and RREntanglements, Florence, Oregon (Dr Mills)
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Gao J, Qu H, McGregor KM, Yadav AS, Yuen HK. Associations between Duration of Homelessness and Cardiovascular Risk Factors: A Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14698. [PMID: 36429419 PMCID: PMC9690194 DOI: 10.3390/ijerph192214698] [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: 10/27/2022] [Accepted: 11/05/2022] [Indexed: 06/16/2023]
Abstract
Cardiovascular disease (CVD) in the United States disproportionally affects people who are homeless. This disparity is a critical concern that needs to be addressed to improve the health of individuals who are homeless. The connections between a history of homelessness, i.e., its duration and frequency, and CVD risk are not well understood. The present study sought to investigate how a history of homelessness is correlated with CVD risk factors in a sample of homeless persons in the Deep South. This study recruited participants who were homeless from two local adult homeless shelters in Birmingham, AL. Participants (n = 61) underwent interviews, physical measurements, and a capillary blood draw. Their mean age was 47 years, and 82% were men. Results showed the duration of homelessness was positively associated with several CVD risk factors (diabetes mellitus, total cholesterol, and low-density lipoprotein). However, there was no significant association between frequency of homelessness and any CVD risk factors. To get the more accurate estimate of CVD risk in this population, future research should incorporate additional risk factors related to homelessness and seek to develop a robust strategy to collect an accurate history of homelessness.
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Affiliation(s)
- Jie Gao
- Department of Clinical and Diagnostic Science, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Haiyan Qu
- Department of Health Service Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Keith M. McGregor
- Department of Clinical and Diagnostic Science, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Amrej Singh Yadav
- Department of Clinical and Diagnostic Science, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Hon K. Yuen
- Department of Occupational Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Nayak SS, Borkar R, Ghozy S, Agyeman K, Al-Juboori MT, Shah J, Ulrich MT. Social vulnerability, medical care access and asthma related emergency department visits and hospitalization: An observational study. Heart Lung 2022; 55:140-145. [PMID: 35588567 DOI: 10.1016/j.hrtlng.2022.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 03/22/2022] [Accepted: 04/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Social Vulnerability Index (SVI) is a publicly available dataset to identify communities in greatest need of resources. OBJECTIVE To examine the utility of using the county-level SVI as predictors of asthma-related outcomes. METHODS We used the American Community Survey-derived SVI and the National Environmental Public Health Tracking Network - Query Tool to retrieve data for all counties with available SVI data and at least one matched outcome of interest. Then, we tested SVI as a predictor for emergency department visits (EDV) and hospitalizations, with investigating disparities in primary care physician (PCP) density and emergency department physicians (EDP) density. Linear and logistic regression models were used. RESULTS Compared to counties of the lowest SVI quartile, counties of mid-low, mid-high, and highest SVI quartiles had 1%, 4%, and 5% higher odds of asthma-related EDV per 10,000 population, respectively, and 4%, 21%, and 24% higher odds of asthma-related hospitalization per 10,000 population, respectively. Moreover, the data showed an apparent resources mismatch between the EDP densities per 10,000 populations and the SVI quartiles, and the effect of the county level SVI on the asthma-related EDV and hospitalization is not strongly affected by PCP or EDP densities. CONCLUSION The counties with the highest SVI -and the most vulnerable to asthma hazards- have a lower coverage of PCP and EDP. Interventions directed to address persistent social vulnerability would offer the opportunity of primary prevention with less exhaustion for the medical resources.
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Affiliation(s)
- Sandeep S Nayak
- Department of Internal Medicine, NYC Health + Hospitals/Metropolitan, NY 10029, USA; Department of Internal Medicine, Yale New Haven Health Bridgeport Hospital, CT 06610, USA.
| | - Rachana Borkar
- Department of Internal Medicine, NYC Health + Hospitals/Metropolitan, NY 10029, USA.
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC program), Oxford University, UK.
| | - Kwame Agyeman
- Department of Internal Medicine, Loma Linda University Medical Center, CA 92354, USA.
| | - Mohammed T Al-Juboori
- Department of Internal Medicine, NYC Health + Hospitals/Metropolitan, NY 10029, USA.
| | - Jaffer Shah
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.
| | - Michael T Ulrich
- Department of Internal Medicine, Loma Linda University Medical Center, CA 92354, USA; Department of Internal Medicine, Riverside University Health System, CA 92555, USA.
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9
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David F, Philipp J, Henrike AB, Nikolaos PP, Christine PH, Martin C, Oliver PR, Benjamin S. Impact of the Educational Level on Non-Fatal Health Outcomes following Myocardial Infarction. Curr Probl Cardiol 2022; 47:101340. [DOI: 10.1016/j.cpcardiol.2022.101340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/29/2022] [Indexed: 11/03/2022]
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10
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Boesgaard Graversen C, Brink Valentin J, Lytken Larsen M, Riahi S, Holmberg T, Paaske Johnsen S. Non-Persistence with Medication as a Mediator for the Social Inequality in Risk of Major Adverse Cardiovascular Events in Patients with Incident Acute Coronary Syndrome: A Nationwide Cohort Study. Clin Epidemiol 2021; 13:1071-1083. [PMID: 34803405 PMCID: PMC8597923 DOI: 10.2147/clep.s335133] [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: 08/19/2021] [Accepted: 10/19/2021] [Indexed: 11/29/2022] Open
Abstract
Aim Low socioeconomic status is associated with higher risk of major adverse cardiovascular events (MACE) among patients with incident acute coronary syndrome (ACS). We examined whether non-persistence with antiplatelet and statin therapy mediated the income- and educational-related inequality in risk of MACE. Methods Using national registers, all Danish patients diagnosed with incident ACS from 2010 to 2017 were identified. The primary outcome (MACE) comprised all-cause death, cardiac death and cardiac readmission. Risk of MACE was handled by discrete time analyses using inverse probability of treatment weights. The mediator variable comprised non-persistence to a combined 2-dimensional measure of statin and antiplatelet treatment. The mediation analysis was evaluated by population average effects. Results The study population was 45,874 patients, of whom 16,958 (37.0%) were non-persistent with medication and 16,365 (35.7%) suffered MACE during the median follow-up of 3.5 years. Compared to patients with low income, the adjusted hazard ratio of MACE was lowered by 33% (HR: 0.67, 95% CI: 0.61–0.72) in men and by 34% (HR: 0.66, 95% CI: 0.61–0.72) in women with high income, respectively. Similar results were observed according to level of education. A socioeconomic difference in risk of non-persistence was found in men but not women and only in relation to income. The lower risk of non-persistence observed in high-income men mediated the lower risk of MACE by 12.6% (95% CI: 11.1–14.1%) compared with low-income men. Conclusion Non-persistence with medication mediated some of the income-related inequality in risk of MACE in men, but not women, with incident ACS.
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Affiliation(s)
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Mogens Lytken Larsen
- Department of Clinical Medicine, The Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, The Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Teresa Holmberg
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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11
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Huded CP, Dalton JE, Kumar A, Krieger NI, Kassis N, Phelan M, Kravitz K, Reed GW, Krishnaswamy A, Kapadia SR, Khot U. Relationship of Neighborhood Deprivation and Outcomes of a Comprehensive ST Elevation Myocardial Infarction Protocol. J Am Heart Assoc 2021; 10:e024540. [PMID: 34779652 PMCID: PMC9075260 DOI: 10.1161/jaha.121.024540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background We evaluated whether a comprehensive ST‐segment–elevation myocardial infarction protocol (CSP) focusing on guideline‐directed medical therapy, transradial percutaneous coronary intervention, and rapid door‐to‐balloon time improves process and outcome metrics in patients with moderate or high socioeconomic deprivation. Methods and Results A total of 1761 patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention at a single hospital before (January 1, 2011–July 14, 2014) and after (July 15, 2014– July 15, 2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤50th percentile; 29.0%), moderate (51st –90th percentile; 40.8%), and high (>90th percentile; 30.2%). The primary process outcome was door‐to‐balloon time. Achievement of guideline‐recommend door‐to‐balloon time goals improved in all deprivation groups after CSP implementation (low, 67.8% before CSP versus 88.5% after CSP; moderate, 50.7% before CSP versus 77.6% after CSP; high, 65.5% before CSP versus 85.6% after CSP; all P<0.001). Median door‐to‐balloon time among emergency department/in‐hospital patients was significantly noninferior in higher versus lower deprivation groups after CSP (noninferiority limit=5 minutes; Pnoninferiority high versus moderate = 0.002, high versus low <0.001, moderate versus low = 0.02). In‐hospital mortality, the primary clinical outcome, was significantly lower after CSP in patients with moderate/high deprivation in unadjusted (before CSP 7.0% versus after CSP 3.1%; odds ratio [OR], 0.42 [95% CI, 0.25–0.72]; P=0.002) and risk‐adjusted (OR, 0.42 [95% CI, 0.23–0.77]; P=0.005) models. Conclusions A CSP was associated with improved ST‐segment–elevation myocardial infarction care across all deprivation groups and reduced mortality in those from moderate or high deprivation neighborhoods. Standardized initiatives to reduce care variability may mitigate social determinants of health in time‐sensitive conditions such as ST‐segment–elevation myocardial infarction.
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Affiliation(s)
- Chetan P Huded
- Department of Cardiology Saint Luke's Mid-America Heart Institute Kansas City MO
| | - Jarrod E Dalton
- Department of Quantitative Health Sciences Lerner Research Institute Cleveland Clinic Cleveland OH
| | - Anirudh Kumar
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH.,Center for Healthcare Delivery Innovation Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Nikolas I Krieger
- Department of Quantitative Health Sciences Lerner Research Institute Cleveland Clinic Cleveland OH
| | - Nicholas Kassis
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH.,Center for Healthcare Delivery Innovation Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Michael Phelan
- Department of Emergency Medicine Emergency Services Institute Cleveland Clinic Cleveland OH
| | - Kathleen Kravitz
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Grant W Reed
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Samir R Kapadia
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Umesh Khot
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH.,Center for Healthcare Delivery Innovation Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
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12
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van den Broek-Altenburg EM, Atherly AJ, Hess S, Benson J. The effect of unobserved preferences and race on vaccination hesitancy for COVID-19 vaccines: implications for health disparities. J Manag Care Spec Pharm 2021; 27:S4-S13. [PMID: 34534008 DOI: 10.18553/jmcp.2021.27.9-a.s4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Reducing the extra burden COVID-19 has on people already facing disparities is among the main national priorities for the COVID-19 vaccine rollout. Early reports from states releasing vaccination data by race show that White residents are being vaccinated at significantly higher rates than Black residents. Public health efforts are being targeted to address vaccine hesitancy among Black and other minority populations. However, health care interventions intended to reduce health disparities that do not reflect the underlying values of individuals in underrepresented populations are unlikely to be successful. OBJECTIVE: To identify key factors underlying the disparities in COVID-19 vaccination. METHODS: Primary data were collected from an online survey of a representative sample of the populations of the 4 largest US states (New York, California, Texas, and Florida) between August 10 and September 3, 2020. Using latent class analysis, we built a model identifying key factors underlying the disparities in COVID-19 vaccination. RESULTS: We found that individuals who identify as Black had lower rates of vaccine hesitancy than those who identify as White. This was true overall, by latent class and within latent class. This suggests that, contrary to what is currently being reported, Black individuals are not universally more vaccine hesitant. Combining the respondents who would not consider a vaccine (17%) with those who would consider one but ultimately choose not to vaccinate (11%), our findings indicate that more than 1 in 4 (28%) persons will not be willing to vaccinate. The no-vaccine rate is highest in White individuals and lowest in Black individuals. CONCLUSIONS: Results suggest that other factors, potentially institutional, are driving the vaccination rates for these groups. Our model results help point the way to more effective differentiated policies. DISCLOSURES: No funding was received for this study. The authors have nothing to disclose.
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Affiliation(s)
| | - Adam J Atherly
- Larner College of Medicine, University of Vermont, Burlington
| | - Stephane Hess
- Choice Modelling Centre and Institute for Transport Studies, University of Leeds, United Kingdom
| | - Jamie Benson
- Larner College of Medicine, University of Vermont, Burlington
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13
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Yue D, Ponce NA, Needleman J, Ettner SL. The relationship between educational attainment and hospitalizations among middle-aged and older adults in the United States. SSM Popul Health 2021; 15:100918. [PMID: 34568538 PMCID: PMC8449049 DOI: 10.1016/j.ssmph.2021.100918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND There has been little research on the relationship between education and healthcare utilization, especially for racial/ethnic minorities. This study aimed to examine the association between education and hospitalizations, investigate the mechanisms, and disaggregate the relationship by gender, race/ethnicity, and age groups. METHODS A retrospective cohort analysis was conducted using data from the 1992-2016 US Health and Retirement Study. The analytic sample consists of 35,451 respondents with 215,724 person-year observations. We employed a linear probability model with standard errors clustered at the respondent level and accounted for attrition bias using an inverse probability weighting approach. RESULTS On average, compared to having an education less than high school, having a college degree or above was significantly associated with an 8.37 pp (95% CI, -9.79 pp to -7.95 pp) lower probability of being hospitalized, and having education of high school or some college was related to 3.35 pp (95% CI, -4.57 pp to -2.14 pp) lower probability. The association slightly attenuated after controlling for income but dramatically reduced once holding health conditions constant. Specifically, given the same health status and childhood environment conditions, compared to those with less than high school degree, college graduates saw a 1.79 pp (95% CI, -3.16 pp to -0.42 pp) lower chance of being hospitalized, but the association for high school graduates became indistinguishable from zero. Additionally, the association was larger for females, whites, and those younger than 78. The association was statistically significantly smaller for black college graduates than their white counterparts, even when health status is held constant. CONCLUSIONS Educational attainment is a strong predictor of hospitalizations for middle-aged and older US adults. Health mediates most of the education-hospitalization gradients. The heterogeneous results across age, gender, race, and ethnicity groups should inform further research on health disparities.
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Affiliation(s)
- Dahai Yue
- Department of Health Policy and Management, University of Maryland School of Public Health, 4200 Valley Drive, College Park, MD, 20742, USA
| | - Ninez A. Ponce
- Department of Health Policy and Management, University of California, Los Angeles, USA
| | - Jack Needleman
- Department of Health Policy and Management, University of California, Los Angeles, USA
| | - Susan L. Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, USA
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14
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van den Broek-Altenburg EM, Atherly AJ, Hess S, Benson J. Valuing diversity in value assessment: introducing the PhRMA Foundation Health Disparities Challenge Award. J Manag Care Spec Pharm 2021; 27:S2-S3. [PMID: 34534009 PMCID: PMC10408392 DOI: 10.18553/jmcp.2021.27.9-a.s2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES:: No funding supported the writing of this article. The author has received grants from BeiGene, Ltd., and Pfizer, Inc., and advisory board fees from PhRMA Foundation.
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Affiliation(s)
| | - Adam J Atherly
- Larner College of Medicine, University of Vermont, Burlington
| | - Stephane Hess
- Choice Modelling Centre and Institute for Transport Studies, University of Leeds, United Kingdom
| | - Jamie Benson
- Larner College of Medicine, University of Vermont, Burlington
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15
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Moledina A, Tang KL. Socioeconomic Status, Mortality, and Access to Cardiac Services After Acute Myocardial Infarction in Canada: A Systematic Review and Meta-analysis. CJC Open 2021; 3:950-964. [PMID: 34401702 PMCID: PMC8347872 DOI: 10.1016/j.cjco.2021.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/01/2021] [Indexed: 12/13/2022] Open
Abstract
Background Low socioeconomic status (SES) is an important prognosticator for those with acute myocardial infarction (AMI), having previously been described to be associated with increased short-term mortality. Whether this effect persists over time, and whether access to cardiac interventions is equitable within Canada’s universal health care system, remains unknown. Methods We conducted a systematic review to determine the associations of SES with mortality and access to a spectrum of interventions including cardiac catheterization, revascularization, and cardiac rehabilitation. Electronic databases (EMBASE and MEDLINE) were searched in March 2019 and December 2019. Original studies from Canada examining associations between SES and any of the above outcomes in AMI patients were included. Meta-analyses were conducted using random effects models. Results Nineteen studies were included, 11 of which could be meta-analyzed. Low SES was associated with a 48% and 34% increase in short-term and intermediate-term mortality, respectively. There was a trend toward increased long-term mortality more than 1-year post-event (pooled odds ratio [OR] 1.34 [95% confidence interval {CI} 0.95-1.88]). Low SES was also associated with lower rates of cardiac catheterization (pooled OR 0.80 [95% CI 0.65-0.99]) and revascularization (pooled OR 0.76 [95% CI 0.63-0.90]) post-AMI. Studies on cardiac rehabilitation showed reduced access and participation in low-SES groups. Conclusions Low SES is associated with not only increased mortality post-AMI, but also reduced access to cardiac interventions that have demonstrated benefits for mortality and morbidity. Interventions that improve access to catheterization, revascularization, and cardiac rehabilitation for low-SES populations are needed if true equitable care in Canada is desired.
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Affiliation(s)
- Aliza Moledina
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Karen L Tang
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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16
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Goitia J, Phan DQ, Lee MS, Moore N, Mansukhani P, Aharonian V, Brar SS, Zadegan R. The role of neighborhood disadvantage in predicting mortality in patients after transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2021; 98:E938-E946. [PMID: 34259367 DOI: 10.1002/ccd.29872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/10/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Neighborhoods have a powerful impact on health. Prior investigations into disparities associated with transcatheter aortic valve replacement (TAVR) have focused on race and access to the procedure. We sought to investigate the role of neighborhood disadvantage on mortality post-TAVR. METHODS Patients who underwent TAVR at Kaiser Permanente Los Angeles Medical Center between June, 2011 and March, 2019 were evaluated. Neighborhood disadvantage was defined using the area deprivation index, an established and validated index that considers multiple socioeconomic metrics. Cutoffs used for disadvantage were national percentile ≥25% and state decile ≥6. Cox proportional hazards regression analysis was used to assess outcomes. RESULTS A total of 668 patients (age 82.1 ± 7.5 years, 49% female) were included, of which 215 (32.2%) were from disadvantaged neighborhoods by state decile, and 167 (25%) by national percentile. At a median follow-up of 18.8 months (interquartile range 8.7-36.5 months), neighborhood disadvantage was independently associated with increased all-cause mortality (National percentile: hazard ratio [HR] 1.91, 95% confidence interval [CI] 1.35-2.69; state decile: HR 1.68, 95% CI 1.21-2.34). On propensity scored analysis, neighborhood disadvantaged remained independently associated with increased all-cause mortality (National percentile: IPTW HR 1.86, 95% CI 1.52-2.28, PSM HR 1.67, 95% CI 1.11-2.51; state decile: IPTW HR 1.55, 95% CI 1.26-1.91, PSM HR 2.0, 95% CI 1.33-2.99). CONCLUSION Living in a disadvantaged neighborhood was independently associated with increased mortality post-TAVR on multivariate and propensity score matched analysis. Further investigations into the role of neighborhood disadvantage are needed to address disparities and improve outcomes post-TAVR.
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Affiliation(s)
- Jesse Goitia
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Derek Q Phan
- Regional Cardiac Catheterization Lab, Kaiser Permanente, Los Angeles, California, USA
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Naing Moore
- Regional Cardiac Catheterization Lab, Kaiser Permanente, Los Angeles, California, USA
| | - Prakash Mansukhani
- Regional Cardiac Catheterization Lab, Kaiser Permanente, Los Angeles, California, USA
| | - Vicken Aharonian
- Regional Cardiac Catheterization Lab, Kaiser Permanente, Los Angeles, California, USA
| | - Somjot S Brar
- Regional Cardiac Catheterization Lab, Kaiser Permanente, Los Angeles, California, USA
| | - Ray Zadegan
- Regional Cardiac Catheterization Lab, Kaiser Permanente, Los Angeles, California, USA
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17
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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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18
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Wu CX, Suresh E, Phng FWL, Tai KP, Pakdeethai J, D'Souza JLA, Tan WS, Phan P, Lew KSM, Tan GYH, Chua GSW, Hwang CH. Effect of a Real-Time Risk Score on 30-day Readmission Reduction in Singapore. Appl Clin Inform 2021; 12:372-382. [PMID: 34010978 DOI: 10.1055/s-0041-1726422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To develop a risk score for the real-time prediction of readmissions for patients using patient specific information captured in electronic medical records (EMR) in Singapore to enable the prospective identification of high-risk patients for enrolment in timely interventions. METHODS Machine-learning models were built to estimate the probability of a patient being readmitted within 30 days of discharge. EMR of 25,472 patients discharged from the medicine department at Ng Teng Fong General Hospital between January 2016 and December 2016 were extracted retrospectively for training and internal validation of the models. We developed and implemented a real-time 30-day readmission risk score generation in the EMR system, which enabled the flagging of high-risk patients to care providers in the hospital. Based on the daily high-risk patient list, the various interfaces and flow sheets in the EMR were configured according to the information needs of the various stakeholders such as the inpatient medical, nursing, case management, emergency department, and postdischarge care teams. RESULTS Overall, the machine-learning models achieved good performance with area under the receiver operating characteristic ranging from 0.77 to 0.81. The models were used to proactively identify and attend to patients who are at risk of readmission before an actual readmission occurs. This approach successfully reduced the 30-day readmission rate for patients admitted to the medicine department from 11.7% in 2017 to 10.1% in 2019 (p < 0.01) after risk adjustment. CONCLUSION Machine-learning models can be deployed in the EMR system to provide real-time forecasts for a more comprehensive outlook in the aspects of decision-making and care provision.
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Affiliation(s)
- Christine Xia Wu
- Quality, Innovation and Improvement, Ng Teng Fong General Hospital, Singapore
| | - Ernest Suresh
- Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | | | - Kai Pik Tai
- Quality, Innovation and Improvement, Ng Teng Fong General Hospital, Singapore
| | | | | | - Woan Shin Tan
- Health Services and Outcomes Research, National Healthcare Group, Singapore
| | - Phillip Phan
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States.,Department of Medicine, National University of Singapore, Singapore
| | - Kelvin Sin Min Lew
- Quality, Innovation and Improvement, Ng Teng Fong General Hospital, Singapore
| | | | | | - Chi Hong Hwang
- Quality, Innovation and Improvement, Ng Teng Fong General Hospital, Singapore
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19
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Farwati M, Saad AM, Jain V, Ahuja KR, Bansal A, Gad MM, Isogai T, Abdelfattah O, Shekhar S, Kassis N, Hariri E, Svensson L, Krishnaswamy A, Kapadia S. Impact of Economic Status on Utilization and Outcomes of Transcatheter Aortic Valve Implantation and Mitraclip. Am J Cardiol 2021; 142:116-123. [PMID: 33285094 DOI: 10.1016/j.amjcard.2020.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
Data on the impact of economic status on Transcatheter aortic valve implantation (TAVI) and MitraClip (MC) is lacking. Patients who underwent TAVI and/or MC during 2012 to 2017 were identified in the Nationwide Readmission Database and divided by zip code estimated income quartile into 4 groups (Q1 to Q4). The utilization of TAVI and/or MC was defined as the number of TAVIs and/or MCs over all admissions with an aortic and/or mitral valve disease (AVD and/or MVD) and represented per 1,000 admissions. A total of 168,853 patients underwent TAVI; 20.6% in Q1, 26.3% in Q2, 27.3% in Q3, and 25.8% in Q4, while 15,387 patients underwent MC; 22% in Q1, 26.2% in Q2, 26.3% in Q3, and 25.5% in Q4. The annual utilization of TAVIs and/or MCs increased over the study period and was generally lower with lower income. In 2012, TAVI was performed for 8.2, 8.8, 10.8, and 11.3 per 1,000 AVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2017, TAVI was performed for 54.1, 65.1, 68.6, and 71 per 1,000 AVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2014, MC was performed for 1.6, 2.1, 1.8, and 1.9 per 1,000 MVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2017, MC was performed for 5.6, 6.5, 8, and 8 per 1,000 MVD admissions in Q1, Q2, Q3, and Q4, respectively. In-hospital mortality, stroke, and 30-day readmissions were generally comparable across groups. Lower-income patients may be underrepresented among patients undergoing TAVI and MC despite comparable outcomes. Further studies are needed to examine the etiologies behind these disparities and identify targeted strategies for its mitigation.
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Hoyler MM, Abramovitz MD, Ma X, Khatib D, Thalappillil R, Tam CW, Samuels JD, White RS. Social determinants of health affect unplanned readmissions following acute myocardial infarction. J Comp Eff Res 2021; 10:39-54. [PMID: 33438461 DOI: 10.2217/cer-2020-0135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Low socioeconomic status predicts inferior clinical outcomes in many patient populations. The effects of patient insurance status and hospital safety-net status on readmission rates following acute myocardial infarction are unclear. Materials & methods: A retrospective review of State Inpatient Databases for New York, California, Florida and Maryland, 2007-2014. Results: A total of 1,055,162 patients were included. Medicaid status was associated with 37.7 and 44.0% increases in risk-adjusted readmission odds at 30 and 90 days (p < 0.0001). Uninsured status was associated with reduced odds of readmission at both time points. High-burden safety-net status was associated with 9.6 and 9.5% increased odds of readmission at 30 and 90 days (p < 0.0003). Conclusion: Insurance status and hospital safety-net burden affect readmission odds following acute myocardial infarction.
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Affiliation(s)
- Marguerite M Hoyler
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Mark D Abramovitz
- Department of Electrical Engineering, Princeton University, Engineering Quadrangle, 41 Olden Street, Princeton, NJ 08544, USA
| | - Xiaoyue Ma
- Department of Healthcare Policy & Research, Weill Cornell Medicine, 428 East 72nd St., Suite 800A, NY 10021, USA
| | - Diana Khatib
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Richard Thalappillil
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Christopher W Tam
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Jon D Samuels
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Robert S White
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
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Johnston KJ, Joynt Maddox KE. The Role Of Social, Cognitive, And Functional Risk Factors In Medicare Spending For Dual And Nondual Enrollees. Health Aff (Millwood) 2020; 38:569-576. [PMID: 30933581 DOI: 10.1377/hlthaff.2018.05032] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Centers for Medicare and Medicaid Services is increasingly focused on value-based payment programs, which tie payment to performance on quality and cost measures. In this context, there is rising concern that such programs systematically disadvantage providers that care for vulnerable populations, such as the poor, by holding the providers accountable for factors beyond their control that influence patient outcomes and utilization. In this nationally representative study of Medicare beneficiaries, we found that dually enrolled Medicare beneficiaries (those also enrolled in Medicaid) had strikingly higher levels of medical, functional, and cognitive comorbidities, as well as social needs, compared to their non-dually enrolled counterparts. Dual enrollees also had significantly higher annual costs of care. Including functional, cognitive, and social factors in cost prediction, in addition to risk factors derived from medical claims, improved risk prediction and decreased differences between dual and nondual enrollees. Medicare could consider such adjustment to improve accuracy and fairness in value-based payment programs.
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Affiliation(s)
- Kenton J Johnston
- Kenton J. Johnston ( ) is an assistant professor of health management and policy at Saint Louis University, in Missouri
| | - Karen E Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine (cardiology) at the Washington University School of Medicine, in St. Louis
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Stankovic N, Høybye M, Lind PC, Holmberg M, Andersen LW. Socioeconomic status and in-hospital cardiac arrest: A systematic review. Resusc Plus 2020; 3:100016. [PMID: 34223299 PMCID: PMC8244497 DOI: 10.1016/j.resplu.2020.100016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/06/2020] [Accepted: 06/27/2020] [Indexed: 12/15/2022] Open
Abstract
Aim To perform a review of the literature on the association between socioeconomic status and risk of and outcomes after in-hospital cardiac arrest. Data sources PubMed and Embase were searched on January 24, 2020 for studies evaluating the association between socioeconomic status and risk of and/or outcomes after in-hospital cardiac arrest. Two reviewers independently screened the titles/abstracts and selected full texts for relevance. Data were extracted from included studies. Risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool. Results The literature search yielded 4960 unique records. We included nine studies evaluating the association between socioeconomic status and risk of and/or outcomes after in-hospital cardiac arrest. All studies were observational cohort studies, of which seven were from the USA. Seven studies were in an adult population, while two studies were in a pediatric population. Results were overall inconsistent although some studies found a higher in-hospital cardiac arrest incidence in patients from low-income communities. There was no clear association between other socioeconomic factors (i.e. education, occupation, marital status, and insurance) and risk of or outcomes after in-hospital cardiac arrest. Due to the scarcity and heterogeneity of available studies, meta-analyses were not performed. Conclusion There are limited data regarding the association between socioeconomic status and risk of and outcomes after in-hospital cardiac arrest and further research is warranted. Understanding the association between socioeconomic status and in-hospital cardiac arrest may reveal strategies to mitigate potential inequalities.
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Affiliation(s)
- Nikola Stankovic
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Maria Høybye
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Peter Carøe Lind
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mathias Holmberg
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Lars W. Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Olof Palmes Allé 34, Aarhus N, 8200, Denmark
- Corresponding author. Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Bygning J, Plan 1, Aarhus N, 8200, Denmark.
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Johnston KJ, Mittler J, Hockenberry JM. Patient social risk factors and continuity of care for Medicare beneficiaries. Health Serv Res 2020; 55:445-456. [PMID: 32037553 DOI: 10.1111/1475-6773.13272] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To identify patient social risk factors associated with Continuity of Care (COC) index. DATA SOURCES/STUDY SETTING Medicare Current Beneficiary Survey (MCBS), the Dartmouth Institute, and Area Resource File for 2006-2013. STUDY DESIGN We use regression methods to assess the effect of patient social risk factors on COC after adjusting for medical complexity. In secondary analyses, we assess the effect of social risk factors on annual utilization of physicians and specialists for evaluation and management (E&M). DATA COLLECTION/EXTRACTION METHODS We retrospectively identified 59 499 patient years for Medicare beneficiaries with one year of enrollment and three or more E&M visits. PRINCIPAL FINDINGS After adjustment for medical complexity, individual-level social risk factors such as lack of education, low income, and living alone are all associated with better patient COC (P < .05). Similarly, area-level social risk factors such as living in areas that are nonurban or high poverty, as well as in areas with low specialist or high primary care physician supply, are all associated with better patient COC (P < .05). We found the opposite pattern of associations between these same risk factors and annual patient utilization of physicians and specialists (P < .05). CONCLUSIONS Medicare patients with multiple social risk factors have consistently better COC; these same social risk factors are associated with reduced patient-realized access to specialist physician care.
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Affiliation(s)
- Kenton J Johnston
- Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri
| | - Jessica Mittler
- Department of Health Administration, College of Health Professions, Virginia Commonwealth University, Richmond, Virginia
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Mukhopadhyay A, D'Angelo R, Senser E, Whelan K, Wee CC, Mukamal KJ. Racial and insurance disparities among patients presenting with chest pain in the US: 2009-2015. Am J Emerg Med 2019; 38:1373-1376. [PMID: 31843328 DOI: 10.1016/j.ajem.2019.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 11/12/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Nationally representative studies have shown significant racial and socioeconomic disparities in the triage and diagnostic evaluation of patients presenting to the emergency department (ED) with chest pain. However, these studies were conducted over a decade ago and have not been updated amidst growing awareness of healthcare disparities. OBJECTIVE We aimed to reevaluate the effect of race and insurance type on triage acuity and diagnostic testing to assess if these disparities persist. METHODS We identified ED visits for adults presenting with chest pain in the 2009-2015 National Hospital Ambulatory Health Care Surveys. Using weighted logistic regression, we examined associations between race and payment type with triage acuity and likelihood of ordering electrocardiography (ECG) or cardiac enzymes. RESULTS A total of 10,441 patients met inclusion criteria, corresponding to an estimated 51.4 million patients nationwide. When compared with white patients, black patients presenting with chest pain were less likely to have an ECG ordered (adjusted odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.69-0.99). Patients with Medicare, Medicaid, and no insurance were also less likely to have an ECG ordered compared to patients with private insurance (Medicare: OR = 0.79, CI = 0.63-0.99; Medicaid: OR = 0.67, CI = 0.53-0.84; no insurance: OR = 0.68, CI = 0.55-0.84). Those with Medicare and Medicaid were less likely to be triaged emergently (Medicare: OR = 0.84, CI = 0.71-0.99; Medicaid: OR = 0.76, CI = 0.64-0.91) and those with Medicare were less likely to have cardiac enzymes ordered (OR = 0.84, CI = 0.72-0.98). CONCLUSIONS Persistent racial and insurance disparities exist in the evaluation of chest pain in the ED. Compared to earlier studies, disparities in triage acuity and cardiac enzymes appear to have diminished, but disparities in ECG ordering have not. Given current Class I recommendations for ECGs on all patients presenting with chest pain emergently, our findings highlight the need for improvement in this area.
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Affiliation(s)
- Amrita Mukhopadhyay
- Department of Cardiology, New York University, New York, NY, United States; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States.
| | - Robert D'Angelo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Ethan Senser
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Cardiology, Dartmouth University, Hanover, NH, United States
| | - Kyle Whelan
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Cardiology, Dartmouth University, Hanover, NH, United States
| | - Christina C Wee
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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Roberts ET, Mellor JM, McInerney M, Sabik LM. State variation in the characteristics of Medicare-Medicaid dual enrollees: Implications for risk adjustment. Health Serv Res 2019; 54:1233-1245. [PMID: 31576563 DOI: 10.1111/1475-6773.13205] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment. DATA SOURCE 2010-2013 Medicare Current Beneficiary Survey. STUDY DESIGN Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies. PRINCIPAL FINDINGS Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs. CONCLUSIONS Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.
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Affiliation(s)
- Eric T Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | | | | | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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Johnston KJ, Wen H, Schootman M, Joynt Maddox KE. Association of Patient Social, Cognitive, and Functional Risk Factors with Preventable Hospitalizations: Implications for Physician Value-Based Payment. J Gen Intern Med 2019; 34:1645-1652. [PMID: 31025305 PMCID: PMC6667509 DOI: 10.1007/s11606-019-05009-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 12/04/2018] [Accepted: 03/04/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Ambulatory care-sensitive condition (ACSC) hospitalizations are used to evaluate physicians' performance in Medicare value-based payment programs. However, these measures may disadvantage physicians caring for vulnerable populations because they omit social, cognitive, and functional factors that may be important determinants of hospitalization. OBJECTIVE To determine whether social, cognitive, and functional risk factors are associated with ACSC hospitalization rates and whether adjusting for them changes outpatient safety-net providers' performance. DESIGN Using data from the Medicare Current Beneficiary Survey, we conducted patient-level multivariable regression to estimate the association (as incidence rate ratios (IRRs)) between patient-reported social, cognitive, and functional risk factors and ACSC hospitalizations. We compared outpatient safety-net and non-safety-net providers' performance after adjusting for clinical comorbidities alone and after additional adjustment for social, cognitive, and functional factors captured in survey data. SETTING Safety-net and non-safety-net clinics. PARTICIPANTS Community-dwelling Medicare beneficiaries contributing 38,616 person-years from 2006 to 2013. MEASUREMENTS Acute and chronic ACSC hospitalizations. RESULTS After adjusting for clinical comorbidities, Alzheimer's/dementia (IRR 1.30, 95% CI 1.02-1.65), difficulty with 3-6 activities of daily living (ADLs) (IRR 1.43, 95% CI 1.05-1.94), difficulty with 1-2 instrumental ADLs (IADLs, IRR 1.54, 95% CI 1.26-1.90), and 3-6 IADLs (IRR 1.90, 95% CI 1.49-2.43) were associated with acute ACSC hospitalization. Low income (IRR 1.28, 95% CI 1.03-1.58), lack of educational attainment (IRR 1.33, 95% CI 1.04-1.69), being unmarried (IRR 1.18, 95% CI 1.01-1.36), difficulty with 1-2 IADLs (IRR 1.30, 95% CI 1.05-1.60), and 3-6 IADLs (IRR 1.44, 95% CI 1.16-1.80) were associated with chronic ACSC hospitalization. Adding these factors to standard Medicare risk adjustment eliminated outpatient safety-net providers' performance gap (p < .05) on ACSC hospitalization rates relative to non-safety-net providers. CONCLUSIONS Social, cognitive, and functional risk factors are independently associated with ACSC hospitalizations. Failure to account for them may penalize outpatient safety-net providers for factors that are beyond their control.
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Affiliation(s)
- Kenton J Johnston
- Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA.
| | - Hefei Wen
- Department of Health Management and Policy, University of Kentucky, Lexington, KY, USA
| | - Mario Schootman
- Department of Clinical Analytics and Insights, Center for Clinical Excellence, SSM Health, St. Louis, MO, USA
| | - Karen E Joynt Maddox
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA
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Survivors of an Acute Coronary Syndrome With Lower Patient Activation Are More Likely to Experience Declines in Health-Related Quality of Life. J Cardiovasc Nurs 2019; 33:168-178. [PMID: 28574974 DOI: 10.1097/jcn.0000000000000429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patient activation comprises the knowledge, skills, and confidence for self-care and may lead to better health outcomes. OBJECTIVES We examined the relationship between patient activation and changes in health-related quality of life (HRQOL) after hospitalization for an acute coronary syndrome (ACS). METHODS We studied patients from 6 medical centers in central Massachusetts and Georgia who had been hospitalized for an ACS between 2011 and 2013. At 1 month after hospital discharge, the patients completed the 6-item Patient Activation Measure and were categorized into 4 levels of activation. Multinomial logistic regression analyses compared activation level with clinically meaningful changes (≥3.0 points, generic; ≥10.0 points, disease-specific) in generic physical (SF-36v2 Physical Component Summary [PCS]), generic mental (SF-36v2 Mental Component Summary [MCS]), and disease-specific (Seattle Angina Questionnaire [SAQ]) HRQOL from 1 to 3 and 1 to 6 months after hospitalization, adjusting for potential sociodemographic and clinical confounders. RESULTS The patients (N = 1042) were, on average, 62 years old, 34% female, and 87% non-Hispanic white. A total of 10% were in the lowest level of activation. The patients with the lowest activation had 1.95 times (95% confidence interval, 1.05-3.62) and 2.18 times (95% confidence interval, 1.17-4.05) the odds of experiencing clinically significant declines in MCS and SAQ HRQOL, respectively, between 1 and 6 months than the most activated patients. The patient activation level was not associated with meaningful changes in PCS scores. CONCLUSIONS Hospital survivors of an ACS with lower activation may be more likely to experience declines in mental and disease-specific HRQOL than more-activated patients, identifying a group at risk of poor outcomes.
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Bennett KK, Smith AJ, Harry KM, Clark JMR, Waters MA, Umhoefer AJ, Bergland DS, Eways KR, Wilson EJ. Multilevel Factors Predicting Cardiac Rehabilitation Attendance and Adherence in Underserved Patients at a Safety-Net Hospital. J Cardiopulm Rehabil Prev 2019; 39:97-104. [DOI: 10.1097/hcr.0000000000000383] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Carter J, Ward C, Thorndike A, Donelan K, Wexler DJ. Social Factors and Patient Perceptions Associated With Preventable Hospital Readmissions. J Patient Exp 2019; 7:19-26. [PMID: 32128367 PMCID: PMC7036679 DOI: 10.1177/2374373518825143] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Preventable hospital readmissions are costly and erode the quality of care delivery.
Few efforts to incorporate the patient perspectives and social factors associated with
readmission preventability exist. Objective: To identify patient perceptions and social barriers to care related to readmission. Methods: Prospective cohort study of 202 respondents readmitted within 30 days of hospital
discharge from 2 inpatient adult medicine units at Massachusetts General Hospital,
Boston, Massachusetts between January 2012 and January 2016. Results: Few participants indicated that their readmission was due to unattainable health care
after discharge. Almost half indicated that they needed more general assistance to stay
well outside the hospital. Those reporting a barrier related to at least 2 measures of
social determinants of health were more likely to have preventable readmissions (34% vs
17%, P = .006). Participants with a history of homelessness or
substance use disorder were more likely to have preventable readmissions (44% vs 20%,
P = .04 and 32% vs 18%, P = .03, respectively). Conclusion: Strengthening nonmedical support systems and general social policy may be required to
reduce preventable readmissions.
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Affiliation(s)
- Jocelyn Carter
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Charlotte Ward
- Center for Healthcare Studies, Northwestern University, Chicago, IL, USA.,Center for Health Statistics, University of Chicago, Chicago, IL, USA
| | - Anne Thorndike
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Karen Donelan
- Harvard Medical School, Boston, MA, USA.,Mongan Institute for Health Policy Center, Massachusetts General Hospital, Boston, MA, USA
| | - Deborah J Wexler
- Harvard Medical School, Boston, MA, USA.,MGH Diabetes Center, Boston, MA, USA
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Steele L, Palmer J, Lloyd A, Fotheringham J, Iqbal J, Grech ED. Impact of socioeconomic status on survival following ST-elevation myocardial infarction in a universal healthcare system. Int J Cardiol 2019; 276:26-30. [DOI: 10.1016/j.ijcard.2018.11.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/02/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
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Huo X, Khera R, Zhang L, Herrin J, Bai X, Wang Q, Lu Y, Nasir K, Hu S, Li J, Li X, Zheng X, Masoudi FA, Spertus JA, Krumholz HM, Jiang L. Education level and outcomes after acute myocardial infarction in China. Heart 2019; 105:946-952. [PMID: 30661037 PMCID: PMC6582708 DOI: 10.1136/heartjnl-2018-313752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 11/25/2018] [Accepted: 11/30/2018] [Indexed: 11/13/2022] Open
Abstract
Objective To assess the association between educational attainment and acute myocardial infarction (AMI) outcomes in China to inform future healthcare interventions. Methods We used data from the China Patient-centred Evaluative Assessment of Cardiac Events-Prospective AMI study of 3369 consecutive patients hospitalised with AMI from 53 hospitals. Educational attainment was categorised as: high (senior high school, college or postgraduate degree), intermediate (junior high school) or low (primary school or illiterate). We used survival models to assess the relationship between education and 1-year major adverse cardiovascular events (MACE), all-cause mortality, both unadjusted and after adjustment for demographic characteristics and cardiovascular risk factors. Results The median participant age was 61 (52, 69) years, 23.2% were women, and 33.3% had high, 32.4% intermediate and 34.3% low educational attainment. In unadjusted analysis, compared with high educational attainment, low educational attainment was associated with a higher 1-year risk of MACE (HR 2.41, 95% CI 1.72 to 3.37) and death (HR for low vs high education 3.09, 95% CI 1.69 to 5.65). In risk-adjusted analyses, the association between education and death was attenuated and no longer statistically significant (adjusted HR 1.41, 95% CI 0.74 to 2.69, p=0.30). However, the risk of 1-year MACE (adjusted HR 1.68, 95% CI 1.18 to 2.41, p=0.004) remained significantly greaterin low educational attainment group. Conclusions In a national Chinese cohort of patients hospitalised with AMI, low educational attainment was associated with a higher risk of adverse events in the year following discharge. This association highlights the need to consider interventions to improve AMI outcomes in adults with low levels of education. Clinical trial registration NCT01624909; Results.
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Affiliation(s)
- Xiqian Huo
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Lihua Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xueke Bai
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qianying Wang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Lu
- Center for Outcomes Research and Evaluation, Yale-New Heaven Hospital, New Heaven, Connecticut, USA
| | - Khurram Nasir
- Center for Outcomes Research and Evaluation, Yale-New Heaven Hospital, New Heaven, Connecticut, USA
| | - Shuang Hu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Connecticut, USA
| | - John A Spertus
- Health Outcomes Research, Saint Luke's Mid America Heart Institude/University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Center for Outcomes Research and Evaluation, Yale-New Heaven Hospital, New Heaven, Connecticut, USA.,Department of Health Policy and Management, Yale Univeristy School of Public Health, New Heaven, Connecticut, USA
| | - Lixin Jiang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lee JH, Kim MS, Yoo BS, Park SJ, Park JJ, Shin MS, Youn JC, Lee SE, Jang SY, Choi S, Cho HJ, Kang SM, Choi DJ. KSHF Guidelines for the Management of Acute Heart Failure: Part II. Treatment of Acute Heart Failure. Korean Circ J 2019; 49:22-45. [PMID: 30637994 PMCID: PMC6331324 DOI: 10.4070/kcj.2018.0349] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 10/14/2018] [Accepted: 12/18/2018] [Indexed: 12/11/2022] Open
Abstract
The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic HF were introduced in March 2016. However, chronic and acute HF represent distinct disease entities. Here, we introduce the Korean guidelines for the management of acute HF with reduced or preserved ejection fraction. Part II of this guideline covers the treatment of acute HF.
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Affiliation(s)
- Ju Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Min Seok Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Su Yoo
- Division of Cardiology, Department of Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea.
| | - Sung Ji Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Joo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Mi Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jong Chan Youn
- Division of Cardiology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Sang Eun Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Se Yong Jang
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Seonghoon Choi
- Division of Cardiology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyun Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seok Min Kang
- Division of Cardiology, Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ju Choi
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
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Biswas S, Andrianopoulos N, Duffy SJ, Lefkovits J, Brennan A, Walton A, Chan W, Noaman S, Shaw JA, Ajani A, Clark DJ, Freeman M, Hiew C, Oqueli E, Reid CM, Stub D. Impact of Socioeconomic Status on Clinical Outcomes in Patients With ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2019; 12:e004979. [DOI: 10.1161/circoutcomes.118.004979] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sinjini Biswas
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
| | - Stephen J. Duffy
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia (J.L., A.A.)
| | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
| | - Antony Walton
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
| | - William Chan
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia (W.C., D.S.)
| | - Samer Noaman
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
| | - James A. Shaw
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
| | - Andrew Ajani
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia (J.L., A.A.)
| | - David J. Clark
- Department of Cardiology, Austin Health, Melbourne, Australia (D.J.C.)
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia (M.F.)
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Australia (C.H.)
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Australia (E.O.)
| | - Christopher M. Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- School of Public Health, Curtin University, Perth, Australia (C.M.R.)
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia (W.C., D.S.)
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Alonso F, Nazzal C, Cerecera F, Ojeda JI. Reducing Health Inequalities: Comparison of Survival After Acute Myocardial Infarction According to Health Provider in Chile. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2018; 49:127-141. [PMID: 30428269 DOI: 10.1177/0020731418809851] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Health inequalities are marked in Chile. To address this situation, a health reform was implemented in 2005 that guarantees acute myocardial infarction (AMI) health care for the entire population. We evaluated if the health reform changed AMI early and long-term survival rates by hospital provider (public/private) using a longitudinal population-based study of patients ≥15 years with a first AMI in Chile between 2002 and 2011. Time trends and early (within 28 days) and long-term (29-365 days) survival by age were assessed. We identified 59,557 patients: median age of 64 years; 68.9% men; 83.2% treated at public hospitals; 74.4% with public insurance. Early and long-term case-fatality was higher at public hospitals (14.6% vs 9.3%; P < .001 and 5.8% vs 3.3%; P < .001, respectively). There was a higher annual increase for early and long-term survival in public hospitals, 0.008 percentage points (95% CI: 0.006, 0.009; P < .0001) and 0.03 (0.002, 0.003; P < .0001), than in private hospitals, 0.0002 (95% CI: -0.0001, 0.005; P = .10) and 0.002 (95% CI: 0.0007, 0.003; P = .004), respectively. Being served at public hospitals affected early and long-term survival, especially in patients <70 years: hazard ratio was 2.01 (95% CI: 1.77, 2.28) and 3.11 (2.41, 4.01), respectively. Therefore, even if inequalities persist, there was a higher increase in early and long-term survival in public versus private hospitals.
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Affiliation(s)
- Faustino Alonso
- 1 School of Public Health, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Carolina Nazzal
- 1 School of Public Health, Faculty of Medicine, University of Chile, Santiago, Chile
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Graham GN, Jones PG, Chan PS, Arnold SV, Krumholz HM, Spertus JA. Racial Disparities in Patient Characteristics and Survival After Acute Myocardial Infarction. JAMA Netw Open 2018; 1:e184240. [PMID: 30646346 PMCID: PMC6324589 DOI: 10.1001/jamanetworkopen.2018.4240] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Black patients experience worse outcomes than white patients following acute myocardial infarction (AMI). OBJECTIVE To examine the degree to which nonrace characteristics explain observed survival differences between white patients and black patients following AMI. DESIGN, SETTING, AND PARTICIPANTS This cohort study used the extensive socioeconomic and clinical characteristics from patients recovering from an AMI that were prospectively collected at 31 hospitals across the contiguous United States between 2003 and 2008 for the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery registry and the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status registry. Survival was assessed using data from the National Death Index. Data were analyzed from December 2016 to July 2018. MAIN OUTCOMES AND MEASURES Patient characteristics were categorized into 8 domains, and the degree to which each domain discriminated self-identified black patients from white patients was determined by calculating propensity scores associated with black race for each domain as well as cumulatively across all domains. The final propensity score was associated with 1- and 5-year mortality rates. RESULTS Among 6402 patients (mean [SD] age, 60 [13] years; 2127 [33.2%] female; 1648 [25.7%] black individuals), the 5-year mortality rate following AMI was 28.9% (476 of 1648) for black patients and 18.0% (856 of 4754) for white patients (hazard ratio, 1.72; 95% CI, 1.54-1.92; P < .001). Most categories of patient characteristics differed substantially between black patients and white patients. The cumulative propensity score discriminated race, with a C statistic of 0.89, and the propensity scores were associated with 1- and 5-year mortality rates (hazard ratio for the 75th percentile of the propensity score vs 25th percentile, 1.72; 95% CI, 1.43-2.08; P < .001). Patients in the lowest propensity score quintile associated with being a black individual (regardless of whether they were of white or black race) had a 5-year mortality rate of 15.5%, while those in the highest quintile had a 5-year mortality rate of 31.0% (P < .001). After adjusting for the propensity associated with being a black patient, there was no significant mortality rate difference by race (adjusted hazard ratio, 1.09; 95% CI, 0.93-1.26; P = .37) and no statistical interaction between race and propensity score (P = .42). CONCLUSIONS AND RELEVANCE Characteristics of black patients and white patients differed significantly at the time of admission for AMI. Those characteristics were associated with an approximately 3-fold difference in 5-year mortality rate following AMI and mediated most of the observed mortality rate difference between the races.
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Affiliation(s)
- Garth N Graham
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City
| | - Philip G Jones
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City
| | - Paul S Chan
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City
| | - Suzanne V Arnold
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - John A Spertus
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City
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Carter J, Walton A, Donelan K, Thorndike A. Implementing community health worker-patient pairings at the time of hospital discharge: A randomized control trial. Contemp Clin Trials 2018; 74:32-37. [PMID: 30291997 DOI: 10.1016/j.cct.2018.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 09/24/2018] [Accepted: 09/28/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND In 2011, there were approximately 3.3 million adult 30-day all-cause hospital readmissions in the US generating $41.3 billion in hospital costs. Community health worker (CHW) care delivery is one of very few interventions demonstrated to reduce health care utilization among populations with chronic disease. While there are a number of studies demonstrating improved disease-specific outcomes with CHW interventions, studies examining the effect of CHW care delivery on 30-day readmission rates are rare. METHODS This study is a randomized control trial designed to determine if linking hospitalized patients with chronic disease to community health workers (CHWs) can decrease 30-day readmissions. Participants were randomly assigned to receive the 30-day CHW intervention or usual care (no CHW). All study participants completed surveys at baseline and the end of the study 30 days post-discharge. The primary outcome was 30-day readmission and secondary outcomes included emergency department visits, missed appointments, and patient satisfaction. RESULTS We plan to enroll 1200 hospitalized patients during a 24-month intervals. As of December 2017, 350 patients have been consented and randomly assigned to either the intervention or control arm. A number of challenges have been encountered in implementing a CHW initiative at the time of hospital discharge. CONCLUSION This trial tests the effectiveness of CHW care delivery at the time of hospital discharge in reducing 30-day readmission rates and improving outcomes among patients with chronic disease. We describe and discuss challenges in launching this CHW intervention and strategies utilized to overcome these obstacles. Clinical Trials.gov registration submitted 3/14/2017: Protocol ID# 2017A050810 and Clinical Trials.gov ID# NCT03085264 Community Health Worker Care Transitions Study (C-CAT).
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Affiliation(s)
- Jocelyn Carter
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Anne Walton
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Karen Donelan
- Mongan Institute for Health Policy Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Anne Thorndike
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Copeland LA, Zeber JE, Thibodeaux LV, McIntyre RT, Stock EM, Hochhalter AK. Postdischarge Correlates of Health Literacy Among Medicaid Inpatients. Popul Health Manag 2018; 21:493-500. [PMID: 29596034 DOI: 10.1089/pop.2017.0095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Health literacy may represent a target for intervention to improve hospital transitions. This study analyzed the association of health literacy with postdischarge utilization among Medicaid patients treated in an integrated health care system. Discharged inpatients covered by Medicaid (N = 112) participated in this observational study set in a single 600-bed hospital in a private, nonprofit, integrated health care system in the southwestern United States. Participants completed surveys within 15 days of discharge, self-reporting demographics, self-care behaviors, and 2 measures of health literacy (REALM-SF [Short Form of the Rapid Estimate of Adult Literacy in Medicine] and Chew [health literacy screen from Chew et al]). Electronic medical records data were incorporated to determine occurrence of 30-day/90-day postdischarge emergency visits and readmission. Half the respondents (54%) scored at the high-school grade equivalent on REALM-SF, while 46% scored adequate health literacy on the Chew. Forty percent (40%) experienced either emergency care or readmission within 90 days post discharge. Patients who were younger, female, or living with children had relatively better health literacy. Health literacy itself was not associated with readmission or postdischarge emergency care, although African American race was. Although Medicaid patients varied considerably on health literacy, this factor was not associated with adverse health care outcomes. Future work should better identify individuals requiring supportive transition services to reduce problems following hospital discharge.
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Affiliation(s)
- Laurel A Copeland
- 1 Center for Applied Health Research , Baylor Scott & White Health, Temple, Texas
- 2 VA Central Western Massachusetts Healthcare , Leeds, Massachusetts
- 3 Department of Psychiatry, UT Health , San Antonio, Texas
| | - John E Zeber
- 1 Center for Applied Health Research , Baylor Scott & White Health, Temple, Texas
- 3 Department of Psychiatry, UT Health , San Antonio, Texas
- 4 Central Texas Veterans Health Care System , Temple, Texas
| | | | | | - Eileen M Stock
- 6 VA Maryland Health Care System , Perry Point, Maryland
| | - Angela K Hochhalter
- 5 Baylor Scott & White Health , Temple, Texas
- 7 Texas A&M Health Science Center , Temple, Texas
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Tang KL, Pilote L, Behlouli H, Godley J, Ghali WA. An exploration of the subjective social status construct in patients with acute coronary syndrome. BMC Cardiovasc Disord 2018; 18:22. [PMID: 29409448 PMCID: PMC5801903 DOI: 10.1186/s12872-018-0759-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 01/26/2018] [Indexed: 03/21/2023] Open
Abstract
Background Perception of low subjective social status (SSS) relative to others in society or in the community has been associated with increased risk of cardiovascular disease. Our objectives were to determine whether low SSS in society was associated with barriers to access to care or hospital readmission in patients with established cardiovascular disease, and whether perceptions of discordantly high SSS in the community modified this association. Methods We conducted a prospective cohort study from 2009 to 2013 in Canada, United States, and Switzerland in patients admitted to hospital with acute coronary syndrome (ACS). Data on access to care and SSS variables were obtained at baseline. Readmission data were obtained 12 months post-discharge. We conducted multivariable logistic regression to model the odds of access to care and readmission outcomes in those with low versus high societal SSS. Results One thousand ninety patients admitted with ACS provided both societal and community SSS rankings. The low societal SSS cohort had greater odds of reporting that their health was affected by lack of health care access (OR 1.48, 95% CI 1.11, 1.97) and of experiencing cardiac readmissions (1.88, 95% CI 1.15, 3.06). Within the low societal SSS cohort, there was a trend toward fewer access to care barriers for those with discordantly high community SSS though findings varied based on the outcome variable. There were no statistically significant differences in readmissions based on community SSS rankings. Conclusion Low societal SSS is associated with increased barriers to access to care and cardiac readmissions. Though attenuated, these trends remained even when adjusting for clinical and sociodemographic factors, suggesting that perceived low societal SSS has health effects above and beyond objective socioeconomic factors. Furthermore, high community SSS may potentially mitigate the risk of experiencing barriers to access to health care in those with low societal SSS, though these associations were not statistically significant. Subjective social status relative to society versus relative to the community seem to represent distinct concepts. Insight into the differences between these two SSS constructs is imperative in the understanding of cardiovascular health and future development of public health policies. Electronic supplementary material The online version of this article (10.1186/s12872-018-0759-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karen L Tang
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
| | - Louise Pilote
- Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, 687 Pine Ave West, Montreal, Quebec, H3A 1A1, Canada.,Division of General Internal Medicine, McGill University Health Centre, 687 Pine Ave West, Montreal, Quebec, H3A 1A1, Canada
| | - Hassan Behlouli
- Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, 687 Pine Ave West, Montreal, Quebec, H3A 1A1, Canada
| | - Jenny Godley
- Department of Sociology, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.,O' Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - William A Ghali
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.,O' Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
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Abstract
PURPOSE Cardiac rehabilitation (CR) is a program of structured exercise and interventions for coronary risk factor reduction that reduces morbidity and mortality rates following a major cardiac event. Although a dose-response relationship between the number of CR sessions completed and health outcomes has been demonstrated, adherence with CR is not high. In this study, we examined associations between the number of sessions completed within CR and patient demographics, clinical characteristics, smoking status, and socioeconomic status (SES). METHODS Multiple logistic regression and classification and regression tree (CART) modeling were used to examine associations between participant characteristics measured at CR intake and the number of sessions completed in a prospectively collected CR clinical database (n = 1658). RESULTS Current smoking, lower SES, nonsurgical diagnosis, exercise-limiting comorbidities, and lower age independently predicted fewer sessions completed. The CART analysis illustrates how combinations of these characteristics (ie, risk profiles) predict the number of sessions completed. Those with the highest-risk profile for nonadherence (<65 years old, current smoker, lower SES) completed on average 9 sessions while those with the lowest-risk profile (>72 years old, not current smoker, higher SES, surgical diagnosis) completed 27 sessions on average. CONCLUSIONS Younger individuals, as well as those who report smoking or economic challenges or have a nonsurgical diagnosis, may require additional support to maintain CR session attendance.
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40
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Carter J, Ward C, Wexler D, Donelan K. The association between patient experience factors and likelihood of 30-day readmission: a prospective cohort study. BMJ Qual Saf 2017; 27:683-690. [PMID: 29146680 DOI: 10.1136/bmjqs-2017-007184] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/09/2017] [Accepted: 10/15/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Hospital care comprises nearly a third of US healthcare expenditures. Fifteen to 20 per cent of this spending is considered to be potentially preventable. Risk prediction models have suboptimal accuracy and typically exclude patient experience data. No studies have explored patient perceptions of the likelihood of readmission during index admission. Our objective was to examine associations between patient perceptions of care during index hospital admission and 30-day readmission. DESIGN Prospective cohort study. SETTING Two inpatient adult medicine units at Massachusetts General Hospital, Boston, Massachusetts. PARTICIPANTS Eight hundred and forty-six patients admitted to study units between January 2012 and January 2016 who met eligibility criteria and consented to enrolment. MAIN OUTCOME Odds of 30-day readmission. RESULTS Of 1754 eligible participants, 846 (48%) were enrolled and 201 (23.8%) were readmitted within 30 days. Readmitted participants were less likely to have a high school diploma/GED (44.3% not readmitted vs 53.5% readmitted, P=0.02). In multivariable models adjusting for baseline differences, respondents who reported being 'very satisfied' with the care received during the index hospitalisation were less likely to be readmitted (adjusted OR 0.61, 95% CI 0.43 to 0.88, P=0.007). Participants reporting doctors 'always listened to them carefully' were less likely to be readmitted (adjusted OR 0.68, 95% CI 0.48 to 0.97, P=0.03). Participants reporting they were 'very likely' to be readmitted were not more likely to be readmitted (adjusted OR 1.35, 95% CI 0.83 to 2.19, P=0.22). CONCLUSION Participants reporting high satisfaction and good provider communication were less likely to be readmitted. Rates of readmission were increased among participants stating they were very likely to be readmitted though this association was not statistically significant. Incorporating patient-reported measures during index hospitalisations may improve readmission prediction.
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Affiliation(s)
- Jocelyn Carter
- Department of Medicine, Massachussetts General Hospital, Boston, Massachusetts, USA
| | - Charlotte Ward
- Center for Healthcare Studies, Northwestern University, Bridgeview, Illinois, USA.,Center for Health Statistics, University of Chicago, Chicago, Illinois, USA
| | - Deborah Wexler
- Diabetes Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen Donelan
- Department of Medicine, Massachussetts General Hospital, Boston, Massachusetts, USA.,Mongan Institute for Health Policy Centre, Massachusetts General Hospital, Boston, Massachusetts, USA
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Khera R, Jain S, Pandey A, Agusala V, Kumbhani DJ, Das SR, Berry JD, de Lemos JA, Girotra S. Comparison of Readmission Rates After Acute Myocardial Infarction in 3 Patient Age Groups (18 to 44, 45 to 64, and ≥65 Years) in the United States. Am J Cardiol 2017; 120:1761-1767. [PMID: 28865892 PMCID: PMC5825232 DOI: 10.1016/j.amjcard.2017.07.081] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 11/24/2022]
Abstract
Postacute myocardial infarction (AMI) readmissions are common among Medicare beneficiaries (≥65 years) and are associated with significant resource utilization. However, patterns of AMI readmissions for younger age groups in the United States are not known. In the Nationwide Readmissions Database, a nationally representative all-payer database of inpatient hospitalizations, we identified 212,171 index AMI hospitalizations in January to November 2013, weighted to represent 478,247 hospitalizations nationally (mean age 66.9 years, 38% women, 29% low income). This included 26,516 cases in the 18 to 44 age group, 183,703 in the 45 to 64 age group, and 268,027 in the ≥65 age group. The overall 30-day readmission rate was 14.5% and varied across age groups (9.7% [18 to 44], 11.2% [45 to 64], and 17.3% [≥65]). The cumulative cost of 30-day readmissions was $1.1 billion, of which $365 million was spent on those <65 years of age. In multivariable hierarchical models, the risk of readmission was higher in women and in low-income patients, but the effect varied by age (p value for age-gender and age-income interactions <0.05) and was more prominent in the younger age groups. Further, patients in all age groups continue to have a high hospitalization burden beyond the typical 30-day readmission period, with an overall 24% post-AMI 90-day readmission rate. In conclusion, readmissions in young and middle-aged AMI survivors pose a substantial burden on patients and on U.S. health-care resources. Women and low-income patients with AMI, particularly those in younger age groups, are more frequently readmitted, and readmissions continue to burden the health-care system beyond the typical 30-day window. Future investigations would need to be targeted toward a better understanding and improvement of the rehospitalization burden for vulnerable patient groups.
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Affiliation(s)
- Rohan Khera
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas.
| | - Snigdha Jain
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Ambarish Pandey
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas
| | - Vijay Agusala
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas
| | - Dharam J Kumbhani
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas
| | - Sandeep R Das
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas
| | - Jarett D Berry
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas
| | - James A de Lemos
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas
| | - Saket Girotra
- Division of Cardiology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa
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Dupre ME, Nelson A, Lynch SM, Granger BB, Xu H, Willis JM, Curtis LH, Peterson ED. Identifying Nonclinical Factors Associated With 30-Day Readmission in Patients with Cardiovascular Disease: Protocol for an Observational Study. JMIR Res Protoc 2017; 6:e118. [PMID: 28619703 PMCID: PMC5491895 DOI: 10.2196/resprot.7434] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/18/2017] [Accepted: 05/05/2017] [Indexed: 12/17/2022] Open
Abstract
Background Cardiovascular disease (CVD) is the leading cause of hospitalization in older adults and high readmission rates have attracted considerable attention as actionable targets to promote efficiency in care and to reduce costs. Despite a plethora of research over the past decade, current strategies to predict readmissions have been largely ineffective and efforts to identify novel clinical predictors have been largely unsuccessful. Objective The objective of this study is to examine a wide array of socioeconomic, psychosocial, behavioral, and clinical factors to predict risks of 30-day hospital readmission in cardiovascular patients. Methods The study includes patients (aged 18 years and older) admitted for the treatment of cardiovascular-related illnesses at the Duke Heart Center, which is among the nation’s largest and top-ranked cardiovascular care hospitals. The study uses a novel standardized survey to ascertain data on a comprehensive array of patient characteristics that will be linked to their electronic medical records. A series of univariate and multivariate models will be used to estimate the associations between the patient-level factors and 30-day readmissions. The performance of the risk models will be examined based on 2 components of accuracy—model calibration and discrimination—to determine how closely the predicted outcome agrees with the observed (actual) outcome and how well the model distinguishes patients who were readmitted and those who were not. The purpose of this paper is to present the protocol for the implementation of this study. Results The study was launched in February 2014 and is actively recruiting patients from the Heart Center. Approximately 550 patients have been enrolled to date and the study is expected to continue recruitment until February 2018. Preliminary results show that participants in the study were aged 63.6 years on average (SD 14.0), predominately male (61.2%), and primarily non-Hispanic white (64.6%) or non-Hispanic black (31.7%). The demographic characteristics of study participants were not significantly different from all patients admitted to the Heart Center during this period with an average age of 65.0 years (SD 15.3) and predominately male (58.6%), non-Hispanic white (62.9%) or non-Hispanic black (31.8%) The integration of the interview data with clinical data from the patient electronic medical records is currently underway. The study has received funding and ethical approval. Conclusions Many US hospitals continue to struggle with high readmission rates in patients with cardiovascular disease. The primary objective of this study is to collect and integrate a comprehensive array of patient attributes to develop a powerful yet parsimonious model to stratify risks of rehospitalization in cardiovascular patients. The results of this research also have the potential to identify actionable targets for tailored interventions to improve patient outcomes.
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Affiliation(s)
- Matthew E Dupre
- Duke Clinical Research Institute, Duke University, Durham, NC, United States.,Department of Sociology, Duke University, Durham, NC, United States.,Department of Community and Family Medicine, Duke University, Durham, NC, United States
| | - Alicia Nelson
- Department of Community and Family Medicine, Duke University, Durham, NC, United States
| | - Scott M Lynch
- Department of Sociology, Duke University, Durham, NC, United States
| | - Bradi B Granger
- Duke University School of Nursing, Duke University, Durham, NC, United States
| | - Hanzhang Xu
- Duke University School of Nursing, Duke University, Durham, NC, United States
| | - Janese M Willis
- Department of Community and Family Medicine, Duke University, Durham, NC, United States
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
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Gaalema DE, Elliott RJ, Morford ZH, Higgins ST, Ades PA. Effect of Socioeconomic Status on Propensity to Change Risk Behaviors Following Myocardial Infarction: Implications for Healthy Lifestyle Medicine. Prog Cardiovasc Dis 2017; 60:159-168. [PMID: 28063785 PMCID: PMC5498261 DOI: 10.1016/j.pcad.2017.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/02/2017] [Indexed: 01/04/2023]
Abstract
Failure to change risk behaviors following myocardial infarction (MI) increases the likelihood of recurrent MI and death. Lower-socioeconomic status (SES) patients are more likely to engage in high-risk behaviors prior to MI. Less well known is whether propensity to change risk behaviors after MI also varies inversely with SES. We performed a systematized literature review addressing changes in risk behaviors following MI as a function of SES. 2160 abstracts were reviewed and 44 met eligibility criteria. Behaviors included smoking cessation, cardiac rehabilitation (CR), medication adherence, diet, and physical activity (PA). For each behavior, lower-SES patients were less likely to change after MI. Overall, lower-SES patients were 2 to 4 times less likely to make needed behavior changes (OR's 0.25-0.56). Lower-SES populations are less successful at changing risk behaviors post-MI. Increasing their participation in CR/secondary prevention programs, which address multiple risk behaviors, including increasing PA and exercise, should be a priority of healthy lifestyle medicine (HLM).
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Affiliation(s)
- Diann E Gaalema
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT; Department of Psychiatry, University of Vermont, Burlington, VT; Department of Psychological Science, University of Vermont, Burlington, VT.
| | - Rebecca J Elliott
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT; Department of Psychiatry, University of Vermont, Burlington, VT
| | - Zachary H Morford
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT; Department of Psychiatry, University of Vermont, Burlington, VT; Department of Psychological Science, University of Vermont, Burlington, VT
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT; Department of Psychiatry, University of Vermont, Burlington, VT; Department of Psychological Science, University of Vermont, Burlington, VT
| | - Philip A Ades
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT; Department of Medicine, Division of Cardiology, University of Vermont Medical Center, Burlington, VT
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44
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Navathe AS, Zhong F, Lei VJ, Chang FY, Sordo M, Topaz M, Navathe SB, Rocha RA, Zhou L. Hospital Readmission and Social Risk Factors Identified from Physician Notes. Health Serv Res 2017; 53:1110-1136. [PMID: 28295260 DOI: 10.1111/1475-6773.12670] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To evaluate the prevalence of seven social factors using physician notes as compared to claims and structured electronic health records (EHRs) data and the resulting association with 30-day readmissions. STUDY SETTING A multihospital academic health system in southeastern Massachusetts. STUDY DESIGN An observational study of 49,319 patients with cardiovascular disease admitted from January 1, 2011, to December 31, 2013, using multivariable logistic regression to adjust for patient characteristics. DATA COLLECTION/EXTRACTION METHODS All-payer claims, EHR data, and physician notes extracted from a centralized clinical registry. PRINCIPAL FINDINGS All seven social characteristics were identified at the highest rates in physician notes. For example, we identified 14,872 patient admissions with poor social support in physician notes, increasing the prevalence from 0.4 percent using ICD-9 codes and structured EHR data to 16.0 percent. Compared to an 18.6 percent baseline readmission rate, risk-adjusted analysis showed higher readmission risk for patients with housing instability (readmission rate 24.5 percent; p < .001), depression (20.6 percent; p < .001), drug abuse (20.2 percent; p = .01), and poor social support (20.0 percent; p = .01). CONCLUSIONS The seven social risk factors studied are substantially more prevalent than represented in administrative data. Automated methods for analyzing physician notes may enable better identification of patients with social needs.
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Affiliation(s)
- Amol S Navathe
- Division of Health Policy, University of Pennsylvania, Philadelphia, PA.,CMC Philadelphia VA Medical Center, Philadelphia, PA.,Leonard Davis Institute of Health Economics, The Wharton School, University of Pennsylvania, Philadelphia, PA.,Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Feiran Zhong
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Victor J Lei
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Frank Y Chang
- Clinical Informatics, Partners eCare, Partners Healthcare Inc., Boston, MA
| | - Margarita Sordo
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.,Clinical Informatics, Partners eCare, Partners Healthcare Inc., Boston, MA
| | - Maxim Topaz
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Shamkant B Navathe
- School of Computer Science, College of Computing, Georgia Institute of Technology, Atlanta, GA
| | - Roberto A Rocha
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.,Clinical Informatics, Partners eCare, Partners Healthcare Inc., Boston, MA
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.,Clinical Informatics, Partners eCare, Partners Healthcare Inc., Boston, MA
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45
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Arpey NC, Gaglioti AH, Rosenbaum ME. How Socioeconomic Status Affects Patient Perceptions of Health Care: A Qualitative Study. J Prim Care Community Health 2017; 8:169-175. [PMID: 28606031 PMCID: PMC5932696 DOI: 10.1177/2150131917697439] [Citation(s) in RCA: 212] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Clinician perceptions of patients with low socioeconomic status (SES) have been shown to affect clinical decision making and health care delivery in this group. However, it is unknown how and if low SES patients perceive clinician bias might affect their health care. Methods: In-depth interviews with 80 enrollees in a state Medicaid program were analyzed to identify recurrent themes in their perceptions of care. Results: Most subjects perceived that their SES affected their health care. Common themes included treatment provided, access to care, and patient-provider interaction. Discussion: This study highlights complex perceptions patients have around how SES affects their health care. These results offer opportunities to reduce health care disparities through better understanding of their impact on the individual patient-provider relationship. This work may inform interventions that promote health equity via a multifaceted approach, which targets both providers and the health care system as a whole.
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Affiliation(s)
- Nicholas C Arpey
- 1 University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Anne H Gaglioti
- 2 National Center for Primary Care, Morehouse School of Medicine, Atlanta, GA, USA
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46
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Cafagna G, Seghieri C. Educational level and 30-day outcomes after hospitalization for acute myocardial infarction in Italy. BMC Health Serv Res 2017; 17:18. [PMID: 28069004 PMCID: PMC5220616 DOI: 10.1186/s12913-016-1966-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 12/21/2016] [Indexed: 12/01/2022] Open
Abstract
Background There is a growing interest in the factors that influence short-term mortality and readmission after hospitalization for acute myocardial infarction (AMI) since such outcomes are commonly considered as hospital performance measures. Socioeconomic status (SES) is one of the factors contributing to healthcare outcomes after hospitalization for AMI. However, no study has been published on education and 30-day readmission in Europe. The objective of this study is to examine the association between educational level and 30-day mortality and readmission among patients hospitalized for AMI in Tuscany (Italy). Methods A retrospective cohort study using data from hospital discharge records was conducted. The analysis included all patients discharged with a principal diagnosis of AMI between January 1, 2011, and November 30, 2014, from all hospitals in Tuscany. Educational level was categorized as low (no middle school diploma), mid (middle school diploma) and high (high school diploma or more). Three multilevel models were developed, sequentially controlling for patient-level socio-demographic and clinical variables and hospital-level variables. Patients were stratified by age (≤75 and >75 years). Results Mortality analysis included 23,402 patients, readmission analysis included 22,181 patients. In both unadjusted and full-adjusted models, patients with a high education had lower odds of 30-day mortality compared to those patients with low education (OR age ≤ 75 years 0.67, 95% CI:0.47–0.94; OR age > 75 years 0.72, 95% CI:0.54–0.95). With regard to 30-day readmission, only patients aged over 75 years with a high education had lower odds of short-term readmission compared to those patients with low education (OR age > 75 0.73, 95% CI:0.58–0.93). Conclusions Among patients hospitalized in Tuscany for AMI, low levels of education were associated with increased odds of 30-day mortality for both age groups and increased odds of 30-day readmission only for patients aged over 75 years. Our findings suggest that the educational component should not be underestimated in order to improve short-term outcomes, which are considered as performance measures at the hospital level. Hospital managers might consider strategies that are sensitive to patients with low SES, such as providing post-hospitalization support to less-educated patients and promoting a healthier lifestyle, to improve both health equity and performance outcomes.
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Affiliation(s)
- Gianluca Cafagna
- Health and Management Laboratory (MeS Lab), Institute of Management, Sant'Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy.
| | - Chiara Seghieri
- Health and Management Laboratory (MeS Lab), Institute of Management, Sant'Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy
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47
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Gaalema DE, Savage PD, Rengo JL, Cutler AY, Higgins ST, Ades PA. Financial incentives to promote cardiac rehabilitation participation and adherence among Medicaid patients. Prev Med 2016; 92:47-50. [PMID: 26892911 PMCID: PMC4985497 DOI: 10.1016/j.ypmed.2015.11.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/20/2015] [Accepted: 11/27/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE Cardiac rehabilitation (CR) improves medical outcomes after myocardial infarction or coronary revascularization. Lower socioeconomic status (SES) patients are less likely to participate in and complete CR. The aim of this study was to test whether financial incentives may increase participation and adherence to CR among lower-SES patients. METHODS Patients eligible to participate in CR with Medicaid insurance coverage were approached for inclusion. Patients were placed on an escalating incentive schedule of financial incentives contingent upon CR attendance. CR participation was compared to a usual care group of 101 Medicaid patients eligible for CR in the 18months prior to the study. Attendance (participating in ≥one CR sessions) and adherence (sessions completed out of 36) were compared between groups. The study was conducted in Vermont, USA, 2013-2015. RESULTS Of 13 patients approached to be in the study and receive incentives, 10 (77%) agreed to participate. All 10 patients completed at least one session of CR, significantly greater than the 25/101 (25%) in the control condition (p<0.001). Of patients in both groups who attended at least one session of CR, adherence was higher in the intervention group (average of 31.1 sessions completed vs. 13.6 in the control group, p<0.001). CR completion rates were also higher during the intervention with 8 of 10 (80%) intervention patients completing all 36 sessions compared to only 2 of 25 (8%) control patients (p<0.001). CONCLUSIONS Financial incentives may be an efficacious strategy for increasing CR participation and adherence among Medicaid patients.
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Affiliation(s)
- Diann E Gaalema
- Vermont Center on Behavior and Health, University of Vermont, United States; Department of Psychiatry, University of Vermont, United States; Department of Psychology, University of Vermont, United States.
| | - Patrick D Savage
- Department of Medicine, Division of Cardiology, University of Vermont Medical Center, United States
| | - Jason L Rengo
- Department of Medicine, Division of Cardiology, University of Vermont Medical Center, United States
| | - Alexander Y Cutler
- Vermont Center on Behavior and Health, University of Vermont, United States; Department of Psychiatry, University of Vermont, United States
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, University of Vermont, United States; Department of Psychiatry, University of Vermont, United States; Department of Psychology, University of Vermont, United States
| | - Philip A Ades
- Vermont Center on Behavior and Health, University of Vermont, United States; Department of Medicine, Division of Cardiology, University of Vermont Medical Center, United States
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48
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Cisse B, Moore L, Kuimi BLB, Porgo TV, Boutin A, Lavoie A, Bourgeois G. Impact of socio-economic status on unplanned readmission following injury: A multicenter cohort study. Injury 2016; 47:1083-90. [PMID: 26746984 DOI: 10.1016/j.injury.2015.11.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 11/11/2015] [Accepted: 11/21/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Unplanned readmissions cost the US economy approximately $17 billion in 2009 with a 30-day incidence of 19.6%. Despite the recognised impact of socio-economic status (SES) on readmission in diagnostic populations such as cardiovascular patients, its impact in trauma patients is unclear. We examined the effect of SES on unplanned readmission following injury in a setting with universal health insurance. We also evaluated whether additional adjustment for SES influenced risk-adjusted readmission rates, used as a quality indicator (QI). STUDY DESIGN We conducted a multicenter cohort study in an integrated Canadian trauma system involving 56 adult trauma centres using trauma registry and hospital discharge data collected between 2005 and 2010. The main outcome was unplanned 30-day readmission; all cause, due to complications of injury and due to subsequent injury. SES was determined using ecological indices of material and social deprivation. Odds ratios of readmission and 95% confidence intervals adjusted for covariates were generated using multivariable logistic regression with a correction for hospital clusters. We then compared a readmission QI validated previously (original QI) to a QI with additional adjustment for SES (SES-adjusted QI) using the mean absolute difference. RESULTS The cohort consisted of 52,122 trauma admissions of which 6.5% were rehospitalised within 30 days of discharge. Compared to patients in the lowest quintile of social deprivation, those in the highest quintile had a 20% increase in the odds of all-cause unplanned readmission (95% CI=1.06-1.36) and a 27% increase in the odds of readmission due to complications of injury (95% CI=1.04-1.54). No association was observed for material deprivation or for readmissions due to subsequent injuries. We observed a strong agreement between the original and SES-adjusted readmission (mean absolute difference= 0.04%). CONCLUSIONS Patients admitted for traumatic injury who suffer from social deprivation have an increased risk of unplanned rehospitalisation due to complications of injury in the 30 days following discharge. Better discharge planning or follow up for such patients may improve patient outcome and resource use for trauma admissions. Despite observed associations, results suggest that the trauma QI based on unplanned readmission does not require additional adjustment for SES.
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Affiliation(s)
- Brahim Cisse
- Department of social and preventive medicine, Université Laval, Québec, QC, Canada; Axe Santé des Populations - Pratiques Optimales en Santé (Population Health - Practice - Changing Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada.
| | - Lynne Moore
- Department of social and preventive medicine, Université Laval, Québec, QC, Canada; Axe Santé des Populations - Pratiques Optimales en Santé (Population Health - Practice - Changing Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Brice Lionel Batomen Kuimi
- Department of social and preventive medicine, Université Laval, Québec, QC, Canada; Axe Santé des Populations - Pratiques Optimales en Santé (Population Health - Practice - Changing Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Teegwendé Valérie Porgo
- Department of social and preventive medicine, Université Laval, Québec, QC, Canada; Axe Santé des Populations - Pratiques Optimales en Santé (Population Health - Practice - Changing Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Amélie Boutin
- Department of social and preventive medicine, Université Laval, Québec, QC, Canada; Axe Santé des Populations - Pratiques Optimales en Santé (Population Health - Practice - Changing Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - André Lavoie
- Institut National d'Excellence en Santé et en Services Sociaux, Montréal, QC, Canada
| | - Gilles Bourgeois
- Institut National d'Excellence en Santé et en Services Sociaux, Montréal, QC, Canada
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49
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Mårtensson S, Gyrd-Hansen D, Prescott E, Andersen PK, Gislason G, Jacobsen RK, Osler M. Does access to invasive examination and treatment influence socioeconomic differences in case fatality for patients admitted for the first time with non-ST-elevation myocardial infarction or unstable angina? EUROINTERVENTION 2016; 11:1495-502. [DOI: 10.4244/eijy15m09_06] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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50
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Hagen TP, Iversen T, Moger TA. Risk adjustment in measurements of predicted mortality after myocardial infarction. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:423-7. [PMID: 26983146 DOI: 10.4045/tidsskr.13.1292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND In 2014, the government introduced elements of quality-based funding (pay-for-performance) for the hospital sector. Survival is included as a quality indicator. If such quality indicators are to be used for funding purposes, it must be established that the observed variations are caused by conditions that the hospital trusts are able to influence, and not by any underlying variables. The objective of this study was to investigate how the predicted mortality after myocardial infarction was influenced by various forms of risk adjustment. MATERIAL AND METHOD Data from the Norwegian Patient Register on 10,717 patients who had been discharged with the diagnosis of myocardial infarction in 2009 were linked to data on socioeconomic status, comorbidity, travel distances and mortality. The predicted 30-day mortality after myocardial infarction was analysed at the hospital-trust level, using three different models for risk adjustment. RESULTS Unadjusted 30-day mortality was highest in the catchment area of Førde Hospital Trust (12.5%) and lowest in Asker og Bærum (5.2%). Risk adjustment changed the estimates of mortality for many of the hospital trusts. In the model involving the most comprehensive risk adjustment, mortality was highest in the catchment area of Akershus University Hospital (10.9%) and lowest in the catchment areas of Sunnmøre Hospital Trust (5.2%) and Nordmøre og Romsdal Hospital Trust (5.2%). INTERPRETATION The variation in treatment quality between the hospital trusts, as measured by predicted mortality after myocardial infarction, is influenced by the methods used for risk adjustment. If the quality-based funding scheme is to continue, well-documented models for risk adjustment of the quality indicators need to be established.
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Affiliation(s)
- Terje P Hagen
- Avdeling for helseledelse og helseøkonomi Institutt for helse og samfunn Universitetet i Oslo
| | - Tor Iversen
- Avdeling for helseledelse og helseøkonomi Institutt for helse og samfunn Universitetet i Oslo
| | - Tron Anders Moger
- Avdeling for helseledelse og helseøkonomi Institutt for helse og samfunn Universitetet i Oslo
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