Regional Variation in Cardiac Catheterization Appropriateness and Baseline Risk After Acute Myocardial Infarction

Long-Term Outcomes of Cardiogenic Shock Complicating Myocardial Infarction

BACKGROUND

Cardiogenic shock secondary to acute myocardial infarction (AMI-CS) is associated with substantial short-term mortality; however, there are limited data on long-term outcomes and trends.

OBJECTIVES

This study sought to examine long-term outcomes of AMI-CS patients.

METHODS

This was a population-based, retrospective cohort study in Ontario, Canada of critically ill adult patients with AMI-CS who were admitted to hospitals between April 1, 2009 and March 31, 2019. Outcome data were captured using linked health administrative databases.

RESULTS

A total of 9,789 consecutive patients with AMI-CS from 135 centers were included. The mean age was 70.5 ± 12.3 years, and 67.7% were male. The incidence of AMI-CS was 8.2 per 100,000 person-years, and it increased over the study period. Critical care interventions were common, with 5,422 (55.4%) undergoing invasive mechanical ventilation, 1,425 (14.6%) undergoing renal replacement therapy, and 1,484 (15.2%) receiving mechanical circulatory support. A total of 2,961 patients (30.2%) died in the hospital, and 4,004 (40.9%) died by 1 year. Mortality at 5 years was 58.9%. Small improvements in short- and long-term mortality were seen over the study period. Among survivors to discharge, 2,870 (42.0%) required increased support in care from their preadmission baseline, 3,244 (47.5%) were readmitted to the hospital within 1 year, and 1,047 (15.3%) died within 1 year. The mean number of days at home in the year following discharge was 307.9 ± 109.6.

CONCLUSIONS

Short- and long-term mortality among patients with AMI-CS is high, with minimal improvement over time. AMI-CS survivors experience significant morbidity, with high risks of readmission and death. Future studies should evaluate interventions to minimize postdischarge morbidity and mortality among AMI-CS survivors.

Regional Variation in Health Care Utilization Among Adults With Inadequate Cardiovascular Health in the USA

Background Prior evidence of region-level differences in health outcomes and specialized healthcare services in the US poses questions of whether there are differences in utilization of healthcare that may account for regional differences in healthcare outcomes. This study aimed to examine regional differences in healthcare utilization for individuals with poor cardiovascular health (CVH) compared to those with ideal/intermediate CVH.  Methods In this cross-sectional analytical study, two 3-year periods (2008-2010 and 2018-2020) were pooled and analyzed using multivariate Poisson's regression of region on counts of healthcare utilization, while controlling for relevant covariates. The interaction of the non-southern regions with recent years was to reveal how the regional dispersion in healthcare usage was changing over time for the non-southern regions compared to the south. Results The results showed significant regional variation in healthcare usage for individuals with poor CVH, with lower health utilization rates observed primarily in southern states, consistent with higher rates of coronary heart disease in those regions. The impact of a unit improvement on CVH score was to reduce the level of healthcare utilization by 15.7% ([95% CI, 15 - 17%; p < 0.001]) for individuals with poor CVH and 19.1% ([95% CI, 19 - 20%; p < 0.001]) for the intermediate and ideal subgroups, with the Northeast exhibiting the highest level of healthcare usage. Conclusion Our results suggest that there is a need for public health interventions to reduce regional disparities in access to healthcare for the people at greatest risk of cardiovascular events by considering individual factors as well as the broader regional and policy contexts where these people live.

European Society of Cardiology: cardiovascular disease statistics 2021

AIMS

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries.

METHODS AND RESULTS

Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures.

CONCLUSION

Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.

The reduction of race and gender bias in clinical treatment recommendations using clinician peer networks in an experimental setting

Bias in clinical practice, in particular in relation to race and gender, is a persistent cause of healthcare disparities. We investigated the potential of a peer-network approach to reduce bias in medical treatment decisions within an experimental setting. We created "egalitarian" information exchange networks among practicing clinicians who provided recommendations for the clinical management of patient scenarios, presented via standardized patient videos of actors portraying patients with cardiac chest pain. The videos, which were standardized for relevant clinical factors, presented either a white male actor or Black female actor of similar age, wearing the same attire and in the same clinical setting, portraying a patient with clinically significant chest pain symptoms. We found significant disparities in the treatment recommendations given to the white male patient-actor and Black female patient-actor, which when translated into real clinical scenarios would result in the Black female patient being significantly more likely to receive unsafe undertreatment, rather than the guideline-recommended treatment. In the experimental control group, clinicians who were asked to independently reflect on the standardized patient videos did not show any significant reduction in bias. However, clinicians who exchanged real-time information in structured peer networks significantly improved their clinical accuracy and showed no bias in their final recommendations. The findings indicate that clinician network interventions might be used in healthcare settings to reduce significant disparities in patient treatment.

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department

This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.

Sex Disparities in the Use and Outcomes of Temporary Mechanical Circulatory Support for Acute Myocardial Infarction-Cardiogenic Shock

Background

There are limited sex-specific data on patients receiving temporary mechanical circulatory support (MCS) for acute myocardial infarction-cardiogenic shock (AMI-CS).

Methods

All admissions with AMI-CS with MCS use were identified using the National Inpatient Sample from 2005 to 2016. Outcomes of interest included in-hospital mortality, discharge disposition, use of palliative care and do-not-resuscitate (DNR) status, and receipt of durable left ventricular assist device (LVAD) and cardiac transplantation.

Results

In AMI-CS admissions during this 12-year period, MCS was used more frequently in men-50.4% vs 39.5%; P < 0.001. Of the 173,473 who received MCS (32% women), intra-aortic balloon pumps, percutaneous LVAD, extracorporeal membrane oxygenation, and ≥ 2 MCS devices were used in 92%, 4%, 1%, and 3%, respectively. Women were on average older (69 ± 12 vs 64 ± 13 years), of black race (10% vs 6%), and had more comorbidity (mean Charlson comorbidity index 5.0 ± 2.0 vs 4.5 ± 2.1). Women had higher in-hospital mortality than men (34% vs 29%, adjusted odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.16-1.23; P < 0.001) overall, in intra-aortic balloon pumps users (OR: 1.20 [95% CI: 1.16-1.23]; P < 0.001), and percutaneous LVAD users (OR: 1.75 [95% CI: 1.49-2.06]; P < 0.001), but not in extracorporeal membrane oxygenation or ≥ 2 MCS device users (P > 0.05). Women had higher use of palliative care, DNR status, and discharges to skilled nursing facilities.

Conclusions

There are persistent sex disparities in the outcomes of AMI-CS admissions receiving MCS support. Women have higher in-hospital mortality, palliative care consultation, and use of DNR status.

Regional Variation in the Management and Outcomes of Acute Myocardial Infarction With Cardiogenic Shock in the United States

BACKGROUND

There are few studies evaluating regional disparities in the care of acute myocardial infarction-cardiogenic shock (AMI-CS).

METHODS AND RESULTS

Using the National Inpatient Sample from 2000 to 2016, we identified adults with a primary diagnosis of AMI and concomitant CS admitted to the United States census regions of Northeast, Midwest, South, and West. Interhospital transfers were excluded. End points of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support, hospitalization costs, length of stay, and discharge disposition. Multivariable regression was used to adjust for potential confounding. Of the 402 825 AMI-CS admissions, 16.8%, 22.5%, 39.3%, and 21.4% were admitted to the Northeast, Midwest, South, and West, respectively. Higher rates of ST-elevation AMI-CS were noted in the Midwest and West. Admissions to the Northeast were on average characterized by a higher frequency of whites, Medicare beneficiaries, and lower rates of cardiac arrest. Admissions to the Northeast were less likely to receive coronary angiography, percutaneous coronary intervention, and mechanical circulatory support, despite the highest rates of extracorporeal membrane oxygenation use. Compared with the Northeast, in-hospital mortality was lower in the Midwest (adjusted odds ratio [aOR], 0.96 [95% CI, 0.93-0.98]; P<0.001) and West (aOR, 0.96 [95% CI, 0.94-0.98]; P=0.001) but higher in the South (aOR, 1.04 [95% CI, 1.01-1.06]; P=0.002). The Midwest (aOR, 1.68 [95% CI, 1.62-1.74]; P<0.001), South (aOR, 1.86 [95% CI, 1.80-1.92]; P<0.001), and West (aOR, 1.93 [95% CI, 1.86-2.00]; P<0.001) had higher discharges to home.

CONCLUSIONS

There remain significant regional disparities in the management and outcomes of AMI-CS.

Extracorporeal Membrane Oxygenation Use in Acute Myocardial Infarction in the United States, 2000 to 2014

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly used in acute myocardial infarction (AMI); however, there are limited large-scale national data.

METHODS

Using the National Inpatient Sample database from 2000 to 2014, a retrospective cohort of AMI utilizing ECMO was identified. Use of percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous left ventricular assist device (LVAD) was also identified in this population. Outcomes of interest included temporal trends in utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD), in-hospital mortality, and resource utilization.

RESULTS

In ≈9 million AMI admissions, ECMO was used in 2962 (<0.01%) and implanted a median of 1 day after admission. ECMO was used in 0.5% and 0.3% AMI admissions complicated by cardiogenic shock and cardiac arrest, respectively. ECMO was used more commonly in admissions that were younger, nonwhite, and with less comorbidity. ECMO use was 11× higher in 2014 as compared with 2000 (odds ratio, 11.37 [95% CI, 7.20-17.97]). Same-day percutaneous coronary intervention was performed in 23.1%; intra-aortic balloon pump/percutaneous LVAD was used in 57.9%, of which 30.3% were placed concomitantly. In-hospital mortality with ECMO was 59.2% overall but decreased from 100% (2000) to 45.1% (2014). Durable LVAD and cardiac transplantation were performed in 11.7% as an exit strategy. Of the hospital survivors, 40.8% were discharged to skilled nursing facilities. Older age, male sex, nonwhite race, and lower socioeconomic status were independently associated with higher in-hospital mortality with ECMO use.

CONCLUSIONS

In AMI admissions, a steady increase was noted in the utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD). In-hospital mortality remained high in AMI admissions treated with ECMO.

Temporal trends, predictors, and outcomes of acute kidney injury and hemodialysis use in acute myocardial infarction-related cardiogenic shock

Background

There are limited data on acute kidney injury (AKI) complicating acute myocardial infarction with cardiogenic shock (AMI-CS). This study sought to evaluate 15-year national prevalence, temporal trends and outcomes of AKI with no need for hemodialysis (AKI-ND) and requiring hemodialysis (AKI-D) following AMI-CS.

Methods

This was a retrospective cohort study from 2000–2014 from the National Inpatient Sample (20% stratified sample of all community hospitals in the United States). Adult patients (>18 years) admitted with a primary diagnosis of AMI and secondary diagnosis of CS were included. The primary outcome was in-hospital mortality in cohorts with no AKI, AKI-ND, and AKI-D. Secondary outcomes included predictors, resource utilization and disposition.

Results

During this 15-year period, 440,257 admissions for AMI-CS were included, with AKI in 155,610 (35.3%) and hemodialysis use in 14,950 (3.4%). Older age, black race, non-private insurance, higher comorbidity, organ failure, and use of cardiac and non-cardiac organ support were associated with the AKI development and hemodialysis use. There was a 2.6-fold higher adjusted risk of developing AKI in 2014 compared to 2000. Presence of AKI-ND and AKI-D was associated with a 1.3 and 1.7-fold higher adjusted risk of mortality. Compared to the cohort without AKI, AKI-ND and AKI-D were associated with longer length of stay (9±10, 12±13, and 18±19 days respectively; p<0.001) and higher hospitalization costs ($101,859±116,204, $159,804±190,766, and $265,875 ± 254,919 respectively; p<0.001).

Conclusion

AKI-ND and AKI-D are associated with higher in-hospital mortality and resource utilization in AMI-CS.

Contemporary prevalence, trends, and outcomes of coronary chronic total occlusions in acute myocardial infarction with cardiogenic shock

BACKGROUND

There are limited data on the prevalence and outcomes of chronic total occlusions (CTO) of the coronary artery in acute myocardial infarction with cardiogenic shock (AMI-CS) patients.

METHODS

Using the National Inpatient Sample, all admissions with AMI-CS that underwent diagnostic angiography between January 1, 2008, and December 31, 2014, were included. CTO, percutaneous coronary intervention (PCI), comorbidities and concomitant cardiac arrest was identified for all admissions. Outcomes of interest included temporal trends, in-hospital mortality, and resource utilization in cohorts with and without CTO.

RESULTS

In this 7-year period, 163,628 admissions with AMI-CS admissions met the inclusion criteria, with 68% being ST-elevation AMI-CS. CTO was noted in 27,343 (16.7%) admissions, with an increase in prevalence during the study period. The cohort with CTOs was more likely to be male and bearing private insurance. The CTO cohort had higher cardiovascular comorbidity, higher rates of cardiac arrest and higher use of PCI and mechanical circulatory support. The presence of a CTO was independently associated with higher in-hospital mortality (adjusted odds ratio 1.20 [95% confidence interval 1.16-1.23]; p < 0.001). The cohort with CTO had lower resource utilization (hospital stay and hospitalization costs) but was discharged more frequently to other hospitals. The presence of a CTO was associated with higher in-hospital mortality in the sub-groups of ST-elevation AMI-CS (31.5% vs. 28.7%; p < 0.001) and non-ST-elevation AMI-CS (24.8% vs. 23.2%; p < 0.001).

CONCLUSIONS

In this cohort of AMI-CS admissions that underwent diagnostic angiography, the presence of a CTO identified a higher risk cohort that had higher in-hospital mortality.

Geographic and Demographic Variation in Use of Ranibizumab Versus Bevacizumab for Neovascular Age-related Macular Degeneration in the United States

PURPOSE

To examine demographic and geographic variation in the use of ranibizumab and bevacizumab for the treatment of neovascular age-related macular degeneration (AMD) among Medicare beneficiaries.

DESIGN

Retrospective cohort study.

METHODS

Using a 100% sample of Medicare claims data, we evaluated Medicare beneficiaries (N = 195 812) with an index claim for neovascular AMD between July 1, 2006, and June 30, 2009, to determine whether beneficiaries first received ranibizumab or bevacizumab following initial diagnosis.

RESULTS

The overall proportion of beneficiaries that first received ranibizumab for neovascular AMD was 35%, and varied significantly (0.9%-84.6%) across the 306 US hospital referral regions (median = 33%, interquartile range = 17%-49%). Based on hierarchical logistic regression models, the likelihood of receiving ranibizumab declined over time (adjusted odds ratio (aOR) comparing treatment in 2009 vs 2006 = 0.39, P < .001). After we controlled for year of treatment, black beneficiaries were 45% less likely to receive ranibizumab compared to non-blacks (P < .0001). Beneficiaries residing in urban areas (aOR vs isolated rural towns = 1.12, P < .001), in zip codes with higher median incomes, and in the New England and East South Central census regions (aOR vs Pacific census region = 5.57, P < .001; aOR = 3.58, P < .001, respectively) had increased odds of receiving ranibizumab.

CONCLUSIONS

The odds of receiving bevacizumab vs ranibizumab as initial therapy for neovascular AMD among US Medicare beneficiaries varied substantially across geographic and demographic groups. Relatively fewer patients received ranibizumab for initial neovascular AMD treatment in 2009 vs 2006. Future research should study the drivers of variation in utilization of these interventions, the extent this variation indicates differential access to these agents, and whether treatment choice impacts patient outcomes.

Regional Variation in Postoperative Myocardial Infarction in Patients Undergoing Vascular Surgery in the United States

BACKGROUND

The aim of this study is to assess for regional variation in the incidence of postoperative myocardial infarction (POMI) following nonemergent vascular surgery across the United States to identify potential areas for quality improvement initiatives.

METHODS

We evaluated POMI rates across 17 regional Vascular Quality Initiative (VQI) groups that comprised 243 centers with 1,343 surgeons who performed 75,057 vascular operations from 2010 to 2014. Four procedures were included in the analysis: carotid endarterectomy (CEA, n = 39,118), endovascular abdominal aortic aneurysm (AAA) repair (EVAR, n = 15,106), infrainguinal bypass (INFRA, n = 17,176), and open infrarenal AAA repair (OAAA, n = 3,657). POMI was categorized by the method of diagnosis as troponin-only or clinical/ECG and rates were investigated in regions with ≥100 consecutive cases. Regions with significantly different POMI rates were defined as those >1.5 interquartile lengths beyond the 75th percentile of the distribution. Risk-adjusted rates of POMI were assessed using the VQI Cardiac Risk Index all-procedures prediction model to compare the observed versus expected rates for each region.

RESULTS

Overall rates of POMI varied by procedure type: CEA 0.8%, EVAR 1.1%, INFRA 2.7%, and OAAA 4.2% (P < 0.001). Significant variation in POMI rates was observed between regions, resulting in differing ranges of POMI rates for each procedure: CEA 0.5-2.0% (P = 0.001), EVAR 0.3-3.1% (P < 0.001), INFRA 1.1-4.8% (P < 0.001), and OAAA 2.2-10.0% (P < 0.001). A single region in 3 of the 4 procedure-specific datasets was identified as a statistical outlier with a significantly higher POMI rate after CEA, EVAR, and OAAA; this region was identical for the EVAR and OAAA datasets but was a different region for the CEA dataset. No significant variation in POMI was noted between regions after INFRA. Procedure-specific clinical POMI rates (mean; range) were significantly different between regions for EVAR (0.4%; 0-1.1%, P = 0.01) and INFRA (1.4%; 0.5-2.9%, P = 0.01), but not for CEA (0.4%; 0-0.8%, P = 0.53) or OAAA (1.6%; 0-3.8%, P = 0.23). Procedure-specific troponin-only POMI rates (mean; range) were significantly different between regions for all procedures: CEA (0.4%; 0.1-1.2%, P < 0.001), EVAR (0.7%; 0-2.1%, P < 0.001), INFRA (1.3%; 0.4-2.5%, P = 0.001), and OAAA (2.5%; 0-8.5%, P < 0.001). After risk adjustment, regional variation was again noted with 3 regions having higher and 4 regions having lower than expected rates of POMI.

CONCLUSIONS

Significant variation in POMI rates following major vascular surgery exists across VQI regions even after risk adjustment. These findings may present an opportunity for focused regional quality improvement efforts.

Use of diagnostic coronary angiography in women and men presenting with acute myocardial infarction: a matched cohort study

Background

Based on evident sex-related differences in the invasive management of patients presenting with acute myocardial infarction (AMI), we sought to identify predictors of diagnostic coronary angiography (DCA) and to investigate reasons for opting out an invasive strategy in women and men.

Methods

The study was designed as a matched cohort study. We randomly selected 250 female cases from a source population of 4000 patients hospitalized with a first AMI in a geographically confined region of Denmark from January 2010 to November 2011. Each case was matched to a male control on age and availability of cardiac invasive facilities at the index hospital. We systematically reviewed medical records for risk factors, comorbid conditions, clinical presentation, and receipt of DCA. Clinical justifications, as stated by the treating physician, were noted for the subset of patients who did not receive a DCA.

Results

Overall, 187 women and 198 men received DCA within 60 days (75 % vs. 79 %, hazard ratio: 0.82 [0.67-1.00], p = 0.047).In the subset of patients who did not receive a DCA (n = 114), clinical justifications for opting out an invasive strategy was not documented for 21 patients (18.4 %). Type 2 myocardial infarction was noted in 11 patients (women versus men; 14.5 % vs. 3.8 %, p = 0.06) and identified as a potential confounder of the sex-DCA relationship.

Receipt of DCA was predicted by traditional risk factors for ischaemic heart disease (family history of cardiovascular disease, hypercholesterolemia, and smoking) and clinical presentation (chest pain, ST-segment elevations). Although prevalent in both women and men, the presence of relative contraindications did not prohibit the use of DCA.

Conclusion

In this matched cohort of patients with a first AMI, women and men had different clinical presentations despite similar age. However, no differences in the distribution of relative contraindications for DCA were found between the sexes. Type 2 MI posed a potentiel confounder for the sex-related differences in the use of DCA. Importantly,clinical justification for opting out an invasive strategy was not documented in almost one fifth of patients not receiving a DCA.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0248-9) contains supplementary material, which is available to authorized users.

Variation in use of echocardiography among veterans who use the Veterans Health Administration vs Medicare

BACKGROUND

Rapid growth in the provision of cardiac imaging tests has led to concerns about overuse. Little is known about the degree to which health care delivery system characteristics influence use and variation in echocardiography.

METHODS

We analyzed administrative claims of veterans with heart failure older than 65 years from 2007 to 2010 across 34 metropolitan service areas (MSAs). We compared overall rates and geographic variation in use of transthoracic echocardiography (TTE) between veterans who used the Veterans Health Administration (VA) and propensity-matched veterans who used Medicare. "Dual users" were excluded.

RESULTS

There were no significant differences in clinical characteristics or mortality between the propensity-matched cohorts (overall n = 30,404 veterans, mean age 76 years, mortality rate 52%). The Medicare cohort had a significantly higher overall rate of TTE use compared with the VA cohort (1.25 vs 0.38 TTEs per person-year, incidence rate ratio 2.89 [95% CI 2.80-3.00], both P < .001), but a similar coefficient of variation across MSAs (0.36 [95% CI 0.27-0.45] vs 0.48 [95% CI 0.37-0.59]). There was a moderate to strong correlation in variation at the MSA level between cohorts (Spearman r = 0.58, P < .001).

CONCLUSION

Overall rates of TTE use were significantly higher in a Medicare cohort compared with a propensity score-matched VA cohort of veterans with heart failure living in urban areas, with similar relative degrees of geographic variation and moderate to strong regional correlation. Rates of TTE use may be strongly influenced by health care system characteristics, but local practice styles influence echocardiography rates irrespective of health system.

Geographic Variation of Endoscopic Sinus Surgery in Canada: An Alberta-Based Small Area Variation Analysis

OBJECTIVE

With an estimated 10,000 to 15,000 endoscopic sinus surgery (ESS) cases performed in Canada each year, identifying potential unwarranted practice patterns is important. The objective of this study is to examine the rates and geographic variation of ESS in the province of Alberta, Canada.

STUDY DESIGN

Small area variation analysis.

SETTING

Province of Alberta, Canada.

SUBJECTS AND METHODS

The National Ambulatory Care Reporting System database was searched to identify all patients who received ESS between April 1, 2010, and March 31, 2013, in Alberta, Canada. The annual adjusted rates of ESS per 1000 people were calculated for each Alberta health zone and health status area. Geographic variations were evaluated with the extremal quotient, weighted coefficient of variation, and systematic component of variance. Chi-squared-test was used to quantify the significance of variation of the adjusted ESS rates across regions.

RESULTS

The annual adjusted rate of ESS was 0.33 per 1000 people in Alberta, Canada. The mean extremal quotient for health status areas was 6.9, indicating a 7-fold difference between the highest and lowest regions. The mean coefficient of variation was 41.0, and the mean systematic component of variance was 10.5, which demonstrates "very high" variation.

CONCLUSION

This study observed very high geographic variation in the rates of ESS across the province of Alberta. Given the negative impact of unwarranted surgical variation on quality of care, outcomes from this study indicate a need to further evaluate the delivery of care for ESS in Canada to improve overall health system performance.

Regional-Level Correlations in Inappropriate Imaging Rates for Prostate and Breast Cancers: Potential Implications for the Choosing Wisely Campaign

IMPORTANCE

The association between regional norms of clinical practice and appropriateness of care is incompletely understood. Understanding regional patterns of care across diseases might optimize implementation of programs like Choosing Wisely, an ongoing campaign to decrease wasteful medical expenditures.

OBJECTIVE

To determine whether regional rates of inappropriate prostate and breast cancer imaging were associated.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using the the Surveillance, Epidemiology, and End Results-Medicare linked database. We identified patients diagnosed from 2004 to 2007 with low-risk prostate (clinical stage T1c/T2a; Gleason score, ≤6; and prostate-specific antigen level, <10 ng/mL) or breast cancer (in situ, stage I, or stage II disease), based on Choosing Wisely definitions.

MAIN OUTCOMES AND MEASURES

In a hospital referral region (HRR)-level analysis, our dependent variable was HRR-level imaging rate among patients with low-risk prostate cancer. Our independent variable was HRR-level imaging rate among patients with low-risk breast cancer. In a subsequent patient-level analysis we used multivariable logistic regression to model prostate cancer imaging as a function of regional breast cancer imaging and vice versa.

RESULTS

We identified 9219 men with prostate cancer and 30,398 women with breast cancer residing in 84 HRRs. We found high rates of inappropriate imaging for both prostate cancer (44.4%) and breast cancer (41.8%). In the first, second, third, and fourth quartiles of breast cancer imaging, inappropriate prostate cancer imaging was 34.2%, 44.6%, 41.1%, and 56.4%, respectively. In the first, second, third, and fourth quartiles of prostate cancer imaging, inappropriate breast cancer imaging was 38.1%, 38.4%, 43.8%, and 45.7%, respectively. At the HRR level, inappropriate prostate cancer imaging rates were associated with inappropriate breast cancer imaging rates (ρ = 0.35; P < .01). At the patient level, a man with low-risk prostate cancer had odds ratios (95% CIs) of 1.72 (1.12-2.65), 1.19 (0.78-1.81), or 1.76 (1.15-2.70) for undergoing inappropriate prostate imaging if he lived in an HRR in the fourth, third, or second quartiles, respectively, of inappropriate breast cancer imaging, compared with the lowest quartile.

CONCLUSIONS AND RELEVANCE

At a regional level, there is an association between inappropriate prostate and breast cancer imaging rates. This finding suggests the existence of a regional-level propensity for inappropriate imaging utilization, which may be considered by policymakers seeking to improve quality of care and reduce health care spending in high-utilization areas.

Validation of the appropriate use criteria for coronary angiography: a cohort study

BACKGROUND

The use of invasive coronary angiography in stable ischemic heart disease (IHD) varies widely.

OBJECTIVE

To validate the 2012 appropriate use criteria for diagnostic catheterization by examining the relationship between the appropriateness of cardiac catheterization in patients with suspected stable IHD and the proportion of patients with obstructive coronary artery disease (CAD) and subsequent revascularization.

DESIGN

Population-based, observational, multicenter cohort study.

SETTING

The Cardiac Care Network, a registry of all patients having elective angiography at 18 hospitals in Ontario, Canada, between 1 October 2008 and 30 September 2011.

PATIENTS

Persons without prior coronary revascularization or myocardial infarction who had angiography for suspected stable CAD.

MEASUREMENTS

Appropriateness scores were ascertained by using data collected at the time of the index angiography and were categorized as appropriate, inappropriate, or uncertain.

RESULTS

Among the final cohort of 48 336 patients, 58.2% of angiographic studies were classified as appropriate, 10.8% were classified as inappropriate, and 31.0% were classified as uncertain. Overall, 45.5% of patients had obstructive CAD. In patients with appropriate indications for angiography, 52.9% had obstructive CAD, with 40.0% undergoing revascularization. In those with inappropriate indications, 30.9% had obstructive CAD and 18.9% underwent revascularization; in those with uncertain indications, 36.7% had obstructive CAD and 25.9% had revascularization. Although more patients with appropriate indications had obstructive CAD and underwent revascularization (P < 0.001), a substantial proportion of those with inappropriate or uncertain indications had important coronary disease.

LIMITATION

Data were not available on whether symptoms were atypical.

CONCLUSION

Despite the association between appropriateness category and obstructive CAD, this study raises concerns about the ability of the appropriate use criteria to guide clinical decision making.

PRIMARY FUNDING SOURCE

Canadian Institutes of Health Research.

Geographic variation of endoscopic sinus surgery in the United States

OBJECTIVES/HYPOTHESIS

The objective of this study was to examine the rates and geographic variation of endoscopic sinus surgery (ESS) in a representative sample of the US working population.

STUDY DESIGN

Observational cohort study using the MarketScan Commercial Claim and Encounters database.

METHODS

All patients who received ESS between 2009 and 2013 were included. The annual adjusted rates of ESS per 1,000 people were calculated for each US state. Geographic variations were evaluated using the extremal quotient (EQ), weighted coefficient of variation (CV), systematic component of variance (SCV), and empirical Bayes statistic. The χ(2) statistic tests was used to quantify variation of the adjusted ESS rates across states within the US.

RESULTS

The annual adjusted rate of ESS was 0.94 per 1,000 people in the US. South Dakota and Alabama were observed to have the highest rates of ESS, 1.80 and 1.69, respectively. Vermont and Arkansas were observed to have the lowest rates of ESS, 0.51 and 0.57, respectively. The mean EQ was 4.54, indicating a four- to fivefold difference between the highest (South Dakota) and lowest (Vermont) states. The mean CV was 31.4 and mean SCV was 10.1, which demonstrates very high variation.

CONCLUSIONS

This study observed very high geographic variation in the rates of ESS across the United States. Given that practice variation indicates the presence of potentially harmful and inefficient unwarranted care, outcomes from this study indicate a need to further evaluate the delivery of ESS to improve overall health system performance.

LEVEL OF EVIDENCE

2b.

The impact of individual variation analysis on myocardial perfusion imaging utilization within a hospitalist group

BACKGROUND

Increased recognition of ionizing radiation risks has placed an emphasis on the appropriate use of myocardial perfusion imaging (MPI). Hospitalists frequently order MPI in the evaluation of chest pain and are thus at the forefront of its inpatient utilization.

METHODS

We collected baseline figures for a group MPI rate (March 2010-February 2011) as well as individual MPI rates for hospitalists caring for cardiac floor patients at a community teaching hospital. We performed a 2-part intervention; we presented the individual MPI rate data back to the hospitalist division and carried out longitudinal educational efforts on MPI appropriateness criteria. We then calculated the group MPI utilization rate for 3 postintervention periods (March 2011-February 2012, March 2012-February 2013, and March 2013-February 2014) and the MPI rate for the subgroup of cardiac floor patients. Finally, we calculated the percentage of inappropriately performed stress tests before and after our intervention.

RESULTS

Group MPI rate declined from 6.1% to 5.0% in the first year after our intervention (P = 0.009); a decrease was maintained a year later-MPI rate 4.9% (P = 0.004)-and became even more pronounced 2 years later-MPI rate 3.9% (P < 0.0001). The MPI rate for the subgroup of patients on the cardiac floor similarly decreased from 8.0% to 6.7% (P = 0.039). Finally, we report a particularly encouraging and significant trend of a 46% postintervention decrease (from 16.5% to 9%, P = 0.034) in the proportion of inappropriate stress tests ordered.

CONCLUSIONS

Analyzing individual ordering rates and combining them with educational efforts was an effective strategy for impacting MPI utilization in the hospitalist group studied.

Nationwide trends in use and timeliness of diagnostic coronary angiography in acute coronary syndromes from 2005 to 2011: Does distance to invasive heart centres matter?

AIMS

To examine trends in the use of diagnostic coronary angiography according to distance from home to the nearest invasive heart centre following implementation of fast-track protocols and extensive pre-hospital triaging of acute coronary syndrome patients.

METHODS AND RESULTS

We performed a register-based cohort study of all patients admitted to Danish hospitals with incident acute coronary syndrome in 2005-2011. Diagnostic coronary angiography within 60 days of admission was investigated according to distance tertiles (DTs) calculated as range from each patient's home to the nearest invasive heart centre (short DT: <22 km, medium DT: 22-65 km, long DT: >65 km). Cox proportional hazards models were applied.Among the 52,409 patients included, diagnostic coronary angiography was increasingly used during 2005-2011 (short DT: 76% to 81%; medium DT: 74% to 81%; long DT: 69% to 78%; all p-values for trend <0.001). Using the short DT as reference the adjusted hazard ratios for medium DT were 0.87 (0.84-0.89) for 2005-2007, 0.94 (0.90-0.98) for 2008-2009 and 0.94 (0.90-0.98) for 2010-2011. Corresponding figures for long DT were 0.74 (0.72-0.76) for 2005-2007, 0.87 (0.83-0.90) for 2008-2009 and 0.94 (0.90-0.98) for 2010-2011. Length of hospital stay, time to coronary angiography, and 60-day mortality decreased in all DT.

CONCLUSIONS

This nationwide study found significant increases in diagnostic coronary angiography use over time in incident acute coronary syndrome patients with a relatively larger increase in patients residing farthest from an invasive heart centre. Additionally, selected quality of care measures improved in the entire cohort, suggesting a benefit of national clinical protocols.

Institutional characteristics associated with receipt of emergency care for obstructive pyelonephritis at community hospitals

PURPOSE

Delivering the recommended care is an important quality measure that has been insufficiently studied in urology. Obstructive pyelonephritis is a suitable case study for this focus because many patients do not receive such care, although guidelines advocate decompression. We determined the influence of hospital factors, particularly familiarity with urolithiasis, on the likelihood of decompression in such patients.

MATERIALS AND METHODS

We used the NIS from 2002 to 2011 to retrospectively identify patients admitted to community hospitals with severe infection and ureteral calculi. Hospital familiarity with nephrolithiasis was estimated by calculating hospital stone volume (divided into quartiles) and hospital treatment intensity (the decompression rate in patients with ureteral calculi and no infection). After calculating national estimates we performed logistic regression to determine the association between the receipt of decompression and hospital stone volume, controlling for treatment intensity and other covariates thought to be associated with receiving recommended care.

RESULTS

Of an estimated 107,848 patients with obstructive pyelonephritis 27.4% failed to undergo decompression. Discrepancies were greatest between hospitals with the highest and lowest stone volumes (76% vs 25%, OR 2.77, 95% CI 1.94-3.96, p <0.01) as well as high and low treatment intensity (78% vs 37%, p <0.01).

CONCLUSIONS

High hospital stone volume and treatment intensity were associated with an increased likelihood of receiving decompression. Such findings might be useful to identify hospitals and regions where access to quality urological care should be augmented.

Regional variation across the United States in management and outcomes of ST-elevation myocardial infarction: analysis of the 2003 to 2010 nationwide inpatient sample database

BACKGROUND

Regional differences in the treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI) within the United States remain poorly understood.

HYPOTHESIS

Treatment choice and outcomes in patients with STEMI differ between regions within the United States.

METHODS

We used the 2003 to 2010 Nationwide Inpatient Sample databases to identify all patients age ≥ 40 years hospitalized with STEMI. Patients were divided into 4 groups according to region: Northeast, Midwest, South, and West. Multivariable logistic regression was used to identify differences in treatment choice and outcomes (in-hospital mortality, acute stroke, and cardiogenic shock) among the 4 regions.

RESULTS

Of 1,990,486 patients age ≥ 40 years with STEMI, 350,073 (17.6%) were hospitalized in the Northeast, 483,323 (24.3%) in the Midwest, 784,869 (39.4%) in the South, and 372,222 (18.7%) in the West. Compared with the Northeast, patients in the Midwest, South, and West were less likely to receive medical therapy alone and more likely to receive percutaneous coronary intervention and coronary artery bypass grafting. Risk-adjusted in-hospital mortality was higher in the Midwest (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 1.05-1.09, P <0.001), South (OR: 1.03, 95% CI: 1.01-1.05, P = 0.001), and West (OR: 1.06, 95% CI: 1.04-1.08, P <0.001), as compared with the Northeast. When adjusted further for regional variation in treatment selection, risk-adjusted in-hospital mortality was even higher in the Midwest, West, and South.

CONCLUSIONS

Despite higher reperfusion and revascularization rates, STEMI patients in the Midwest, West, and South have paradoxically higher risk-adjusted in-hospital mortality as compared with patients in the Northeast.

Determinants of invasive treatment in lower extremity peripheral arterial disease

OBJECTIVE

Since it is unknown what factors are weighed in a clinician's decision to refer patients with symptomatic lower extremity peripheral arterial disease (PAD) for invasive treatment, we examined the relationship between health status, lesion location, and site variations and invasive treatment referral ≤1 year following diagnosis in patients with PAD.

METHODS

This was a prospective observational cohort study on ambulatory patients that presented themselves at two vascular surgery outpatient clinics. A total of 970 patients with new symptoms of PAD or with an exacerbation of existing PAD symptoms that required clinical evaluation and treatment (Rutherford Grade I) were eligible, 884 consented and were included between March 2006 and November 2010. We report on 505 patients in the current study. Prior to patients' initial PAD evaluation, the Short Form-12, Physical Component Scale (PCS) was administered to measure health status. Anatomical lesion location (proximal vs distal) was derived from duplex ultrasounds. PCS scores, lesion location, and site were evaluated as determinants of receiving invasive (endovascular, surgery) vs noninvasive treatment ≤1 year following diagnosis in Poisson regression analyses, adjusting for demographics, ankle-brachial index, and risk factors.

RESULTS

Invasive treatment as a first-choice was offered to 167 (33%) patients. While an association between poorer health status and invasive therapy was found in unadjusted analyses (relative risk [RR], 0.98; 95% confidence interval [CI], 0.97-1.00; P = .011), proximal lesion location (RR, 3.66; 95% CI, 2.70-4.96; P < .0001) and site (RR, 1.69; 95% CI, 1.11-2.58; P = .014) were independent predictors of invasive treatment referral in the final model.

CONCLUSIONS

One-third of patients were treated invasively following PAD diagnosis. Patients' health status was considered in providers' decision to refer patients for invasive treatment, but having a proximal lesion was the strongest predictor. This study also found some important first indications of site variations in offering invasive treatment among patients with PAD. Future work is needed to further document these variations in care.

Prostate cancer imaging trends after a nationwide effort to discourage inappropriate prostate cancer imaging

BACKGROUND

Reducing inappropriate use of imaging to stage incident prostate cancer is a challenging problem highlighted recently as a Physician Quality Reporting System quality measure and by the American Society of Clinical Oncology and the American Urological Association in the Choosing Wisely campaign. Since 2000, the National Prostate Cancer Register (NPCR) of Sweden has led an effort to decrease national rates of inappropriate prostate cancer imaging by disseminating utilization data along with the latest imaging guidelines to urologists in Sweden. We sought to determine the temporal and regional effects of this effort on prostate cancer imaging rates.

METHODS

We performed a retrospective cohort study among men diagnosed with prostate cancer from the NPCR from 1998 to 2009 (n = 99 879). We analyzed imaging use over time stratified by clinical risk category (low, intermediate, high) and geographic region. Generalized linear models with a logit link were used to test for time trend.

RESULTS

Thirty-six percent of men underwent imaging within 6 months of prostate cancer diagnosis. Overall, imaging use decreased over time, particularly in the low-risk category, among whom the imaging rate decreased from 45% to 3% (P < .001), but also in the high-risk category, among whom the rate decreased from 63% to 47% (P < .001). Despite substantial regional variation, all regions experienced clinically and statistically (P < .001) significant decreases in prostate cancer imaging.

CONCLUSIONS

A Swedish effort to provide data on prostate cancer imaging use and imaging guidelines to clinicians was associated with a reduction in inappropriate imaging over a 10-year period, as well as slightly decreased appropriate imaging in high-risk patients. These results may inform current efforts to promote guideline-concordant imaging in the United States and internationally.

Overuse and systems of care: a systematic review

BACKGROUND

Current health care reform efforts are focused on reorganizing health care systems to reduce waste in the US health care system.

OBJECTIVE

To compare rates of overuse in different health care systems and examine whether certain systems of care or insurers have lower rates of overuse of health care services.

DATA SOURCES

Articles published in MEDLINE between 1978, the year of publication of the first framework to measure quality, and June 21, 2012.

STUDY SELECTION

Included studies compared rates of overuse of procedures, diagnostic tests, or medications in at least 2 systems of care.

DATA EXTRACTION

Four reviewers screened titles; 2 reviewers screened abstracts and full articles and extracted data.

RESULTS

We identified 7 studies which compared rates of overuse of 5 services across multiple different health care settings. National rates of inappropriate coronary angiography were similar in Medicare HMOs and Medicare FFS (13% vs. 13%, P=0.33) and in a state-based study comparing 15 hospitals in New York and 4 hospitals in a Massachusetts-managed care plan (4% vs. 6%, P>0.1). Rates of carotid endarterectomy in New York State were similar in Medicare HMOs and Medicare FFS plans (8.4% vs. 8.6%, P=0.55) but nonrecommended use of antibiotics for the treatment of upper respiratory infection was higher in a managed care organization than a FFS private plan (31% vs. 21%, P=0.02). Rates of inappropriate myocardial perfusion imaging were similar in VA and private settings (22% vs. 16.6%, P=0.24), but rates of inappropriate surveillance endoscopy in the management of gastric ulcers were higher in the VA compared with private settings (37.4% vs. 20.4%-23.3%, P<0.0001).

CONCLUSIONS

The available evidence is limited but there is no consistent evidence that any 1 system of care has been more effective at minimizing the overuse of health care services. More research is necessary to inform current health care reform efforts directed at reducing overuse.

Geographic variation in cardiovascular procedure use among Medicare fee-for-service vs Medicare Advantage beneficiaries

IMPORTANCE

Little is known about how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures influence use of cardiovascular procedures.

OBJECTIVE

To compare regional cardiovascular procedure rates between Medicare Advantage and Medicare FFS beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of Medicare beneficiaries older than 65 years between 2003-2007 comparing rates of coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery across 32 hospital referral regions in 12 states.

MAIN OUTCOMES AND MEASURES

Rates of coronary angiography, PCI, and CABG surgery.

RESULTS

We evaluated a total of 878,339 Medicare Advantage patients and 5,013,650 Medicare FFS patients. Compared with Medicare FFS patients, Medicare Advantage patients had lower age-, sex-, race-, and income-adjusted procedure rates per 1000 person-years for angiography (16.5 [95% CI, 14.8-18.2] vs 25.9 [95% CI, 24.0-27.9]; P < .001) and PCI (6.8 [95% CI, 6.0-7.6] vs 9.8 [95% CI, 9.0-10.6]; P < .001) but similar rates for CABG surgery (3.1 [95% CI, 2.8-3.5] vs 3.4 [95% CI, 3.1-3.7]; P = .33). There were no significant differences between Medicare Advantage and Medicare FFS patients in the rates per 1000 person-years of urgent angiography (3.9 [95% CI, 3.6-4.2] vs 4.3 [95% CI, 4.0-4.6]; P = .24) or PCI (2.4 [95% CI, 2.2-2.7] vs 2.7 [95% CI, 2.5-2.9]; P = .16). Procedure rates varied widely across hospital referral regions among Medicare Advantage and Medicare FFS patients. For angiography, the rates per 1000 person-years ranged from 9.8 to 40.6 for Medicare Advantage beneficiaries and from 15.7 to 44.3 for Medicare FFS beneficiaries. For PCI, the rates ranged from 3.5 to 16.8 for Medicare Advantage and from 4.7 to 16.1 for Medicare FFS. The rates for CABG surgery ranged from 1.5 to 6.1 for Medicare Advantage and from 2.5 to 6.0 for Medicare FFS. Across regions, we found no statistically significant correlation between Medicare Advantage and Medicare FFS beneficiary utilization for angiography (Spearman r = 0.19, P = .29) and modest correlations for PCI (Spearman r = 0.33, P = .06) and CABG surgery (Spearman r = 0.35, P = .05). Among Medicare Advantage beneficiaries, adjustment for additional cardiac risk factors had little influence on procedure rates.

CONCLUSIONS AND RELEVANCE

Although Medicare beneficiaries enrolled in capitated Medicare Advantage programs had lower angiography and PCI procedure rates than those enrolled in Medicare FFS, the degree of geographic variation in procedure rates was substantial among Medicare Advantage beneficiaries and was similar in magnitude to that observed among Medicare FFS beneficiaries.

Regional density of cardiologists and rates of mortality for acute myocardial infarction and heart failure

BACKGROUND

Cardiologists are distributed unevenly across regions of the United States. It is unknown whether patients in regions with fewer cardiologists have worse outcomes after hospitalization for acute myocardial infarction (AMI) or heart failure (HF).

METHODS AND RESULTS

Using Medicare administrative claims data from 2010, we examined the relationship between regional density of cardiologists and risk of death after hospitalization for AMI and HF using hospitalizations for pneumonia as a comparison. We defined density as the number of cardiologists divided by population aged≥65 years within hospital referral regions, categorized into quintiles. Among 171 126 admissions for AMI, 352 853 admissions for HF, and 343 053 admissions for pneumonia, we tested associations between density of cardiologists and 30-day and 1-year mortality for each condition. We used 2-level hierarchical logistic regression models that adjusted for characteristics of patients and hospital referral regions. Patients hospitalized for AMI (odds ratios [OR], 1.13; 95% confidence interval [CI], 1.06-1.21) and HF (OR, 1.19; 95% CI, 1.12-1.27) in the lowest quintile of density had modestly higher 30-day mortality risk compared with patients in the highest quintile, unlike patients hospitalized for pneumonia (OR, 1.02; 95% CI, 0.96-1.09). Patients hospitalized for AMI (OR, 1.06; 95% CI, 1.00-1.12) and HF (OR, 1.09; 95% CI, 1.04-1.13) in the lowest quintile had slightly higher 1-year mortality risk, unlike patients hospitalized for pneumonia (OR, 1.00; 95% CI, 0.95-1.05).

CONCLUSIONS

Patients hospitalized for AMI and HF in regions with a low density of cardiologists experienced modestly higher 30-day and 1-year mortality risk, unlike patients with pneumonia.

Competing with the conventional wisdom: newspaper framing of medical overtreatment

Overtreatment, defined as the use of medical tests, products, and services that are not medically necessary or beneficial to the patient, may account for as much as 30% of all U.S. health care expenditures. This article describes a study of the framing of this important health and economic issue in elite U.S. newspapers from January 1, 2007, through December 31, 2010. Within 98 articles providing some mention of overtreatment, analysis revealed three major frames: uncertainty, cost, and legal issues. Within the uncertainty frame, there was a remarkable emphasis on cancer testing and treatment as a driver of overutilization, which may suggest to readers that overtreatment does not occur or is not important in other types of medical care. Relatively few stories paid much attention to the financial costs of overtreatment.

Appropriate and inappropriate imaging rates for prostate cancer go hand in hand by region, as if set by thermostat

Policy makers interested in containing health care costs are targeting regional variation in utilization, including the use of advanced imaging. However, bluntly decreasing utilization among the highest-utilization regions may have negative consequences. In a cross-sectional study of prostate cancer patients from 2004 to 2005, we found that regions with lower rates of inappropriate imaging also had lower rates of appropriate imaging. Similarly, regions with higher overall imaging rates tended to have not only higher rates of inappropriate imaging, but also higher rates of appropriate imaging. In fact, men with high-risk prostate cancer were more likely to receive appropriate imaging if they resided in areas with higher rates of inappropriate imaging. This "thermostat model" of regional health care utilization suggests that poorly designed policies aimed at reducing inappropriate imaging could limit access to appropriate imaging for high-risk patients. Health care organizations need clearly defined quality metrics and supportive systems to encourage appropriate treatment for patients and to ensure that cost containment does not occur at the expense of quality.

Assessing the association of appropriateness of coronary revascularization and clinical outcomes for patients with stable coronary artery disease

OBJECTIVES

The study assessed the appropriateness of coronary revascularization in Ontario, Canada, and examined its association with longer-term outcomes.

BACKGROUND

Although appropriate use criteria for coronary revascularization have been developed to improve the rational use of cardiac invasive procedures, it is unknown whether greater adherence to appropriateness guidelines is associated with improved clinical outcomes in stable coronary artery disease.

METHODS

A population-based cohort of stable patients undergoing cardiac catheterization was assembled from April 1, 2006, to March 31, 2007. The appropriateness for coronary revascularization at the time of coronary angiography was retrospectively adjudicated using the appropriate use criteria. Clinical outcomes between coronary revascularization and medical treatment without revascularization, stratified by appropriateness categories, were compared.

RESULTS

In 1,625 patients with stable coronary artery disease, percutaneous coronary intervention or coronary artery bypass grafting was only performed in 69% who had an appropriate indication for coronary revascularization. Coronary revascularization was associated with a lower adjusted hazard of death or acute coronary syndrome (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.42 to 0.88) at 3 years compared with medical therapy in appropriate patients. The rate of coronary revascularization was 54% in the uncertain category and 45% in the inappropriate category. No significant difference in death or acute coronary syndrome between coronary revascularization and no revascularization in the uncertain category (HR: 0.57; 95% CI: 0.28 to 1.16) and the inappropriate category (HR: 0.99; 95% CI: 0.48 to 2.02) was observed.

CONCLUSIONS

Using the appropriateness use criteria, we identified substantial underutilization and overutilization of coronary revascularization in contemporary clinical practice. Underutilization of coronary revascularization is associated with significantly increased risks of adverse outcomes in patients with appropriate indications.

Case definitions for acute myocardial infarction in administrative databases and their impact on in-hospital mortality rates

OBJECTIVE

To identify validated ICD-9-CM/ICD-10 coded case definitions for acute myocardial infarction (AMI).

DATA SOURCES

Ovid Medline (1950-2010) was searched to identify studies that validated acute myocardial infarction (AMI) case definitions. Hospital discharge abstract data and chart data were linked to validate identified AMI definitions.

STUDY DESIGN

Systematic literature review, chart review, and administrative data analysis.

DATA COLLECTION/EXTRACTION METHODS

Data on sensitivity/specificity/positive and negative predictive values (PPV and NPV) were extracted from previous studies to identify validated case definitions for AMI. These case definitions were validated in administrative data through chart review and applied to hospital discharge data to assess in-hospital mortality.

PRINCIPAL FINDINGS

Of the eight ICD-9-CM definitions validated in the literature, use of ICD-9-CM code 410 to define AMI had the highest sensitivity (94 percent) and specificity (99 percent). In our data, ICD-9-CM/ICD-10 codes 410/I21-I22 in all available coding fields had high sensitivity (83.3 percent/82.8 percent) and PPV (82.8 percent/82.2 percent). The in-hospital mortality among AMI patients identified using this case definition was 7.6 percent in ICD-9-CM data and 6.6 percent in ICD-10 data.

CONCLUSIONS

We recommend that ICD-9-CM 410 or ICD-10 I21-I22 in the primary diagnosis coding field should be used to define AMI. The use of a consistent validated case definition would improve comparability across studies.

The relationship between geographic variations and overuse of healthcare services: a systematic review

OBJECTIVE

To examine the relationship between overuse of healthcare services and geographic variations in medical care.

DESIGN

Systematic Review.

DATA SOURCES

Articles published in Medline between 1978, the year of publication of the first framework to measure quality, and January 1, 2009.

STUDY SELECTION

Four investigators screened 114,830 titles and 2 investigators screened all selected abstracts and articles for possible inclusion and extracted all data.

DATA EXTRACTION

We extracted data on rates of overuse in different geographic areas. We also extracted data on underuse, if available, for the same population in which overuse was measured.

RESULTS

Five papers examined the relationship between geographic variations and overuse of healthcare services. One study in 2008 compared the appropriateness of coronary angiography (CA) for acute myocardial infarction in high-cost areas versus low cost areas in the Medicare population and found largely similar rates of inappropriateness (12.2% vs. 16.2%). A study in 2000 using national data concluded that overuse of CA explained little of the geographic variations in the use of this procedure in the Medicare program. An older study of Medicare patients found similar rates of inappropriate use of CA (15% to 17% vs. 18%), endoscopy (15% vs. 18% 19%), and carotid endarterectomy (29% vs. 30%) in low-use and high-use regions. A small area reanalysis of data from this study of 3 procedures found no evidence of a relationship between inappropriate use of procedures and volume in 23 adjacent counties of California. Another 2008 study found that inappropriate chemotherapy for stage I cancer was less common in low-cost areas compared with high-cost areas (3.1% vs. 6.3%).

CONCLUSIONS

The limited available evidence does not lend support to the hypothesis that inappropriate use of procedures is a major source of geographic variations in intensity and/or costs of care. More research is needed to improve our understanding of the relationship between geographic variations and the quality of care.

Geographic disparities in the incidence and outcomes of hospitalized myocardial infarction: does a rising tide lift all boats?

BACKGROUND

Improvements in prevention have led to declines in incidence and mortality of myocardial infarction (MI) in selected populations. However, no studies have examined regional differences in recent trends in MI incidence, and few have examined whether known regional disparities in MI care have narrowed over time.

METHODS AND RESULTS

We compared trends in incidence rates of MI, associated procedures and mortality for all US Census Divisions (regions) in Medicare fee-for-service patients between 2000-2008 (292 773 151 patient-years). Two-stage hierarchical models were used to account for patient characteristics and state-level random effects. To assess trends in geographic disparities, we calculated changes in between-state variance for outcomes over time. Although the incidence of MI declined in all regions (P<0.001 for trend for each) between 2000-2008, adjusted rates of decline varied by region (annual declines ranging from 2.9-6.1%). Widening geographic disparities, as measured by percent change of between-state variance from 2000-2008, were observed for MI incidence (37.6% increase, P=0.03) and percutaneous coronary intervention rates (31.4% increase, P=0.06). Significant declines in risk-adjusted 30-day mortality were observed in all regions, with the fastest declines observed in states with higher baseline mortality rates.

CONCLUSIONS

In a large contemporary analysis of geographic trends in MI epidemiology, the incidence of MI and associated mortality declined significantly in all US Census Divisions between 2000-2008. Although geographic disparities in MI incidence may have increased, regional differences in MI-associated mortality have narrowed.

Current trends in coronary revascularization

The options for coronary revascularization broadened in recent years with the introduction of bare-metal stents in the 1990s and drug-eluting stents in 2003. Since then, the rates of percutaneous coronary intervention (PCI) have increased whereas the use of coronary artery bypass grafting (CABG) has decreased. Although historically there have been disparities in the use of revascularization procedures in women, the elderly, and nonwhite patients, there is some evidence to suggest these gaps have narrowed in recent years. In any given clinical circumstance, there is ongoing debate as to whether PCI or CABG is the more appropriate revascularization method depending on coronary anatomy, ventricular function, and associated conditions. Also, trends in coronary revascularization are potentially influenced by emerging clinical evidence and new technologies, national guidelines and appropriateness criteria, procedure reimbursement, and changes in the population being treated. Accordingly, it is unclear whether the trend in increased use of PCI versus CABG will continue.

Temporal Trends in the Use of Percutaneous Coronary Intervention and Coronary Artery Bypass Surgery in New York State and Ontario

Background— Healthcare reform initiatives in the United States have rekindled debate about the role of government regulation in the healthcare system. Although New York State (NYS) historically has had twice as many coronary revascularizations performed as Ontario, the relative evolution of coronary revascularization patterns in both jurisdictions over time is unknown.

Methods and Results— We conducted an observational study comparing the temporal trends of cardiac invasive procedures use in NYS and Ontario using population-based data from 1997 to 2006 stratified by procedure indication. For nonacute myocardial infarction patients, the age- and sex-adjusted rate of percutaneous coronary intervention (PCI) was 2.3 times (95% confidence interval, 2.2 to 2.5) greater in NYS than in Ontario in 2004 to 2006. In contrast, population-based rates of coronary artery bypass grafting among nonacute myocardial infarction patients were not significantly different. For acute myocardial infarction patients, differences in coronary revascularization rates between NYS and Ontario narrowed substantially over time. In 2004 to 2006, the relative ratio was 1.3 times higher for PCI (95% confidence interval, 1.2 to 1.5) and 1.4 times higher (95% confidence interval, 1.1 to 1.8) for coronary artery bypass grafting in NYS relative to Ontario. However, a larger relative gap (relative ratio, 2.0; 95% confidence interval, 1.7 to 2.3) was observed among acute myocardial infarction patients undergoing emergency PCIs in NYS compared with Ontario.

Conclusions— The market-oriented financing approach in NYS is associated with markedly higher rates of PCI procedures for both discretionary indications (eg, PCI in nonacute myocardial infarction patients) and emergent indications (eg, primary PCI) compared with the government-funded single-payer system in Ontario.

Determinants of cardiac catheterization use in older Medicare patients with acute myocardial infarction

BACKGROUND

Cardiac catheterization is substantially underused among higher-risk patients with acute myocardial infarction (AMI) with appropriate indications but overused among patients with inappropriate indications. We sought to determine the importance of anticipated benefit and anticipated harm on the use of cardiac catheterization among older patients with AMI.

METHODS AND RESULTS

We performed an analysis of Medicare fee-for-service beneficiaries hospitalized with an AMI between 1998 and 2001. Multivariate models were developed to determine relative importance of anticipated benefit (baseline cardiovascular risk), anticipated harm (bleeding risk, comorbidities), and demographic factors (age, sex, race, regional invasive intensity) in predicting cardiac catheterization use within 60 days of AMI admission. Analyses were stratified by American College of Cardiology/American Heart Association class I or II as appropriate, and class III as inappropriate. Determinants of reduced likelihood of cardiac catheterization among 42 241 AMI patients with appropriate indications included (in order of importance) older age (likelihood chi(2)=1309.5), higher bleeding risk score (likelihood chi(2)=471.2), more comorbidities (likelihood chi(2)=276.6), female sex (likelihood chi(2)=162.9), hospitalization in low (likelihood chi(2)=67.9) or intermediate intensity invasive regions (likelihood chi(2)=22.4) (all P<0.001), and baseline cardiovascular risk (likelihood chi(2)=6.4, P=0.01). Among 2398 AMI patients with inappropriate indications, significant determinants of greater procedure likelihood included younger age, male sex, lower bleeding risk score, and fewer comorbidities.

CONCLUSIONS

Regardless of the procedure indication, the decision to perform cardiac catheterization in this population appears largely driven by demographic factors and potential harm rather than potential benefit of the procedure.