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Luo QE, Black B, Magid DJ, Masoudi FA, Kini V, Moghtaderi A. A more complete measure of vertical integration between physicians and hospitals. Health Serv Res 2024. [PMID: 38689535 DOI: 10.1111/1475-6773.14314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVE To develop an accurate and reproducible measure of vertical integration between physicians and hospitals (defined as hospital or health system employment of physicians), which can be used to assess the impact of integration on healthcare quality and spending. DATA SOURCES AND STUDY SETTING We use multiple data sources including from the Internal Revenue Service, the Centers for Medicare and Medicaid Services, and others to determine the Tax Identification Numbers (TINs) that hospitals and physicians use to bill Medicare for services, and link physician billing TINs to hospital-related TINs. STUDY DESIGN We developed a new measure of vertical integration, based on the TINs that hospitals and physicians use to bill Medicare, using a broad set of sources for hospital-related TINs. We considered physicians as hospital-employed if they bill Medicare primarily or exclusively using hospital-related TINs. We assessed integration status for all physicians who billed Medicare from 1999 to 2019. We compared this measure with others used in the existing literature. We conducted a simulation study which highlights the importance of accurately identifying integrated physicians when study the effects of integration. DATA COLLECTION/EXTRACTION METHODS We extracted physician and hospital-related TINs from multiple sources, emphasizing specificity (a small proportion of nonintegrated physicians identified as integrated). PRINCIPAL FINDINGS We identified 12,269 hospital-related TINs, used for billing by 546,775 physicians. We estimate that the percentage of integrated physicians rose from 19% in 1999 to 43% in 2019. Our approach identifies many additional physician practices as integrated; a simpler TIN measure, comparable with prior work, identifies only 30% (3877) of the TINs we identify. A service location measure, used in prior work, has both many false positives and false negatives. CONCLUSION We developed a new measure of hospital-physician integration. This measure is reproducible and identifies many additional physician practices as integrated.
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Affiliation(s)
- Qian Eric Luo
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Bernard Black
- Pritzker School of Law, Institute for Policy Research, and Kellogg School of Management, Northwestern University, Chicago, Illinois, USA
| | - David J Magid
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Vinay Kini
- Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Ali Moghtaderi
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA
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Blue L, Kranker K, Markovitz AR, Powell RE, Williams MV, Pu J, Magid DJ, McCall N, Steiner A, Stewart KA, Rollison JM, Markovich P, Peterson GG. Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending: A Randomized Clinical Trial. JAMA 2023; 330:1437-1447. [PMID: 37847273 PMCID: PMC10582785 DOI: 10.1001/jama.2023.19597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/12/2023] [Indexed: 10/18/2023]
Abstract
Importance The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown. Objective To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years. Design, Setting, and Participants This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018. Intervention Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%). Main Outcomes and Measures Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021. Results High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85). Conclusions and Relevance The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention. Trial Registration ClinicalTrials.gov Identifier: NCT04047147.
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Affiliation(s)
| | | | | | - Rhea E. Powell
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Jia Pu
- Mathematica, Oakland, California
| | | | | | | | | | | | - Patricia Markovich
- Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland
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Kini V, Magid DJ, Luo Q, Masoudi FA, Black B, Moghtaderi A. Trends in Short-, Intermediate-, and Long-Term Mortality Following Hospitalization for Myocardial Infarction Among Medicare Beneficiaries, 2008 to 2018. J Am Heart Assoc 2023:e8529. [PMID: 37345751 DOI: 10.1161/jaha.122.029550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Background Advances in technology and care quality have transformed the care of acute myocardial infarction (AMI), but little is known about trends in mortality rates across separate time periods after hospitalization. Methods and Results We identified all Medicare fee-for-service beneficiaries hospitalized with incident AMI from 2008 to 2018. We calculated unadjusted mortality rates by dividing the number of all-cause deaths by the number of patients with incident AMI for the following time periods: acute (in hospital), post acute (0-30 days after hospital discharge), short term (31 days to 1 year after discharge), intermediate term (1-2 years after discharge), and long term (2-3 years after discharge). Each period was considered separately (ie, patients who died during one period were not counted in subsequent periods). Using logistic regression to account for differences in patient characteristics, we calculated annual risk standardized mortality ratios defined as observed over expected mortality based on 2008 rates. Among 768 084 patients with incident AMI (mean age 81 years, 48% male, 87% White), declines in observed-to-expected mortality ratios were observed for each time period: acute (0.68 [95% CI, 0.66-0.71]), postacute (0.72 [95% CI, 0.71-0.75]), short term (0.77 [95% CI, 0.75-0.78]), intermediate term (0.79 [95% CI, 0.77-0.81]), and long term (0.77 [95% CI, 0.75-0.79]). Declines were observed both for patients with and without ST-segment-elevation AMI. Conclusions For patients with incident AMI, there have been improvements in mortality rates across periods spanning the hospital stay through 3 years after discharge, reflecting advances in AMI care from hospitalization through long-term outpatient follow-up.
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Affiliation(s)
- Vinay Kini
- Division of Cardiology Weill Cornell Medical College New York NY USA
| | - David J Magid
- Division of Cardiology University of Colorado Anschutz Medical Campus Lafayette CO USA
| | - Qian Luo
- Department of Health Policy and Management George Washington University Washington DC USA
| | | | - Bernard Black
- Northwestern University, Pritzker School of Law and Kellogg School of Management Chicago IL USA
| | - Ali Moghtaderi
- Department of Health Policy and Management George Washington University Washington DC USA
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Hyman DA, Lerner J, Magid DJ, Black B. Association of Past and Future Paid Medical Malpractice Claims. JAMA Health Forum 2023; 4:e225436. [PMID: 36763369 PMCID: PMC9918873 DOI: 10.1001/jamahealthforum.2022.5436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Importance Many physicians believe that most medical malpractice claims are random events. This study assessed the association of prior paid claims (including a single prior claim) with future paid claims; whether public disclosure of prior paid claims affects future paid claims; and whether the association of prior and future paid claims decayed over time. Objective To examine the association of 1 or more prior paid medical malpractice claims with future paid claims. Design, Setting, and Participants This study assessed the association between prior paid claims (including a single prior claim) with future claims; whether public disclosure of prior claims affects future paid claims; and whether the association of prior and future paid claims decayed over time. This retrospective case-control study included all 881 876 licensed physicians in the US. All data analysis took place between July, 2018 and January, 2023. Exposure Paid medical malpractice claims. Main Outcome and Measures Association between a prior paid medical malpractice claim and likelihood of a paid claim in a future period, compared with simulated results expected if paid claims are random events. Using the same outcomes, we also assessed whether public disclosure of paid claims affects future paid claim rates. Results This study included all 881 876 physicians licensed to practice in the US at the time of the study. Overall, 3.3% of the 841 961 physicians with 0 paid claims in the prior period had 1 or more claims in the future period vs 12.4% of the 34 512 physicians with 1 paid claim in the prior period; 22.4% of the 4189 physicians with 2 paid claims in the prior period; and 37% of the 1214 physicians with 3 paid claims in the prior period. The association between prior claims and future claims was similar for high-medical-malpractice-risk and lower-risk specialties; 1 prior-period claim was associated with a 3.1 times higher likelihood of a future-period claim for high-risk specialties (95% CI, 2.8-3.4) vs a 4.2 times higher likelihood for lower-risk specialties (95% CI, 3.8-4.6). The predictive power of a prior paid claim for future claims declined gradually as the time since the prior claim increased, for prior or future periods up to 10 years. Public disclosure did not affect the association between prior and future paid claims. Conclusions and Relevance In this study of paid medical malpractice claims for all US physicians, a single prior paid claim was associated with substantial, long-lived higher future claim risk, independent of whether a physician was practicing in a high- or low-risk specialty, or whether a state publicly disclosed paid claims. Timely, noncoercive intervention, including education, has the potential to reduce future claims.
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Affiliation(s)
| | - Joshua Lerner
- NORC at the University of Chicago, Chicago, Illinois
| | - David J. Magid
- School of Public Health, University of Colorado, Lafayette
| | - Bernard Black
- Kellogg School of Management and Pritzker School of Law, Northwestern University, Chicago, Illinois
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Kini V, Magid DJ, Luo Q, Masoudi FA, Black B, Moghtaderi A. Abstract 161: Trends In Time-Incremental Mortality After Hospitalization For Incident Acute Myocardial Infarction Among Medicare Beneficiaries, 2008-2017. Circ Cardiovasc Qual Outcomes 2022. [DOI: 10.1161/circoutcomes.15.suppl_1.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
New medical technologies and advancements in care quality have transformed care of patients hospitalized with incident acute myocardial infarction (AMI). While some advances may impact short-term mortality (e.g., mechanical circulatory support), others may take much longer to impact mortality (e.g., cardiac rehabilitation). Little is known about trends in time-incremental AMI mortality rates.
Methods:
We identified all patients hospitalized with incident AMI using a 5% sample of Medicare fee-for-service beneficiaries from 2008 to 2017. We used a three-year look back to exclude patients with a prior AMI hospitalization. We calculated unadjusted in-hospital, 30-day, 1-year, 2-year, and 3-year mortality rates by dividing the total number of all-cause deaths during each period by the corresponding number of patients who were hospitalized. We used logistic regression models to adjust mortality rates for patient demographics (age, sex, race/ethnicity) and a variety of comorbid conditions. Using 2008 as the baseline, we calculated annual incremental mortality rates for each time period. We performed subgroup analyses among AMI patients with ST-segment and non-ST-segment elevation.
Results:
From 2008 to 2017, we identified 42,567 patients hospitalized with incident AMI (mean age 81 years, 44% male, 86% white). The largest incremental declines in mortality rates were observed for the in-hospital (2.9% [CI 2.7 to 3.1%]), 30-day (2.1% [CI 1.9 to 2.3%], and 1-year (2.9% [CI 2.6 to 3.2%] time periods. Mortality declines were smaller but persisted for the 2-year (1.5% [CI 1.2 to 1.8%]), and 3-year (0.5% [CI 0.2 to 0.8%]; Figure) time periods. Similar patterns were observed among both ST-segment and non-ST-segment elevation AMI patients.
Conclusions:
For patients hospitalized with incident AMI, advances in care have led to incremental declines in mortality across time periods spanning the hospital stay through 3 years after discharge.
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Affiliation(s)
| | | | - Qian Luo
- George Washington Univ, Washington D.C., DC
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Peterson GG, Pu J, Magid DJ, Barterian L, Kranker K, Barna M, Conwell L, Rose A, Blue L, Markovitz A, McCall N, Markovich P. Effect of the Million Hearts Cardiovascular Disease Risk Reduction Model on Initiating and Intensifying Medications: A Prespecified Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2021; 6:1050-1059. [PMID: 34076665 DOI: 10.1001/jamacardio.2021.1565] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance The Million Hearts Cardiovascular Disease (CVD) Risk Reduction Model pays provider organizations for measuring and reducing Medicare patients' cardiovascular risk. Objective To assess whether the model increases the initiation or intensification of antihypertensive medications or statins among patients with blood pressure or low-density lipoprotein (LDL) cholesterol levels above guideline thresholds for treatment intensification. Design, Setting, and Participants This prespecified secondary analysis of a cluster-randomized, pragmatic trial included primary care and cardiology practices, health care centers, and hospital-based outpatient departments across the US. Participants included Medicare patients who were enrolled into the model in 2017 by participating organizations and who were at high risk and at medium risk of a myocardial infarction or stroke in 10 years. Patient outcomes were analyzed for 1 year postenrollment (through December 2018) using an intent-to-treat design. Analysis began November 2019. Interventions US Centers for Medicare & Medicaid Services paid organizations for risk stratifying Medicare patients and reducing CVD risk among high-risk patients through discussing risk scores, developing individualized risk reduction plans, and following up with patients twice yearly. Main Outcomes and Measures Initiating or intensifying statin or antihypertensive therapy within 1 year of enrollment, measured in Medicare Part D claims, and LDL cholesterol and systolic blood pressure levels approximately 1 year after enrollment, measured in usual care and reported to Centers for Medicare & Medicaid Services via a data registry (data complete for 51% of high-risk enrollees). The study's primary outcome (incidence of first-time myocardial infarction and stroke) is not reported because the trial is ongoing. Results A total of 330 primary care and cardiology practices, health care centers, and hospital-based outpatient departments and 125 436 Medicare patients were included in this analysis. High-risk patients in the intervention group had a mean (SD) age of 74 (4.1), 15 213 (63%) were male, 21 657 (90%) were receiving antihypertensive medication at baseline, and 16 558 (69%) were receiving statins. Almost all (21 791 [91%]) high-risk intervention group patients had above-threshold systolic blood pressure level (>130 mm Hg), LDL cholesterol level (>70 mg/dL), or both. Patients in the intervention group with these risk factors were more likely than control patients (8127 [37.3%] vs 4753 [32.4%]; adjusted difference in percentage points, 4.8; 95% CI, 2.9-6.7; P < .001) to initiate or intensify statins or antihypertensive medication. Centers for Medicare & Medicaid Services did not pay for CVD risk reduction for medium-risk enrollees, but initiation or intensification rates for these enrollees were also higher in the intervention vs control groups (12 668 [27.9%] vs 7544 [24.8%]; adjusted difference in percentage points, 3.1; 95% CI, 1.9-4.3; P < .001). Among high-risk enrollees with clinical data approximately 1 year after enrollment, LDL cholesterol level was slightly lower in the intervention vs control groups (mean [SD], 89 [31.8] vs 91 [32.1] mg/dL; adjusted difference in percentage points, -1.8; 95% CI, -2.9 to -0.6; P = .002), as was systolic blood pressure (mean [SD], 133 [15.7] vs 135 [16.4] mm Hg; adjusted difference in percentage points, -1.7; 95% CI, -2.8 to -0.6; P = .003). Conclusions and Relevance In this study, a pay-for-performance model led to modest increases in the use of CVD medications in a range of organizations, despite high medication use at baseline.
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Affiliation(s)
| | - Jia Pu
- Mathematica, San Francisco, California
| | | | | | | | | | | | - Adam Rose
- Hebrew University School of Public Health, Jerusalem, Israel
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Peterson GG, Magid DJ. Capsule Commentary on Soylu et al., Readiness and Implementation of Quality Improvement Strategies Among Small and Medium-Sized Primary Care Practices: an Observational Study. J Gen Intern Med 2021; 36:855. [PMID: 32875508 PMCID: PMC7947136 DOI: 10.1007/s11606-020-06153-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - David J Magid
- University of Colorado School of Medicine, Denver, CO, USA
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Kini V, Mosley B, Raghavan S, Khazanie P, Bradley SM, Magid DJ, Ho PM, Masoudi FA. Differences in High- and Low-Value Cardiovascular Testing by Health Insurance Provider. J Am Heart Assoc 2021; 10:e018877. [PMID: 33506684 PMCID: PMC7955432 DOI: 10.1161/jaha.120.018877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Quality of care incentives and reimbursements for cardiovascular testing differ between insurance providers. We hypothesized that there are differences in the use of guideline‐concordant testing between Medicaid versus commercial insurance patients <65 years, and between Medicare Advantage versus Medicare fee‐for‐service patients ≥65 years. Methods and Results Using data from the Colorado All‐Payer Claims Database from 2015 to 2018, we identified patients eligible to receive a high‐value test recommended by guidelines: assessment of left ventricular function among patients hospitalized with acute myocardial infarction or incident heart failure, or a low‐value test that provides minimal patient benefit: stress testing prior to low‐risk surgery or routine stress testing within 2 years of percutaneous coronary intervention or coronary artery bypass graft surgery. Among 145 616 eligible patients, 37% had fee‐for‐service Medicare, 18% Medicare Advantage, 22% Medicaid, and 23% commercial insurance. Using multilevel logistic regression models adjusted for patient characteristics, Medicaid patients were less likely to receive high‐value testing for acute myocardial infarction (odds ratio [OR], 0.84 [0.73–0.98]; P=0.03) and heart failure (OR, 0.59 [0.51–0.70]; P<0.01) compared with commercially insured patients. Medicare Advantage patients were more likely to receive high‐value testing for acute myocardial infarction (OR, 1.35 [1.15–1.59]; P<0.01) and less likely to receive low‐value testing after percutaneous coronary intervention/ coronary artery bypass graft (OR, 0.63 [0.55–0.72]; P<0.01) compared with Medicare fee‐for‐service patients. Conclusions Guideline‐concordant testing was less likely to occur among patients with Medicaid compared with commercial insurance, and more likely to occur among patients with Medicare Advantage compared with fee‐for‐service Medicare. Insurance plan features may provide valuable targets to improve guideline‐concordant testing.
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Affiliation(s)
- Vinay Kini
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| | | | | | - Prateeti Khazanie
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation Minneapolis MN
| | - David J Magid
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| | - P Michael Ho
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO.,Veterans Affairs Eastern Colorado Health Care System Aurora CO
| | - Frederick A Masoudi
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
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Aziz K, Lee CHC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2021; 147:peds.2020-038505E. [PMID: 33087555 DOI: 10.1542/peds.2020-038505e] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Allen LA, Venechuk G, McIlvennan CK, Page RL, Knoepke CE, Helmkamp LJ, Khazanie P, Peterson PN, Pierce K, Harger G, Thompson JS, Dow TJ, Richards L, Huang J, Strader JR, Trinkley KE, Kao DP, Magid DJ, Buttrick PM, Matlock DD. An Electronically Delivered Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure With Reduced Ejection Fraction: The EPIC-HF Trial. Circulation 2020; 143:427-437. [PMID: 33201741 DOI: 10.1161/circulationaha.120.051863] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Major gaps exist in the routine initiation and dose up-titration of guideline-directed medical therapies (GDMT) for patients with heart failure with reduced ejection fraction. Without novel approaches to improve prescribing, the cumulative benefits of heart failure with reduced ejection fraction treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients. METHODS The EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) trial randomized patients with heart failure with reduced ejection fraction from a diverse health system to usual care versus patient activation tools-a 3-minute video and 1-page checklist-delivered electronically 1 week before, 3 days before, and 24 hours before a cardiology clinic visit. The tools encouraged patients to work collaboratively with their clinicians to "make one positive change" in heart failure with reduced ejection fraction prescribing. The primary endpoint was the percentage of patients with GDMT medication initiations and dose intensifications from immediately preceding the cardiology clinic visit to 30 days after, compared with usual care during the same period. RESULTS EPIC-HF enrolled 306 patients, 290 of whom attended a clinic visit during the study period: 145 were sent the patient activation tools and 145 were controls. The median age of patients was 65 years; 29% were female, 11% were Black, 7% were Hispanic, and the median ejection fraction was 32%. Preclinic data revealed significant GDMT opportunities, with no patients on target doses of β-blocker, sacubitril/valsartan, and mineralocorticoid receptor antagonists. From immediately preceding the cardiology clinic visit to 30 days after, 49.0% in the intervention and 29.7% in the control experienced an initiation or intensification of their GDMT (P=0.001). The majority of these changes were made at the clinician encounter itself and involved dose uptitrations. There were no deaths and no significant differences in hospitalization or emergency department visits at 30 days between groups. CONCLUSIONS A patient activation tool delivered electronically before a cardiology clinic visit improved clinician intensification of GDMT. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334188.
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Affiliation(s)
- Larry A Allen
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Grace Venechuk
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Colleen K McIlvennan
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Robert L Page
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora (R.L.P., K.E.T.)
| | | | - Laura J Helmkamp
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Prateeti Khazanie
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Pamela N Peterson
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.).,Denver Health Medical Center, CO (P.N.P.)
| | - Kenneth Pierce
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Geoffrey Harger
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Jocelyn S Thompson
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Tristan J Dow
- University of Colorado Health Poudre Valley Hospital, Loveland (T.J.D., L.R.)
| | - Lance Richards
- University of Colorado Health Poudre Valley Hospital, Loveland (T.J.D., L.R.)
| | - Janice Huang
- University of Colorado Health Memorial Hospital, Colorado Springs (J.H., J.R.S.)
| | - James R Strader
- University of Colorado Health Memorial Hospital, Colorado Springs (J.H., J.R.S.)
| | - Katy E Trinkley
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.).,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora (R.L.P., K.E.T.)
| | - David P Kao
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - David J Magid
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Peter M Buttrick
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Daniel D Matlock
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
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11
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Venechuk GE, Khazanie P, Page RL, Knoepke CE, Helmkamp LJ, Peterson PN, Pierce K, Thompson JS, Huang J, Strader JR, Dow TJ, Richards L, Trinkley KE, Kao DP, McIlvennan CK, Magid DJ, Buttrick PM, Matlock DD, Allen LA. An Electronically delivered, Patient-activation tool for Intensification of medications for Chronic Heart Failure with reduced ejection fraction: Rationale and design of the EPIC-HF trial. Am Heart J 2020; 229:144-155. [PMID: 32866454 DOI: 10.1016/j.ahj.2020.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Heart failure with reduced ejection fraction (HFrEF) benefits from initiation and intensification of multiple pharmacotherapies. Unfortunately, there are major gaps in the routine use of these drugs. Without novel approaches to improve prescribing, the cumulative benefits of HFrEF treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients. HYPOTHESIS Encouraging patients to engage providers in HFrEF prescribing decisions will improve the use of guideline-directed medical therapies. DESIGN The Electronically delivered, Patient-activation tool for Intensification of Chronic medications for Heart Failure with reduced ejection fraction (EPIC-HF) trial randomizes patients with HFrEF to usual care versus patient-activation tools-a 3-minute video and 1-page checklist-delivered prior to cardiology clinic visits that encourage patients to work collaboratively with their clinicians to intensify HFrEF prescribing. The study assesses the effectiveness of the EPIC-HF intervention to improve guideline-directed medical therapy in the month after its delivery while using an implementation design to also understand the reach, adoption, implementation, and maintenance of this approach within the context of real-world care delivery. Study enrollment was completed in January 2020, with a total 305 patients. Baseline data revealed significant opportunities, with <1% of patients on optimal HFrEF medical therapy. SUMMARY The EPIC-HF trial assesses the implementation, effectiveness, and safety of patient engagement in HFrEF prescribing decisions. If successful, the tool can be easily disseminated and may inform similar interventions for other chronic conditions.
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12
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Pellegrino JL, Charlton NP, Carlson JN, Flores GE, Goolsby CA, Hoover AV, Kule A, Magid DJ, Orkin AM, Singletary EM, Slater TM, Swain JM. 2020 American Heart Association and American Red Cross Focused Update for First Aid. Circulation 2020; 142:e287-e303. [PMID: 33084370 DOI: 10.1161/cir.0000000000000900] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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13
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Cheng A, Magid DJ, Auerbach M, Bhanji F, Bigham BL, Blewer AL, Dainty KN, Diederich E, Lin Y, Leary M, Mahgoub M, Mancini ME, Navarro K, Donoghue A. Part 6: Resuscitation Education Science: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S551-S579. [PMID: 33081527 DOI: 10.1161/cir.0000000000000903] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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14
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Berg KM, Cheng A, Panchal AR, Topjian AA, Aziz K, Bhanji F, Bigham BL, Hirsch KG, Hoover AV, Kurz MC, Levy A, Lin Y, Magid DJ, Mahgoub M, Peberdy MA, Rodriguez AJ, Sasson C, Lavonas EJ. Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S580-S604. [PMID: 33081524 DOI: 10.1161/cir.0000000000000899] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.
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15
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Merchant RM, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, Lavonas EJ, Magid DJ. Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S337-S357. [DOI: 10.1161/cir.0000000000000918] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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16
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Magid DJ, Aziz K, Cheng A, Hazinski MF, Hoover AV, Mahgoub M, Panchal AR, Sasson C, Topjian AA, Rodriguez AJ, Donoghue A, Berg KM, Lee HC, Raymond TT, Lavonas EJ. Part 2: Evidence Evaluation and Guidelines Development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S358-S365. [DOI: 10.1161/cir.0000000000000898] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The
2020 American Heart Association
(AHA)
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
is based on the extensive evidence evaluation performed in conjunction with the International Liaison Committee on Resuscitation. The Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups drafted, reviewed, and approved recommendations, assigning to each recommendation a Class of Recommendation (ie, strength) and Level of Evidence (ie, quality). The 2020 Guidelines are organized in knowledge chunks that are grouped into discrete modules of information on specific topics or management issues. The 2020 Guidelines underwent blinded peer review by subject matter experts and were also reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. The AHA has rigorous conflict-of-interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines. Anyone involved in any part of the guideline development process disclosed all commercial relationships and other potential conflicts of interest.
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17
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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18
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Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S524-S550. [DOI: 10.1161/cir.0000000000000902] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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19
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Omboni S, McManus RJ, Bosworth HB, Chappell LC, Green BB, Kario K, Logan AG, Magid DJ, Mckinstry B, Margolis KL, Parati G, Wakefield BJ. Evidence and Recommendations on the Use of Telemedicine for the Management of Arterial Hypertension: An International Expert Position Paper. Hypertension 2020; 76:1368-1383. [PMID: 32921195 DOI: 10.1161/hypertensionaha.120.15873] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Telemedicine allows the remote exchange of medical data between patients and healthcare professionals. It is used to increase patients' access to care and provide effective healthcare services at a distance. During the recent coronavirus disease 2019 (COVID-19) pandemic, telemedicine has thrived and emerged worldwide as an indispensable resource to improve the management of isolated patients due to lockdown or shielding, including those with hypertension. The best proposed healthcare model for telemedicine in hypertension management should include remote monitoring and transmission of vital signs (notably blood pressure) and medication adherence plus education on lifestyle and risk factors, with video consultation as an option. The use of mixed automated feedback services with supervision of a multidisciplinary clinical team (physician, nurse, or pharmacist) is the ideal approach. The indications include screening for suspected hypertension, management of older adults, medically underserved people, high-risk hypertensive patients, patients with multiple diseases, and those isolated due to pandemics or national emergencies.
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Affiliation(s)
- Stefano Omboni
- From the Clinical Research Unit, Italian Institute of Telemedicine, Varese (S.O.).,Scientific Research Department of Cardiology, Science and Technology Park for Biomedicine, Sechenov First Moscow State Medical University, Russian Federation (S.O.)
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (R.J.M.)
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, NC (H.B.B.).,Department of Psychiatry and Behavioral Sciences (H.B.B.), Duke University, Durham, NC.,Division of General Internal Medicine (H.B.B.), Duke University, Durham, NC.,Department of Population Health Sciences (H.B.B.), Duke University, Durham, NC
| | - Lucy C Chappell
- Women's Health Academic Centre, King's College London, United Kingdom (L.C.C.)
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle (B.B.G.)
| | - Kazuomi Kario
- Department of Cardiology, Jichi Medical University School of Medicine, Tochigi, Japan (K.K.)
| | - Alexander G Logan
- Department of Medicine, Mount Sinai Hospital, University Health Network and University of Toronto, ON, Canada (A.G.L.)
| | - David J Magid
- Colorado Permanente Medical Group, Denver and School of Public Health, University of Colorado, Aurora (D.J.M.)
| | - Brian Mckinstry
- Emeritus Professor of Primary Care eHealth, Usher Institute, The University of Edinburgh, United Kingdom (B.M.)
| | | | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Italy (G.P.).,Istituto Auxologico Italiano, IRCCS San Luca, Milano, Italy (G.P.)
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20
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Peterson GG, Pu J, Magid DJ, Barterian L, Barna M, Conwell L, Rose A, Kranker K, McCall N, Markovich P. Abstract 19: Impacts of the Million Hearts® Cardiovascular Disease Risk Reduction Model on the Initiation or Intensification of Statins and Anti-hypertensive Medications: A Pragmatic, Cluster-randomized Trial. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The Million Hearts® Cardiovascular Disease (CVD) Risk Reduction Model pays providers for measuring cardiovascular risk among their Medicare beneficiaries and for reducing risk among their high-risk patients. The Centers for Medicare and Medicaid Services (CMS) is testing whether this model can improve cardiovascular care and reduce the incidence of first-time heart attacks and strokes over 5 years. This study assesses whether, in its first 2 years, the model (1) increased use of CVD medications among those with elevated blood pressure or cholesterol, and (2) increased provider awareness of CVD risks among their patients.
Methods:
In this pragmatic, cluster-randomized trial, CMS enrolled 516 organizations (primary and specialty practices, health centers, and hospitals) throughout the country and assigned half to the intervention group. Organizations enrolled beneficiaries (age 40-79 without a prior CVD event) during routine office visits. We linked enrollment and clinical data with Medicare Part D claims and estimated impacts as intervention-control differences in outcomes. We surveyed one randomly selected provider in each organization about their use of risk CVD stratification (70% response rate).
Results:
The intervention and control organizations enrolled 300,550 Medicare beneficiaries. In both groups, 18% of enrollees were high risk per CMS definitions (≥30% or higher risk of a heart attack or stroke in the next 10 years), 40% were medium risk (15-30% risk), and the remainder were low risk (<15% risk). While almost all high-risk enrollees were taking anti-hypertensive medications or statins at baseline, most (90%) had elevated blood pressure, cholesterol, or both. High-risk enrollees in the intervention group were 4 percentage points more likely than control enrollees (28 vs 24%, p<0.001) to initiate or intensify statins or anti-hypertensive medications within 6 months of enrollment. When including the larger medium-risk group—for whom CMS does not separately pay for CVD risk reduction—rates of initiation or intensification were 3 percentage points higher in the intervention versus control groups (23 vs 20%, p<0.001). According to the survey, intervention group providers were much more likely than control group providers to risk assess at least half of their Medicare patients (71 vs 39%, p<0.001). Most intervention group providers (73%) said that their greater use of risk stratification helped them better identify beneficiaries at risk of CVD events.
Conclusions:
The Million Hearts model significantly improved use of CVD medications among high-risk enrollees, mainly through intensification, and had positive spillover to the much larger medium risk group. These improvements were likely driven, at least partly, by providers become more aware of their patients’ CVD risk through greater use of risk stratification.
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Affiliation(s)
| | - Jia Pu
- Mathematica, San Mateo, CA
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21
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Sheppard JP, Tucker KL, Davison WJ, Stevens R, Aekplakorn W, Bosworth HB, Bove A, Earle K, Godwin M, Green BB, Hebert P, Heneghan C, Hill N, Hobbs FDR, Kantola I, Kerry SM, Leiva A, Magid DJ, Mant J, Margolis KL, McKinstry B, McLaughlin MA, McNamara K, Omboni S, Ogedegbe O, Parati G, Varis J, Verberk WJ, Wakefield BJ, McManus RJ. Self-monitoring of Blood Pressure in Patients With Hypertension-Related Multi-morbidity: Systematic Review and Individual Patient Data Meta-analysis. Am J Hypertens 2020; 33:243-251. [PMID: 31730171 PMCID: PMC7162426 DOI: 10.1093/ajh/hpz182] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/11/2019] [Accepted: 11/13/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Studies have shown that self-monitoring of blood pressure (BP) is effective when combined with co-interventions, but its efficacy varies in the presence of some co-morbidities. This study examined whether self-monitoring can reduce clinic BP in patients with hypertension-related co-morbidity. METHODS A systematic review was conducted of articles published in Medline, Embase, and the Cochrane Library up to January 2018. Randomized controlled trials of self-monitoring of BP were selected and individual patient data (IPD) were requested. Contributing studies were prospectively categorized by whether they examined a low/high-intensity co-intervention. Change in BP and likelihood of uncontrolled BP at 12 months were examined according to number and type of hypertension-related co-morbidity in a one-stage IPD meta-analysis. RESULTS A total of 22 trials were eligible, 16 of which were able to provide IPD for the primary outcome, including 6,522 (89%) participants with follow-up data. Self-monitoring was associated with reduced clinic systolic BP compared to usual care at 12-month follow-up, regardless of the number of hypertension-related co-morbidities (−3.12 mm Hg, [95% confidence intervals −4.78, −1.46 mm Hg]; P value for interaction with number of morbidities = 0.260). Intense interventions were more effective than low-intensity interventions in patients with obesity (P < 0.001 for all outcomes), and possibly stroke (P < 0.004 for BP control outcome only), but this effect was not observed in patients with coronary heart disease, diabetes, or chronic kidney disease. CONCLUSIONS Self-monitoring lowers BP regardless of the number of hypertension-related co-morbidities, but may only be effective in conditions such obesity or stroke when combined with high-intensity co-interventions.
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Affiliation(s)
- J P Sheppard
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - K L Tucker
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - W J Davison
- Ageing and Stroke Medicine, Norwich Medical School, University of East Anglia, United Kingdom
| | - R Stevens
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - W Aekplakorn
- Department of Community Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Bangkok, Thailand
| | - H B Bosworth
- Center for Health Services Research in Primary Care, Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - A Bove
- Cardiology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - K Earle
- Thomas Addison Diabetes Unit, St. George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - M Godwin
- Family Medicine, Memorial University of Newfoundland, St. John’s, Canada
| | - B B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - P Hebert
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
| | - C Heneghan
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - N Hill
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - F D R Hobbs
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - I Kantola
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - S M Kerry
- Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
| | - A Leiva
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, Mallorca, Spain
| | - D J Magid
- Colorado School of Public Health, University of Colorado, Denver, Colorado, USA
| | - J Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - K L Margolis
- HealthPartners Institute, Minneapolis, Minnesota, USA
| | - B McKinstry
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - M A McLaughlin
- Icahn School of Medicine at Mount Sinai New York, New York, New York, USA
| | - K McNamara
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- School of Medicine, Deakin University, Geelong, Australia
| | - S Omboni
- Clinical Research Unit, Italian Institute of Telemedicine, Varese, Italy
- Scientific Research Department of Cardiology, Science and Technology Park for Biomedicine, Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - O Ogedegbe
- Center for Healthful Behavior Change, Division of Health and Behavior, Department of Population Health, Langone School of Medicine, New York University, New York, USA
| | - G Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - J Varis
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - W J Verberk
- Cardiovascular Research Institute Maastricht and Departments of Internal Medicine, Maastricht University, Maastricht, The Netherlands
| | - B J Wakefield
- Department of Veterans (VA) Health Services Research and Development Centre for Comprehensive Access and Delivery Research and Evaluation (CADRE), VA Medical Centre, Iowa City, USA
| | - R J McManus
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
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22
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Masoudi FA, Viragh T, Magid DJ, Moghtaderi A, Schilsky S, Sage WM, Goodrich G, Newton KM, Smith DH, Black B. Trends in Medicare Payment Rates for Noninvasive Cardiac Tests and Association With Testing Location. JAMA Intern Med 2019; 179:1699-1706. [PMID: 31609397 PMCID: PMC6802070 DOI: 10.1001/jamainternmed.2019.4269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE To control spending, the Centers for Medicare & Medicaid Services reduced Medicare fee-for-service (FFS) payments for noninvasive cardiac tests (NCTs) performed in provider-based office settings (ambulatory offices not administratively affiliated with hospitals) starting in 2005. Contemporaneously, payments for hospital-based outpatient testing increased. The association between differential payments by site and test location is unknown. OBJECTIVES To quantify trends in differential Medicare FFS payments for NCTs performed in hospital-based and provider-based settings, determine the association between the hospital-based outpatient testing to provider-based office testing payment ratio and the proportion of hospital-based NCTs, and to examine trends in test location between Medicare FFS and 3 Medicare Advantage health maintenance organizations for which Centers for Medicare & Medicaid Services payments do not depend on testing location. DESIGN, SETTING, AND PARTICIPANTS This observational claims-based study used Medicare FFS claims from 1999 to 2015 (5% random sample) and Medicare Advantage claims from 3 large health maintenance organizations (2005-2015) among Medicare FFS beneficiaries aged 65 years or older and a health maintenance organization control group. Statistical analysis was performed from May 1, 2017, to July 15, 2019. EXPOSURES The weighted mean payment ratio of Medicare FFS hospital-based outpatient testing to provider-based office testing for outpatient NCTs. MAIN OUTCOMES AND MEASURES Proportion of outpatient NCTs performed in the hospital-based setting and Medicare FFS costs. RESULTS The data included a mean of 1.72 million patient-years annually in Medicare FFS (mean age, 75.2 years; 57.3% female in 2015) and a mean of 142 230 patient-years annually in the managed care control group (mean age, 74.8 years; 56.2% female in 2015). The Medicare payment ratio of FFS hospital-based outpatient testing to provider-based office testing increased from 1.05 in 2005 to 2.32 in 2015. The FFS hospital-based outpatient testing proportion increased from 21.1% in 2008 to 43.2% in 2015 and was correlated with the payment ratio (correlation coefficient with a 1-year lag, 0.767; P < .001). In contrast, the hospital-based outpatient testing proportion for the control group declined from 16.6% in 2008 to 15.2% in 2015 (correlation coefficient, -0.024, P = .95). The estimated extra costs owing to tests shifting to the hospital-based outpatient setting in the Medicare FFS group was $661 million in 2015, including $161 million in patient out-of-pocket costs. CONCLUSIONS AND RELEVANCE In settings in which reimbursement depends on test location, increasing hospital-based payments correlated with greater proportions of outpatient NCTs performed in the hospital-based outpatient setting. Site-neutral payments may offer an incentive for testing to be performed in the more efficient location.
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Affiliation(s)
- Frederick A Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Timea Viragh
- School of Education and Social Policy, Northwestern University, Evanston, Illinois
| | - David J Magid
- Colorado Permanente Medical Group, Denver.,School of Public Health, University of Colorado, Aurora
| | - Ali Moghtaderi
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Samantha Schilsky
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Glenn Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | | | | | - Bernard Black
- Pritzker School of Law, Institute for Policy Research, Kellogg School of Management, Northwestern University, Chicago, Illinois
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23
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Hajduk AM, Gurwitz JH, Tabada G, Masoudi FA, Magid DJ, Greenlee RT, Sung SH, Cassidy-Bushrow AE, Liu TI, Reynolds K, Smith DH, Fiocchi F, Goldberg R, Gill TM, Gupta N, Peterson PN, Schuger C, Vidaillet H, Hammill SC, Allore H, Go AS. Influence of Multimorbidity on Burden and Appropriateness of Implantable Cardioverter-Defibrillator Therapies. J Am Geriatr Soc 2019; 67:1370-1378. [PMID: 30892695 DOI: 10.1111/jgs.15839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/25/2019] [Accepted: 01/26/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine whether burden of multiple chronic conditions (MCCs) influences the risk of receiving inappropriate vs appropriate device therapies. DESIGN Retrospective cohort study. SETTING Seven US healthcare delivery systems. PARTICIPANTS Adults with left ventricular systolic dysfunction receiving an implantable cardioverter-defibrillator (ICD) for primary prevention. MEASUREMENTS Data on 24 comorbid conditions were captured from electronic health records and categorized into quartiles of comorbidity burden (0-3, 4-5, 6-7 and 8-16). Incidence of ICD therapies (shock and antitachycardia pacing [ATP] therapies), including appropriateness, was collected for 3 years after implantation. Outcomes included time to first ICD therapy, total ICD therapy burden, and risk of inappropriate vs appropriate ICD therapy. RESULTS Among 2235 patients (mean age = 69 ± 11 years, 75% men), the median number of comorbidities was 6 (interquartile range = 4-8), with 98% having at least two comorbidities. During a mean 2.2 years of follow-up, 18.3% of patients experienced at least one appropriate therapy and 9.9% experienced at least one inappropriate therapy. Higher comorbidity burden was associated with an increased risk of first inappropriate therapy (adjusted hazard ratio [HR] = 1.94 [95% confidence interval {CI} = 1.14-3.31] for 4-5 comorbidities; HR = 2.25 [95% CI = 1.25-4.05] for 6-7 comorbidities; and HR = 2.91 [95% CI = 1.54-5.50] for 8-16 comorbidities). Participants with 8-16 comorbidities had a higher total burden of ICD therapy (adjusted relative risk [RR] = 2.12 [95% CI = 1.43-3.16]), a higher burden of inappropriate therapy (RR = 3.39 [95% CI = 1.67-6.86]), and a higher risk of receiving inappropriate vs appropriate therapy (RR = 1.74 [95% CI = 1.07-2.82]). Comorbidity burden was not significantly associated with receipt of appropriate ICD therapies. Patterns were similar when separately examining shock or ATP therapies. CONCLUSIONS In primary prevention ICD recipients, MCC burden was independently associated with an increased risk of inappropriate but not appropriate device therapies. Comorbidity burden should be considered when engaging patients in shared decision making about ICD implantation.
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Affiliation(s)
- Alexandra M Hajduk
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, a Joint Endeavor of University of Massachusetts Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts
| | - Grace Tabada
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Frederick A Masoudi
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David J Magid
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Robert T Greenlee
- Center for Clinical Epidemiology & Population Health, Marshfield Clinic Research Foundation, Marshfield, Wisconsin
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Taylor I Liu
- Department of Cardiac Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - David H Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Frances Fiocchi
- National Cardiovascular Data Registry, American College of Cardiology Foundation, Washington, DC
| | - Robert Goldberg
- Meyers Primary Care Institute, a Joint Endeavor of University of Massachusetts Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts
| | - Thomas M Gill
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Nigel Gupta
- Department of Cardiac Electrophysiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Pamela N Peterson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Claudio Schuger
- Heart and Vascular Institute, Henry Ford Health System, Detroit, Michigan
| | - Humberto Vidaillet
- Marshfield Clinical Research Foundation, Marshfield Clinic, Marshfield, Wisconsin
| | | | - Heather Allore
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California.,Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, California.,Departments of Medicine, Health Research and Policy, Stanford University School of Medicine, Palo Alto, California
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24
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Tisminetzky M, Gurwitz JH, Fan D, Reynolds K, Smith DH, Magid DJ, Sung SH, Murphy TE, Goldberg RJ, Go AS. Multimorbidity Burden and Adverse Outcomes in a Community-Based Cohort of Adults with Heart Failure. J Am Geriatr Soc 2018; 66:2305-2313. [PMID: 30246862 DOI: 10.1111/jgs.15590] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To assess multimorbidity burden and its association with clinical outcomes in adults with heart failure (HF) according to sex, age, and HF type. DESIGN Retrospective cohort study. SETTING Five healthcare delivery systems across the United States. PARTICIPANTS Adults with HF (N=114,553). MEASUREMENTS We characterized participants with respect to the presence of 26 chronic conditions categorized into quartiles based on overall burden of comorbidity (<5, 5-6, 7-8, ≥9). Outcomes included all-cause death and hospitalization for HF or any cause. Multivariable Cox regression was used to evaluate the adjusted association between categorized burden of multimorbidity burden and outcomes. RESULTS Individuals with more morbidities were more likely to die than those with fewer then 5 morbidities (5-6 morbidities: adjusted hazard ratio (aHR)=1.27 (95% confidence interval (CI)=1.24-1.31; 7-8 morbidities: aHR=1.52, 95% CI=1.48-1.57; ≥9 morbidities: aHR=1.92, 95% CI=1.86-1.99). There was a graded, higher adjusted rate of any-cause hospitalization associated with 5 or 6 (aHR=1.28, 95% CI=1.25-1.30), 7 or 8 (aHR=1.47, 95% CI=1.44-1.50), or 9 or more (aHR=1.77, 95% CI=1.73-1.82) morbidities (vs <5). Similar findings were observed for HF-specific hospitalization in those with 5 or 6 (aHR=1.22, 95% CI=1.19-1.26), 7 or 8 (aHR=1.39, 95% CI=1.34-1.44), or 9 or more (aHR 1.68, 95% CI=1.61-1.74) morbidities (vs <5). Consistent findings were seen according to sex, age group, and HF type (preserved, reduced, borderline HF), in the association between categorical burden of multimorbidity and outcomes especially prominent in individuals younger than 65. CONCLUSION After adjustment, higher levels of multimorbidity predicted worse HF outcomes and may be an important consideration in strategies to improve clinical and person-centered outcomes. J Am Geriatr Soc 66:2305-2313, 2018.
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Affiliation(s)
- Mayra Tisminetzky
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts.,Division of Geriatric Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts.,Division of Geriatric Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - David H Smith
- Center for Health Research, Kaiser Permanente Northwest, Oregon, Portland
| | - David J Magid
- The Kaiser Institute for Health Research Denver, Denver, Colorado
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Terrence E Murphy
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Robert J Goldberg
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California.,Departments of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Departments of Medicine, University of California, San Francisco, San Francisco, California.,Department of Health Research and Policy, School of Medicine, Stanford University, Stanford, California
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25
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Greenlee RT, Go AS, Peterson PN, Cassidy-Bushrow AE, Gaber C, Garcia-Montilla R, Glenn KA, Gupta N, Gurwitz JH, Hammill SC, Hayes JJ, Kadish A, Magid DJ, McManus DD, Multerer D, Powers JD, Reifler LM, Reynolds K, Schuger C, Sharma PP, Smith DH, Suits M, Sung SH, Varosy PD, Vidaillet HJ, Masoudi FA. Device Therapies Among Patients Receiving Primary Prevention Implantable Cardioverter-Defibrillators in the Cardiovascular Research Network. J Am Heart Assoc 2018; 7:e008292. [PMID: 29581222 PMCID: PMC5907599 DOI: 10.1161/jaha.117.008292] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/15/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Primary prevention implantable cardioverter-defibrillators (ICDs) reduce mortality in selected patients with left ventricular systolic dysfunction by delivering therapies (antitachycardia pacing or shocks) to terminate potentially lethal arrhythmias; inappropriate therapies also occur. We assessed device therapies among adults receiving primary prevention ICDs in 7 healthcare systems. METHODS AND RESULTS We linked medical record data, adjudicated device therapies, and the National Cardiovascular Data Registry ICD Registry. Survival analysis evaluated therapy probability and predictors after ICD implant from 2006 to 2009, with attention to Centers for Medicare and Medicaid Services Coverage With Evidence Development subgroups: left ventricular ejection fraction, 31% to 35%; nonischemic cardiomyopathy <9 months' duration; and New York Heart Association class IV heart failure with cardiac resynchronization therapy defibrillator. Among 2540 patients, 35% were <65 years old, 26% were women, and 59% were white. During 27 (median) months, 738 (29%) received ≥1 therapy. Three-year therapy risk was 36% (appropriate, 24%; inappropriate, 12%). Appropriate therapy was more common in men (adjusted hazard ratio [HR], 1.84; 95% confidence interval [CI], 1.43-2.35). Inappropriate therapy was more common in patients with atrial fibrillation (adjusted HR, 2.20; 95% CI, 1.68-2.87), but less common among patients ≥65 years old versus younger (adjusted HR, 0.72; 95% CI, 0.54-0.95) and in recent implants (eg, in 2009 versus 2006; adjusted HR, 0.66; 95% CI, 0.46-0.95). In Centers for Medicare and Medicaid Services Coverage With Evidence Development analysis, inappropriate therapy was less common with cardiac resynchronization therapy defibrillator versus single chamber (adjusted HR, 0.55; 95% CI, 0.36-0.84); therapy risk did not otherwise differ for Centers for Medicare and Medicaid Services Coverage With Evidence Development subgroups. CONCLUSIONS In this community cohort of primary prevention patients receiving ICD, therapy delivery varied across demographic and clinical characteristics, but did not differ meaningfully for Centers for Medicare and Medicaid Services Coverage With Evidence Development subgroups.
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MESH Headings
- Aged
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/mortality
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/prevention & control
- Centers for Medicare and Medicaid Services, U.S.
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Electric Countershock/adverse effects
- Electric Countershock/instrumentation
- Electric Countershock/mortality
- Female
- Heart Rate
- Humans
- Male
- Middle Aged
- Primary Prevention/instrumentation
- Retrospective Studies
- Risk Factors
- Time Factors
- Treatment Outcome
- United States
- Ventricular Dysfunction, Left/diagnosis
- Ventricular Dysfunction, Left/mortality
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/therapy
- Ventricular Function, Left
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Affiliation(s)
| | - Alan S Go
- Kaiser Permanente Northern California, Oakland, CA
| | - Pamela N Peterson
- Denver Health Medical Center, Denver, CO
- University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | | | | | | | - Nigel Gupta
- Kaiser Los Angeles Medical Center, Los Angeles, CA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sue Hee Sung
- Kaiser Permanente Northern California, Oakland, CA
| | - Paul D Varosy
- Department of Veterans Affairs Eastern Colorado Health System, Denver, CO
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26
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Bansal N, Szpiro A, Reynolds K, Smith DH, Magid DJ, Gurwitz JH, Masoudi F, Greenlee RT, Tabada GH, Sung SH, Dighe A, Go AS. Long-term Outcomes Associated With Implantable Cardioverter Defibrillator in Adults With Chronic Kidney Disease. JAMA Intern Med 2018; 178:390-398. [PMID: 29404570 PMCID: PMC5885920 DOI: 10.1001/jamainternmed.2017.8462] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Chronic kidney disease (CKD) is common in adults with heart failure and is associated with an increased risk of sudden cardiac death. Randomized trials of participants without CKD have demonstrated that implantable cardioverter defibrillators (ICDs) decrease the risk of arrhythmic death in selected patients with reduced left ventricular ejection fraction (LVEF) heart failure. However, whether ICDs improve clinical outcomes in patients with CKD is not well elucidated. OBJECTIVE To examine the association of primary prevention ICDs with risk of death and hospitalization in a community-based population of potentially ICD-eligible patients who had heart failure with reduced LVEF and CKD. DESIGN, SETTINGS, AND PARTICIPANTS This noninterventional cohort study included adults with heart failure and an LVEF of 40% or less and measures of serum creatinine levels available from January 1, 2005, through December 31, 2012, who were enrolled in 4 Kaiser Permanente health care delivery systems. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 mL/min/1.73 m2. Patients who received and did not receive an ICD were matched (1:3) on CKD status, age, and high-dimensional propensity score to receive an ICD. Follow-up was completed on December 31, 2013. Data were analyzed from 2015 to 2017. EXPOSURES Placement of an ICD. MAIN OUTCOMES AND MEASURES All-cause death, hospitalizations due to heart failure, and any-cause hospitalizations. RESULTS A total of 5877 matched eligible adults with CKD (1556 with an ICD and 4321 without an ICD) were identified (4049 men [68.9%] and 1828 women [31.1%]; mean [SD] age, 72.9 [8.2] years). In models adjusted for demographics, comorbidity, and cardiovascular medication use, no difference was found in all-cause mortality between patients with CKD in the ICD vs non-ICD groups (adjusted hazard ratio, 0.96; 95% CI, 0.87-1.06). However, ICD placement was associated with increased risk of subsequent hospitalization due to heart failure (adjusted relative risk, 1.49; 95% CI, 1.33-1.60) and any-cause hospitalization (adjusted relative risk, 1.25; 95% CI, 1.20-1.30) among patients with CKD. CONCLUSIONS AND RELEVANCE In a large, contemporary, noninterventional study of community-based patients with heart failure and CKD, ICD placement was not significantly associated with improved survival but was associated with increased risk for subsequent hospitalization due to heart failure and all-cause hospitalization. The potential risks and benefits of ICDs should be carefully considered in patients with heart failure and CKD.
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Affiliation(s)
- Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of, Seattle
| | - Adam Szpiro
- Department of Biostatistics, University of Washington, Seattle
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - David H Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - David J Magid
- Department of Medicine, Kaiser Permanente Colorado, Denver
| | | | | | | | - Grace H Tabada
- Kaiser Permanente Northern California Division of Research, Oakland
| | - Sue Hee Sung
- Kaiser Permanente Northern California Division of Research, Oakland
| | - Ashveena Dighe
- Kidney Research Institute, Division of Nephrology, University of, Seattle
| | - Alan S Go
- Kaiser Permanente Northern California Division of Research, Oakland.,Department of Epidemiology, University of California, San Francisco.,Department of Biostatistics, University of California, San Francisco.,Department of Medicine, University of California, San Francisco
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27
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Peterson PN, Greenlee RT, Go AS, Magid DJ, Cassidy-Bushrow A, Garcia-Montilla R, Glenn KA, Gurwitz JH, Hammill SC, Hayes J, Kadish A, Reynolds K, Sharma P, Smith DH, Varosy PD, Vidaillet H, Zeng CX, Normand SLT, Masoudi FA. Comparison of Inappropriate Shocks and Other Health Outcomes Between Single- and Dual-Chamber Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death: Results From the Cardiovascular Research Network Longitudinal Study of Implantable Cardioverter-Defibrillators. J Am Heart Assoc 2017; 6:JAHA.117.006937. [PMID: 29122811 PMCID: PMC5721776 DOI: 10.1161/jaha.117.006937] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In US clinical practice, many patients who undergo placement of an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death receive dual-chamber devices. The superiority of dual-chamber over single-chamber devices in reducing the risk of inappropriate ICD shocks in clinical practice has not been established. The objective of this study was to compare risk of adverse outcomes, including inappropriate shocks, between single- and dual-chamber ICDs for primary prevention. METHODS AND RESULTS We identified patients receiving a single- or dual-chamber ICD for primary prevention who did not have an indication for pacing from 15 hospitals within 7 integrated health delivery systems in the Longitudinal Study of Implantable Cardioverter-Defibrillators from 2006 to 2009. The primary outcome was time to first inappropriate shock. ICD shocks were adjudicated for appropriateness. Other outcomes included all-cause hospitalization, heart failure hospitalization, and death. Patient, clinician, and hospital-level factors were accounted for using propensity score weighting methods. Among 1042 patients without pacing indications, 54.0% (n=563) received a single-chamber device and 46.0% (n=479) received a dual-chamber device. In a propensity-weighted analysis, device type was not significantly associated with inappropriate shock (hazard ratio, 0.91; 95% confidence interval, 0.59-1.38 [P=0.65]), all-cause hospitalization (hazard ratio, 1.03; 95% confidence interval, 0.87-1.21 [P=0.76]), heart failure hospitalization (hazard ratio, 0.93; 95% confidence interval, 0.72-1.21 [P=0.59]), or death (hazard ratio, 1.19; 95% confidence interval, 0.93-1.53 [P=0.17]). CONCLUSIONS Among patients who received an ICD for primary prevention without indications for pacing, dual-chamber devices were not associated with lower risk of inappropriate shock or differences in hospitalization or death compared with single-chamber devices. This study does not justify the use of dual-chamber devices to minimize inappropriate shocks.
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Affiliation(s)
- Pamela N Peterson
- Denver Health Medical Center, Denver, CO .,University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Robert T Greenlee
- Marshfield Clinic Research Foundation, Marshfield, WI.,Marshfield Clinic, Marshfield, WI
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,University of California San Francisco, San Francisco, CA.,Stanford University School of Medicine, Palo Alto, CA
| | - David J Magid
- University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | | | | | - Karen A Glenn
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | | | | | - John Hayes
- Marshfield Clinic Research Foundation, Marshfield, WI
| | | | - Kristi Reynolds
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena, CA
| | - Param Sharma
- Marshfield Clinic Research Foundation, Marshfield, WI
| | - David H Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, OR
| | - Paul D Varosy
- University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Institute for Health Research, Kaiser Permanente Colorado, Denver, CO.,Eastern Colorado VA Health Care System, Denver, CO
| | | | - Chan X Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | | | - Frederick A Masoudi
- University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
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28
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Gurwitz JH, Magid DJ, Smith DH, Tabada GH, Sung SH, Allen LA, McManus DD, Goldberg RJ, Tisminetzky M, Go AS. Treatment Effectiveness in Heart Failure with Comorbidity: Lung Disease and Kidney Disease. J Am Geriatr Soc 2017; 65:2610-2618. [PMID: 28873219 DOI: 10.1111/jgs.15062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To assess the clinical effectiveness of beta-blocker therapy in individuals with heart failure (HF) and chronic lung disease and of angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin II receptor blockers (ARBs) in individuals with HF and chronic kidney disease. DESIGN Retrospective cohort study. SETTING Community. PARTICIPANTS Individuals with HF with reduced ejection fraction (HFrEF) or HF with preserved ejection fraction (HFpEF). METHODS We undertook separate new-user cohort studies to assess the effectiveness of beta-blocker therapy in treating HF and chronic lung disease and ACE-Is and ARBs in treating HF and chronic kidney disease (CKD). Individuals with a chronic lung disease diagnosis were included in the group with HF and chronic lung disease (International Classification of Diseases, Ninth Revision, codes 490-496, 518). Individuals with an estimated glomerular filtration rate less than 60 mL/min per 1.73 m2 were included in the group with HF and CKD. The clinical outcomes of interest were death from any cause, hospitalization for HF, and hospitalization for any reason. We fitted pooled logistic marginal structural models using inverse probability weighting, stratified according to HF type. RESULTS For individuals with HFrEF with chronic lung disease, beta-blocker therapy was protective against death (relative risk (RR) = 0.58, 95% confidence interval (CI) = 0.44-0.77) and hospitalization for HF (RR = 0.78, 95% CI = 0.60-1.00). For those with HFpEF, no statistically significant associations between beta-blocker therapy use and any of the outcomes were observed. We found ACE-I and ARB use to be protective against all three outcomes of interest in individuals with HFrEF (death from any cause: RR = 0.60, 95% 0.40-0.91; hospitalization for HF: RR = 0.43, 95% CI = 0.28-0.67; hospitalization for any reason: RR = 0.63, 95% CI = 0.45-0.89, respectively) and those with HFpEF (death from any cause: RR = 0.52, 95% CI = 0.33-0.81; hospitalization for HF: RR = 0.35, 95% CI = 0.18-0.68; hospitalization for any reason: RR = 0.67, 95% CI = 0.47-0.95). CONCLUSION Large observational studies may allow for identification of important subgroups of individuals with HF that might benefit from existing treatment approaches. Our findings may also better inform the design of more-definitive future observational studies and randomized trials.
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Affiliation(s)
- Jerry H Gurwitz
- Meyers Primary Care Institute, University of Massachusetts Medical School, Fallon Community Health Plan and Reliant Medical Group, Worcester, Massachusetts.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David J Magid
- Department of Emergency Medicine, Kaiser Permanente Colorado, Denver, Colorado
| | - David H Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Grace H Tabada
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Larry A Allen
- Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado.,School of Medicine, University of Colorado, Aurora, Colorado
| | - David D McManus
- Meyers Primary Care Institute, University of Massachusetts Medical School, Fallon Community Health Plan and Reliant Medical Group, Worcester, Massachusetts.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | - Robert J Goldberg
- Meyers Primary Care Institute, University of Massachusetts Medical School, Fallon Community Health Plan and Reliant Medical Group, Worcester, Massachusetts.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Mayra Tisminetzky
- Meyers Primary Care Institute, University of Massachusetts Medical School, Fallon Community Health Plan and Reliant Medical Group, Worcester, Massachusetts.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California.,Department of Epidemiology, University of California San Francisco, San Francisco, California.,Department of Biostatistics, University of California San Francisco, San Francisco, California.,Department of Medicine, University of California San Francisco, San Francisco, California.,Department of Health Research and Policy, School of Medicine, Stanford University, Palo Alto, California
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29
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Sullivan PW, Globe G, Ghushchyan VH, Campbell JD, Bender B, Magid DJ. Exploring asthma control cutoffs and economic outcomes using the Asthma Control Questionnaire. Ann Allergy Asthma Immunol 2017; 117:251-257.e2. [PMID: 27613458 DOI: 10.1016/j.anai.2016.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/01/2016] [Accepted: 07/15/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Understanding the effect of worsening asthma control on expenditures and health resource utilization (HRU) is important. OBJECTIVE To explore the association of economic outcomes with asthma control cutoffs and longitudinal changes on the Asthma Control Questionnaire 5 (ACQ-5). METHODS The Observational Study of Asthma Control and Outcomes was a survey of patients with persistent asthma who were patients of Kaiser Colorado, including claims-based HRU. Patients completed the ACQ-5 three times during 1 year between April 2011 and June 2012. The ACQ-5 cutoffs that indicated control were assessed in cross-sectional analyses. Longitudinal changes in control were explored: controlled (ACQ-5 score <0.75), indeterminate (ACQ-5 score 0.75 to <1.5), not well controlled (ACQ-5 score 1.5 to <3.0), and very poorly controlled (ACQ-5 score ≥3.0). Analyses used generalized linear models with log link (expenditures) and negative binomial regression (HRU). RESULTS There were 6,666 completed surveys (1,799 individuals completed all 3 survey waves). In the cross-sectional analyses, compared with an ACQ-5 score less than 0.5, individuals with ACQ-5 scores of 4 to 4.5 incurred 7.2 times the number of oral corticosteroid prescriptions, 4.3 times the number of emergency department visits, 6 times the number of inpatient visits, 10.4 times the number of asthma-specific emergency department visits, 4.58 times the number of asthma-specific inpatient visits, and $2,892 more in all-cause and $1,877 in asthma-specific expenditures during 4 months. In the longitudinal change analyses, individuals who improved from an ACQ-5 of 3.0 or greater to less than 0.75 incurred $6,023 less in asthma-specific expenditures during 4 months than those remaining at an ACQ-5 score of 3.0 or higher. CONCLUSION Results provide preliminary economic data on possible control cutoffs for the ACQ-5. Improving asthma control over time may result in significant savings that may justify financial investments designed to improve control.
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Affiliation(s)
| | | | - Vahram H Ghushchyan
- Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy, University of Colorado, Aurora, Colorado; American University of Armenia, Yerevan, Armenia
| | - Jonathan D Campbell
- Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy, University of Colorado, Aurora, Colorado
| | - Bruce Bender
- Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - David J Magid
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
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Allen LA, Matlock DD, Shetterly SM, Xu S, Levy WC, Portalupi LB, McIlvennan CK, Gurwitz JH, Johnson ES, Smith DH, Magid DJ. Use of Risk Models to Predict Death in the Next Year Among Individual Ambulatory Patients With Heart Failure. JAMA Cardiol 2017; 2:435-441. [DOI: 10.1001/jamacardio.2016.5036] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Larry A. Allen
- Division of Cardiology, University of Colorado School of Medicine, Aurora2Institute for Health Research, Kaiser Permanente Colorado, Denver3Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
| | - Daniel D. Matlock
- Institute for Health Research, Kaiser Permanente Colorado, Denver3Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora4Division of Geriatrics, University of Colorado School of Medicine, Aurora
| | | | - Stanley Xu
- Institute for Health Research, Kaiser Permanente Colorado, Denver
| | - Wayne C. Levy
- University of Washington School of Medicine, Seattle
| | - Laura B. Portalupi
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
| | - Colleen K. McIlvennan
- Division of Cardiology, University of Colorado School of Medicine, Aurora3Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
| | - Jerry H. Gurwitz
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester7Meyers Primary Care Institute, a joint endeavor of the University of Massachusetts Medical School, Fallon Health, and the Reliant Medical Group, Worcester
| | - Eric S. Johnson
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - David H. Smith
- Kaiser Permanente Center for Health Research, Portland, Oregon
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Daley MF, Reifler LM, Johnson ES, Sinaiko AR, Margolis KL, Parker ED, Greenspan LC, Lo JC, O’Connor PJ, Magid DJ. Predicting Hypertension Among Children With Incident Elevated Blood Pressure. Acad Pediatr 2017; 17:275-282. [PMID: 28254479 PMCID: PMC5384864 DOI: 10.1016/j.acap.2016.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/16/2016] [Accepted: 09/25/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To develop a model to predict hypertension risk among children with incident elevated blood pressure (BP); to test the external validity of the model. METHODS A retrospective cohort study was conducted in 3 organizations: Kaiser Permanente Colorado was the model derivation site; HealthPartners of Minnesota and Kaiser Permanente Northern California served as external validation sites. During study years 2006 through 2012, all children aged 3 through 17 years with incident elevated BP in an outpatient setting were identified. The predictor variables were demographic and clinical characteristics collected during routine care. Cox proportional hazards regression was used to predict subsequent hypertension, and diagnostic statistics were used to assess model performance. RESULTS Among 5598 subjects at the derivation site with incident elevated BP, 160 (2.9%) developed hypertension during the study period. Eight characteristics were used to predict hypertension risk: age, sex, race, BP preceding incident elevated BP, body mass index percentile, systolic BP percentile, diastolic BP percentile, and clinical setting of the incident elevated BP. At the derivation site, the model discriminated well between those at higher versus lower risk of hypertension (c-statistic = 0.77). At external validation sites, the observed risk of hypertension was higher than the predicted risk, and the model showed poor discrimination (c-statistic ranged from 0.64 to 0.67). CONCLUSIONS Among children with incident elevated BP, a risk model demonstrated good internal validity with respect to predicting subsequent hypertension. However, the risk model did not perform well at 2 external validation sites, which might limit transportability to other settings.
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Affiliation(s)
- Matthew F. Daley
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Liza M. Reifler
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Eric S. Johnson
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Alan R. Sinaiko
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | | | | | | | - Joan C. Lo
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - David J. Magid
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
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Reynolds K, Go AS, Leong TK, Boudreau DM, Cassidy-Bushrow AE, Fortmann SP, Goldberg RJ, Gurwitz JH, Magid DJ, Margolis KL, McNeal CJ, Newton KM, Novotny R, Quesenberry CP, Rosamond WD, Smith DH, VanWormer JJ, Vupputuri S, Waring SC, Williams MS, Sidney S. Trends in Incidence of Hospitalized Acute Myocardial Infarction in the Cardiovascular Research Network (CVRN). Am J Med 2017; 130:317-327. [PMID: 27751900 PMCID: PMC5318252 DOI: 10.1016/j.amjmed.2016.09.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 09/15/2016] [Accepted: 09/16/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Monitoring trends in cardiovascular events can provide key insights into the effectiveness of prevention efforts. Leveraging data from electronic health records provides a unique opportunity to examine contemporary, community-based trends in acute myocardial infarction hospitalizations. METHODS We examined trends in hospitalized acute myocardial infarction incidence among adults aged ≥25 years in 13 US health plans in the Cardiovascular Research Network. The first hospitalization per member for acute myocardial infarction overall and for ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction was identified by International Classification of Diseases, Ninth Revision, Clinical Modification primary discharge codes in each calendar year from 2000 through 2008. Age- and sex-adjusted incidence was calculated per 100,000 person-years using direct adjustment with 2000 US census data. RESULTS Between 2000 and 2008, we identified 125,435 acute myocardial infarction hospitalizations. Age- and sex-adjusted incidence rates (per 100,000 person-years) of acute myocardial infarction decreased an average 3.8%/y from 230.5 in 2000 to 168.6 in 2008. Incidence of ST-segment elevation myocardial infarction decreased 8.7%/y from 104.3 in 2000 to 51.7 in 2008, whereas incidence of non-ST-segment elevation myocardial infarction increased from 126.1 to 129.4 between 2000 and 2004 and then decreased thereafter to 116.8 in 2008. Age- and sex-specific incidence rates generally reflected similar patterns, with relatively larger decreases in ST-segment elevation myocardial infarction rates in women compared with men. As compared with 2000, the age-adjusted incidence of ST-segment elevation myocardial infarction in 2008 was 48% lower among men and 61% lower among women. CONCLUSIONS AND RELEVANCE Among a large, diverse, multicenter community-based insured population, there were significant decreases in incidence of hospitalized acute myocardial infarction and the more serious ST-segment elevation myocardial infarctions between 2000 and 2008. Decreases in ST-segment elevation myocardial infarctions were most pronounced among women. While ecologic in nature, these secular decreases likely reflect, at least in part, results of improvement in primary prevention efforts.
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Affiliation(s)
- Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, Calif.
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif; Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco, Calif; Department of Health Research and Policy, Stanford University School of Medicine, Calif
| | - Thomas K Leong
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| | | | | | | | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Pa
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of Fallon Health, Reliant Medical Group, and University of Massachusetts Medical School, Worcester, Pa
| | - David J Magid
- Colorado Permanente Medical Group, Denver; Colorado School of Public Health, University of Colorado Denver, Aurora; Colorado Cardiovascular Outcomes Research Consortium, Denver
| | - Karen L Margolis
- HealthPartners Institute for Education and Research, Minneapolis, Minn
| | - Catherine J McNeal
- Division of Cardiology, Department of Internal Medicine, Baylor Scott & White Health, Temple, Tex
| | | | - Rachel Novotny
- Human Nutrition, Food and Animal Science Department, College of Tropical Agriculture and Human Resources, University of Hawaii at Manoa, Honolulu
| | | | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - David H Smith
- Kaiser Permanente Center for Health Research, Portland, Ore
| | - Jeffrey J VanWormer
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Foundation, Wis
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Md
| | - Stephen C Waring
- Division of Research, Essentia Institute of Rural Health, Duluth, Minn
| | - Marc S Williams
- Genomic Medicine Institute, Geisinger Health System, Danville, Pa
| | - Stephen Sidney
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
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Bansal N, Szpiro A, Masoudi F, Greenlee RT, Smith DH, Magid DJ, Gurwitz JH, Reynolds K, Tabada GH, Sung SH, Dighe A, Cassidy-Bushrow A, Garcia-Montilla R, Hammill S, Hayes J, Kadish A, Sharma P, Varosy P, Vidaillet H, Go AS. Kidney function and appropriateness of device therapies in adults with implantable cardioverter defibrillators. Heart 2016; 103:529-537. [PMID: 27742796 DOI: 10.1136/heartjnl-2016-309842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 09/08/2016] [Accepted: 09/18/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Patients with chronic kidney disease (CKD) have higher risk of sudden cardiac death; however, they may not receive implantable cardioverter defibrillators (ICDs), in part due to higher risk of complications. We evaluated whether CKD is associated with greater risk of device-delivered shocks/antitachycardia pacing (ATP) therapies among patients receiving a primary prevention ICD. METHODS We studied participants in the observational Cardiovascular Research Network Longitudinal Study of Implantable Cardioverter Defibrillators. CKD was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Outcomes included all delivered shocks/ATPs therapies and type of shock/ATP therapies (inappropriate or appropriate, determined by physician adjudication) within the 3 years. We evaluated the associations between CKD and time to first device therapy, burden of device therapy, and inappropriate versus appropriate device therapy, adjusting for demographics, comorbidity, laboratory values and medication use. RESULTS Among 2161 participants, 1066 (49.3%) had CKD (eGFR 44±11 mL/min/1.73 m2) at ICD implantation. During mean of 2.26±0.89 years, 9.8% and 18.5% of participants had at least one inappropriate and appropriate shock/ATP therapies, respectively. CKD was not associated with time to first shock/ATP therapies (adjusted HR 0.87, 95% CI 0.73 to 1.05), overall burden of shock/ATP therapies (adjusted relative rate 0.93, 95% CI 0.74 to 1.17) or inappropriate versus appropriate shock/ATP therapies (adjusted relative risk 0.88, 95% CI 0.68 to 1.14) compared with not having CKD. CONCLUSIONS In adults receiving a primary prevention ICD, mild-to-moderate CKD was not associated with the timing, burden or appropriateness of subsequent device therapy. Potential concern for inappropriate ICD-delivered therapies should not preclude ICDs among eligible patients with CKD.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Adam Szpiro
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | | | | | - David H Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
| | - David J Magid
- Kaiser Permanente Colorado Institute for Health Research, Oakland, California, USA
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Kristi Reynolds
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena, California, USA
| | - Grace H Tabada
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
| | - Sue Hee Sung
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
| | - Ashveena Dighe
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | | | | | | | - John Hayes
- Marshfield Clinic Research Foundation, Wisconsin, USA
| | | | - Param Sharma
- Marshfield Clinic Research Foundation, Wisconsin, USA
| | - Paul Varosy
- University of Colorado Hospital, Aurora, Colorado, USA
| | | | - Alan S Go
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
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Green AR, Jenkins A, Masoudi FA, Magid DJ, Kutner JS, Leff B, Matlock DD. Decision-Making Experiences of Patients with Implantable Cardioverter Defibrillators. Pacing Clin Electrophysiol 2016; 39:1061-1069. [PMID: 27566614 DOI: 10.1111/pace.12943] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 08/03/2016] [Accepted: 08/18/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND When patients are not adequately engaged in decision making, they may be at risk of decision regret. Our objective was to explore patients' perceptions of their decision-making experiences related to implantable cardioverter defibrillators (ICDs). METHODS Cross-sectional, mailed survey of 412 patients who received an ICD without cardiac resynchronization therapy for any indication between 2006 and 2009. Patients were asked about decision participation and decision regret. RESULTS A total of 295 patients with ICDs responded (72% response rate). Overall, 79% reported that they were as involved in the decision as they wanted. However, 28% reported that they were not told of the option of not getting an ICD and 37% did not remember being asked if they wanted an ICD. In total, 19% reported not wanting their ICD at the time of implantation. Those who did not want the ICD were younger (<65 years; 74% vs 43%, P < 0.001), had higher decision regret (31/100 vs 11/100, P < 0.001), and reported less participation in decision making (the doctor "totally" made the decision, 9% vs 3%; P < 0.001). CONCLUSIONS A considerable number of ICD recipients recalled not wanting their ICD at the time of implantation. While these findings may be prone to recall bias, they likely identify opportunities to improve ICD decision making.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Amy Jenkins
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Frederick A Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado
| | - David J Magid
- Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Jean S Kutner
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Bruce Leff
- Division of Geriatric Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.,Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Daniel D Matlock
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado
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O'Connor PJ, Parker ED, Sinaiko AR, Kharbanda EO, Margolis KL, Daley MF, Trower NK, Sherwood NE, Greenspan LC, Lo JC, Magid DJ. Relation of Change in Weight Status to the Development of Hypertension in Children and Adolescents. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
BACKGROUND Previous studies have shown an association between cost and poor asthma control. However, longitudinal studies of general populations are lacking. OBJECTIVE To examine the cost of poor asthma control and exacerbations across a broad spectrum of asthma patients. METHODS The Observational Study of Asthma Control and Outcomes (OSACO) was a prospective survey of persistent asthma patients in Kaiser Colorado in 2011-2012. Patients received a survey 3 times in one year, which included the Asthma Control Questionnaire (ACQ) and questions on exacerbations. Self-reported exacerbations were compared to actual oral corticosteroid (OCS) use. Regression analyses examined the association of control (ACQ-5 scores) and exacerbations with healthcare expenditures, controlling for sociodemographics and smoking. Analyses of expenditures used Generalized Linear Models (GLM) with log-link. RESULTS 2681 individuals completed at least one survey; 1799 completed all three. ACQ-5 scores were associated with higher all-cause and asthma-specific expenditures across all categories of costs (medical, outpatient, ER, pharmacy) except for inpatient expenditures. Each 1-point increase in the ACQ-5 score (i.e., worse control) was associated with a corresponding increase in all-cause annual healthcare and asthma-specific expenditures of $1443 and $927 ($US 2013). Asthma exacerbations with documented OCS use were associated with an increase of $3014 and $1626 over 4 months, while self-reported exacerbations were $713 and $506. CONCLUSION Results demonstrate that poor asthma control and exacerbations are strongly associated with higher healthcare expenditures. Results also confirm that collection of validated measures of control such as the ACQ-5 may provide valuable information toward improving clinical and economic outcomes.
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Affiliation(s)
| | - Vahram H Ghushchyan
- c Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy , University of Colorado Aurora , CO , USA.,d American University of Armenia , Yerevan , Armenia
| | - Jonathan D Campbell
- c Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy , University of Colorado Aurora , CO , USA
| | - Gary Globe
- e Amgen, Inc. , Thousand Oaks , CA , USA
| | - Bruce Bender
- f Department of Pediatrics , National Jewish Health , Denver , CO , USA
| | - David J Magid
- b Institute for Health Research, Kaiser Permanente Colorado , Denver , CO , USA.,g Colorado School of Public Health, University of Colorado , Denver , CO , USA
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Parker ED, Sinaiko AR, Kharbanda EO, Margolis KL, Daley MF, Trower NK, Sherwood NE, Greenspan LC, Lo JC, Magid DJ, O’Connor PJ. Change in Weight Status and Development of Hypertension. Pediatrics 2016; 137:e20151662. [PMID: 26908707 PMCID: PMC4771125 DOI: 10.1542/peds.2015-1662] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the association of BMI percentile and change in BMI percentile to change in blood pressure (BP) percentile and development of hypertension (HTN). METHODS This retrospective cohort included 101 606 subjects age 3 to 17 years from 3 health systems across the United States. Height, weight, and BPs were extracted from electronic health records, and BMI and BP percentiles were computed with the appropriate age, gender, and height charts. Mixed linear regression estimated change in BP percentile, and proportional hazards regression was used to estimate risk of incident HTN associated with BMI percentile and change in BMI percentile. RESULTS The largest increases in BP percentile were observed among children and adolescents who became obese or maintained obesity. Over a median 3.1 years of follow-up, 0.3% of subjects developed HTN. Obese children ages 3 to 11 had twofold increased risk of developing HTN compared with healthy weight children. Obese children and adolescents had a twofold increased risk of developing HTN, and severely obese children had a more than fourfold increased risk. Compared with those who maintained a healthy weight, children and adolescents who became obese or maintained obesity had a more than threefold increased risk of incident HTN. CONCLUSIONS We observed a strong, statistically significant association between increasing BMI percentile and increases in BP percentile, with risk of incident HTN associated primarily with obesity. The adverse impact of weight gain and obesity in this cohort over a short period underscores the early need for effective strategies for prevention of overweight and obesity.
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Affiliation(s)
- Emily D. Parker
- HealthPartners Institute for Education and Research, HealthPartners, Minneapolis, Minnesota
| | | | - Elyse O. Kharbanda
- HealthPartners Institute for Education and Research, HealthPartners, Minneapolis, Minnesota
| | - Karen L. Margolis
- HealthPartners Institute for Education and Research, HealthPartners, Minneapolis, Minnesota
| | - Matt F. Daley
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Nicole K. Trower
- HealthPartners Institute for Education and Research, HealthPartners, Minneapolis, Minnesota
| | - Nancy E. Sherwood
- HealthPartners Institute for Education and Research, HealthPartners, Minneapolis, Minnesota;,Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Louise C. Greenspan
- Department of Pediatrics, Kaiser Permanente San Francisco, San Francisco, California; and
| | - Joan C. Lo
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - David J. Magid
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Patrick J. O’Connor
- HealthPartners Institute for Education and Research, HealthPartners, Minneapolis, Minnesota
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB. Executive Summary: Heart Disease and Stroke Statistics--2016 Update: A Report From the American Heart Association. Circulation 2016; 133:447-54. [PMID: 26811276 DOI: 10.1161/cir.0000000000000366] [Citation(s) in RCA: 1709] [Impact Index Per Article: 213.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Jones WS, Patel MR, Tsai TT, Shetterly SM, Wagner NM, Magid DJ. Response to Letter to the Editor regarding "Anatomic runoff score predicts cardiovascular outcomes in patients with lower extremity peripheral artery disease undergoing revascularization". Am Heart J 2016; 171:e7. [PMID: 26699610 DOI: 10.1016/j.ahj.2015.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- W Schuyler Jones
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Duke University Medical Center, Durham, NC.
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Duke University Medical Center, Durham, NC
| | - Thomas T Tsai
- Division of Cardiology, Kaiser Permanente Colorado, Denver, CO; Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Susan M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Nicole M Wagner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - David J Magid
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2015; 133:e38-360. [PMID: 26673558 DOI: 10.1161/cir.0000000000000350] [Citation(s) in RCA: 3698] [Impact Index Per Article: 410.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Smith DH, Johnson ES, Boudreau DM, Cassidy-Bushrow AE, Fortmann SP, Greenlee RT, Gurwitz JH, Magid DJ, McNeal CJ, Reynolds K, Steinhubl SR, Thorp M, Tom JO, Vupputuri S, VanWormer JJ, Weinstein J, Yang X, Go AS, Sidney S. Comparative Effectiveness of Statin Therapy in Chronic Kidney Disease and Acute Myocardial Infarction: A Retrospective Cohort Study. Am J Med 2015; 128:1252.e1-1252.e11. [PMID: 26169887 PMCID: PMC4624042 DOI: 10.1016/j.amjmed.2015.06.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 06/19/2015] [Accepted: 06/20/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Whether there is a kidney function threshold to statin effectiveness in patients with acute myocardial infarction is poorly understood. Our study sought to help fill this gap in clinical knowledge. METHODS We undertook a new-user cohort study of the effectiveness of statin therapy by level of estimated glomerular filtration rate (eGFR) in adults who were hospitalized for myocardial infarction between 2000 and 2008. Data came from the Cardiovascular Research Network. The primary clinical outcomes were 1-year all-cause mortality and cardiovascular hospitalizations, with adverse outcomes of myopathy and development of diabetes mellitus. We calculated incidence rates, the number needed to treat, and used Cox proportional hazards regression with propensity score matching and adjustment to control for confounding, with testing for variation of effect by level of kidney function. RESULTS Compared with statin non-initiators (n = 5583), statin initiators (n = 5597) had a lower propensity score-adjusted risk for death (hazard ratio 0.79; 95% confidence interval [CI], 0.71-0.88) and cardiovascular hospitalizations (hazard ratio 0.90; 95% CI, 0.82-1.00). We found little evidence of variation in effect by level of eGFR (P = .86 for death; P = .77 for cardiovascular hospitalization). Adverse outcomes were similar for statin initiators and statin non-initiators. The number needed to treat to prevent 1 additional death over 1 year of follow-up ranged from 15 (95% CI, 11-28) for eGFR <30 mL/min/1.73 m(2) requiring statin treatment over 2 years to prevent 1 additional death, to 67 (95% CI, 49-118) for patients with eGFR >90 mL/min/1.73 m(2). CONCLUSIONS Our findings suggest that there is potential for important public health gains by increasing the routine use of statin therapy for patients with lower levels of kidney function.
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Affiliation(s)
- David H Smith
- Kaiser Permanente Center for Health Research - Northwest, Portland, Ore.
| | - Eric S Johnson
- Kaiser Permanente Center for Health Research - Northwest, Portland, Ore
| | | | | | | | | | - Jerry H Gurwitz
- Meyers Primary Care Institute, Worcester, Mass; Fallon Community Health Plan, Worcester, Mass; University of Massachusetts, Worcester
| | - David J Magid
- Kaiser Permanente Institute for Health Research, Denver, Colo; University of Colorado Health Sciences Center, Denver
| | - Catherine J McNeal
- Baylor Scott & White Center for Applied Health Research, Temple, Tex; Texas A&M Health Science Center, Round Rock
| | - Kristi Reynolds
- Kaiser Permanente Department of Research & Evaluation, Pasadena, Calif
| | | | - Micah Thorp
- Kaiser Permanente Center for Health Research - Northwest, Portland, Ore
| | - Jeffrey O Tom
- Kaiser Permanente Center for Health Research - Hawaii, Honolulu
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Rockville, Md
| | | | - Jessica Weinstein
- Kaiser Permanente Center for Health Research - Northwest, Portland, Ore
| | - Xiuhai Yang
- Kaiser Permanente Center for Health Research - Northwest, Portland, Ore
| | - Alan S Go
- Kaiser Permanente Division of Research, Oakland, Calif; University of California, San Francisco
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Maring B, Greenspan LC, Chandra M, Daniels SR, Sinaiko A, Prineas RJ, Parker ED, Adams KF, Daley MF, Sherwood NE, Kharbanda EO, Margolis KL, Magid DJ, O’Connor PJ, Lo JC. Comparing US paediatric and adult weight classification at the transition from late teenage to young adulthood. Pediatr Obes 2015; 10:371-9. [PMID: 25612172 PMCID: PMC5100891 DOI: 10.1111/ijpo.274] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 09/12/2014] [Accepted: 10/05/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although paediatric growth charts are recommended for weight assessment prior to age 20, many teenagers transition earlier to adult care where absolute body mass index (BMI) is used. This study examines concordance of weight classification in older teenagers using paediatric percentiles and adult thresholds. METHODS BMI from 23 640 US teens ages 18-19 years were classified using paediatric BMI percentile criteria for underweight (< 5th), normal (5th to < 85th), overweight (85th to < 95th), obesity (≥ 95th) and severe obesity (≥ 120% × 95th percentile) and adult BMI (kg m(-2) ) criteria for underweight (< 18.5), normal (18.5-24.9), overweight (25-29.9) and obesity: class I (30-34.9), class II (35-39.9) and class III (≥ 40). Concordance was examined using the kappa (κ) statistic. Blood pressure (BP) from the same visit was classified hypertensive for BP ≥ 140/90. RESULTS The majority of visits (72.8%) occurred in adult primary care. Using paediatric/adult criteria, 3.4%/5.2% were underweight, 66.6%/58.8% normal weight, 15.7%/21.7% overweight, 14.3%/14.3% obese and 4.9%/6.0% severely/class II-III obese, respectively. Paediatric and adult classification for underweight, normal, overweight and obesity were concordant for 90.3% (weighted κ 0.87 [95% confidence interval, 0.87-0.88]). For severe obesity, BMI ≥ 120% × 95th percentile showed high agreement with BMI ≥ 35 kg m(-2) (κ 0.89 [0.88-0.91]). Normal-weight males and moderately obese females by paediatric BMI percentile criteria who were discordantly classified into higher adult weight strata had a greater proportion with hypertensive BP compared with concordantly classified counterparts. CONCLUSIONS Strong agreement exists between US paediatric BMI percentile and adult BMI classification for older teenagers. Adult BMI classification may optimize BMI tracking and risk stratification during transition from paediatric to adult care.
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Affiliation(s)
- Benjamin Maring
- Department of Medicine, Kaiser Permanente Oakland Medical Center, Oakland CA
| | - Louise C. Greenspan
- Department of Pediatrics, Kaiser Permanente San Francisco Medical Center, San Francisco CA
| | - Malini Chandra
- Division of Research, Kaiser Permanente Northern California, Oakland CA
| | - Stephen R. Daniels
- Department of Pediatrics, University of Colorado School of Medicine, Aurora CO
| | - Alan Sinaiko
- Department of Pediatrics, University of Minnesota, Minneapolis MN
| | - Ronald J. Prineas
- Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem NC
| | - Emily D. Parker
- HealthPartners Institute for Education and Research, Minneapolis MN
| | - Kenneth F. Adams
- HealthPartners Institute for Education and Research, Minneapolis MN
| | - Matthew F. Daley
- Department of Pediatrics, University of Colorado School of Medicine, Aurora CO,Institute for Health Research, Kaiser Permanente Colorado, Denver CO
| | | | | | | | - David J. Magid
- Institute for Health Research, Kaiser Permanente Colorado, Denver CO,Colorado School of Public Health, University of Colorado Denver, Aurora CO
| | | | - Joan C. Lo
- Department of Medicine, Kaiser Permanente Oakland Medical Center, Oakland CA,Division of Research, Kaiser Permanente Northern California, Oakland CA
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Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, Godwin M, Green B, Hebert P, Hobbs FDR, Kantola I, Kerry S, Magid DJ, Mant J, Margolis KL, McKinstry B, Omboni S, Ogedegbe O, Parati G, Qamar N, Varis J, Verberk W, Wakefield BJ, McManus RJ. Individual patient data meta-analysis of self-monitoring of blood pressure (BP-SMART): a protocol. BMJ Open 2015; 5:e008532. [PMID: 26373404 PMCID: PMC4577873 DOI: 10.1136/bmjopen-2015-008532] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Self-monitoring of blood pressure is effective in reducing blood pressure in hypertension. However previous meta-analyses have shown a considerable amount of heterogeneity between studies, only part of which can be accounted for by meta-regression. This may be due to differences in design, recruited populations, intervention components or results among patient subgroups. To further investigate these differences, an individual patient data (IPD) meta-analysis of self-monitoring of blood pressure will be performed. METHODS AND ANALYSIS We will identify randomised trials that have compared patients with hypertension who are self-monitoring blood pressure with those who are not and invite trialists to provide IPD including clinic and/or ambulatory systolic and diastolic blood pressure at baseline and all follow-up points where both intervention and control groups were measured. Other data requested will include measurement methodology, length of follow-up, cointerventions, baseline demographic (age, gender) and psychosocial factors (deprivation, quality of life), setting, intensity of self-monitoring, self-monitored blood pressure, comorbidities, lifestyle factors (weight, smoking) and presence or not of antihypertensive treatment. Data on all available patients will be included in order to take an intention-to-treat approach. A two-stage procedure for IPD meta-analysis, stratified by trial and taking into account age, sex, diabetes and baseline systolic BP will be used. Exploratory subgroup analyses will further investigate non-linear relationships between the prespecified variables. Sensitivity analyses will assess the impact of trials which have and have not provided IPD. ETHICS AND DISSEMINATION This study does not include identifiable data. Results will be disseminated in a peer-reviewed publication and by international conference presentations. CONCLUSIONS IPD analysis should help the understanding of which self-monitoring interventions for which patient groups are most effective in the control of blood pressure.
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Affiliation(s)
| | - James P Sheppard
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Richard Stevens
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina, USA
| | - Alfred Bove
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina, USA Department of Cardiology, Temple University School of Medicine, Philadelphia, USA School of Psychology, University of Central Lancashire, Preston, UK Family Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada Group Health Research Institute, Seattle, Washington, USA Department of Health Services, University of Washington School of Public Health, Washington, DC, USA Department of Medicine, Turku University Hospital, Turku, Finland Centre for Primary Care and Public Health, Queen Mary University of London, London, UK Colorado School of Public Health, University of Colorado, Denver, Colorado, USA Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK Health Partners Institute for Education and Research, Minneapolis, Minnesota, USA Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Midlothian, UK Clinical Research Unit, Italian Institute of Telemedicine, Solbiate Arno, Varese, Italy Division of Health and Behavior, Department of Population Health, Center for Healthful Behavior Change, New York University, Langone School of Medicine, New York, USA Departments of Cardiology, and Clinical Medicine and Prevention, University of Milano Bicocca, Milan, Italy Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK Departments of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Maastricht, The Netherlands Department of Veterans (VA) Health Services Research, Development Centre for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Centre, University of Iowa, Iowa City, Iowa, USA
| | - Emma P Bray
- Department of Cardiology, Temple University School of Medicine, Philadelphia, USA School of Psychology, University of Central Lancashire, Preston, UK
| | - Marshal Godwin
- Family Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Beverly Green
- Group Health Research Institute, Seattle, Washington, USA
| | - Paul Hebert
- Department of Health Services, University of Washington School of Public Health, Washington, DC, USA
| | - F D Richard Hobbs
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Ilkka Kantola
- Department of Medicine, Turku University Hospital, Turku, Finland
| | - Sally Kerry
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - David J Magid
- Colorado School of Public Health, University of Colorado, Denver, Colorado, USA
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Karen L Margolis
- Health Partners Institute for Education and Research, Minneapolis, Minnesota, USA
| | - Brian McKinstry
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Midlothian, UK
| | - Stefano Omboni
- Clinical Research Unit, Italian Institute of Telemedicine, Solbiate Arno, Varese, Italy
| | - Olugbenga Ogedegbe
- Division of Health and Behavior, Department of Population Health, Center for Healthful Behavior Change, New York University, Langone School of Medicine, New York, USA
| | - Gianfranco Parati
- Departments of Cardiology, and Clinical Medicine and Prevention, University of Milano Bicocca, Milan, Italy
| | - Nashat Qamar
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Juha Varis
- Department of Medicine, Turku University Hospital, Turku, Finland
| | - Willem Verberk
- Departments of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Maastricht, The Netherlands
| | - Bonnie J Wakefield
- Department of Veterans (VA) Health Services Research, Development Centre for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Centre, University of Iowa, Iowa City, Iowa, USA
| | - Richard J McManus
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
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Tsai TT, Rehring TF, Rogers RK, Shetterly SM, Wagner NM, Gupta R, Jazaeri O, Hedayati N, Jones WS, Patel MR, Ho PM, Go AS, Magid DJ. The Contemporary Safety and Effectiveness of Lower Extremity Bypass Surgery and Peripheral Endovascular Interventions in the Treatment of Symptomatic Peripheral Arterial Disease. Circulation 2015; 132:1999-2011. [PMID: 26362632 PMCID: PMC4652630 DOI: 10.1161/circulationaha.114.013440] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 09/08/2015] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Treatment for symptomatic peripheral artery disease includes lower extremity bypass surgery (LEB) and peripheral endovascular interventions (PVIs); however, limited comparative effectiveness data exist between the 2 therapies. We assessed the safety and effectiveness of LEB and PVI in patients with symptomatic claudication and critical limb ischemia.
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Affiliation(s)
- Thomas T Tsai
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.).
| | - Thomas F Rehring
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - R Kevin Rogers
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Susan M Shetterly
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Nicole M Wagner
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Rajan Gupta
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Omid Jazaeri
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Nasim Hedayati
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - W Schuyler Jones
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Manesh R Patel
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - P Michael Ho
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Alan S Go
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - David J Magid
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
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Jones WS, Patel MR, Tsai TT, Go AS, Gupta R, Hedayati N, Ho PM, Jazaeri O, Rehring TF, Rogers RK, Shetterly SM, Wagner NM, Magid DJ. Anatomic runoff score predicts cardiovascular outcomes in patients with lower extremity peripheral artery disease undergoing revascularization. Am Heart J 2015; 170:400-8. [PMID: 26299239 DOI: 10.1016/j.ahj.2015.04.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although the presence, extent, and severity of obstruction in patients with lower extremity peripheral artery disease (LE PAD) affect their functional status, quality of life, and treatment, it is not known if these factors are associated with future cardiovascular events. We empirically created an anatomic runoff score (ARS) to approximate the burden of LE PAD and determined its association with clinical outcomes. METHODS We evaluated all patients with LE PAD and bilateral angiography undergoing revascularization in a community-based clinical study. Primary clinical outcomes of interest were (1) a composite of all-cause death, myocardial infarction (MI), and stroke and (2) amputation-free survival. Cox proportional hazards models were created to identify predictors of clinical outcomes. RESULTS We evaluated 908 patients undergoing angiography, and a total of 260 (28.0%) patients reached the composite end point (45 MI, 63 stroke, and 152 death) during the study period. Anatomic runoff score ranged from 0 to 15 (mean 4.7; SD 2.5) with higher scores indicating a higher burden of disease, and an optimal cutpoint analysis classified patients into low ARS (<5) and high ARS (≥5). The unadjusted rates of the primary composite end point and amputation-free survival were nearly 2-fold higher in patients with a high ARS when compared with patients with a low ARS. The most significant predictors of the composite end point (death/MI/stroke) were age (δ 10 years; hazard ratio [HR] 1.53; CI 1.32-1.78; P < .001), diabetes mellitus (HR 1.65; CI 1.26-2.18; P < .001), glomerular filtration rate <30 (HR 2.23; CI 1.44-3.44; P < .001), statin use (HR 0.66; CI 0.48-0.88; P < .001), and ARS (δ 2 points; HR 1.21; CI 1.08-1.35; P < .001). CONCLUSIONS After adjustment for clinical factors, the LE PAD ARS was an independent predictor of future cardiovascular morbidity and mortality in a broadly representative patient population undergoing revascularization for symptomatic PAD. A clinically useful anatomic scoring system, if validated, may assist clinicians in risk stratification during the course of clinical decision making.
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Parker ED, Sinaiko AR, Daley MF, Kharbanda EO, Trower NK, Tavel HM, Sherwood NE, Magid DJ, Margolis KL, O'Connor PJ. Factors Associated With Adherence to Blood Pressure Measurement Recommendations at Pediatric Primary Care Visits, Minnesota and Colorado, 2007-2010. Prev Chronic Dis 2015. [PMID: 26203816 PMCID: PMC4515918 DOI: 10.5888/pcd12.140562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction Elevated blood pressure in childhood may predict increased cardiovascular risk in young adulthood. The Task Force on the Diagnosis, Evaluation and Treatment of High Blood pressure in Children and Adolescents recommends that blood pressure be measured in children aged 3 years or older at all health care visits. Guidelines from both Bright Futures and the Expert Panel of Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents recommend annual blood pressure screening. Adherence to these guidelines is unknown. Methods We conducted a cross-sectional study to assess compliance with blood pressure screening recommendations in 2 integrated health care delivery systems. We analyzed electronic health records of 103,693 subjects aged 3 to 17 years. Probability of blood pressure measurement documented in the electronic health record was modeled as a function of visit type (well-child vs nonwell-child); patient age, sex, race/ethnicity, and body mass index; health care use; insurance type; and type of office practice or clinic department (family practice or pediatrics). Results Blood pressure was measured at 95% of well-child visits and 69% of nonwell-child outpatient visits. After adjusting for potential confounders, the percentage of nonwell-child visits with measurements increased linearly with patient age (P < .001). Overall, the proportion of children with annual blood pressure measurements was high and increased with age. Family practice clinics were more likely to adhere to blood pressure measurement guidelines compared with pediatric clinics (P < .001). Conclusion These results show good compliance with recommendations for routine blood pressure measurement in children and adolescents. Findings can inform the development of EHR-based clinical decision support tools to augment blood pressure screening and recognition of prehypertension and hypertension in pediatric patients.
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Affiliation(s)
- Emily D Parker
- HealthPartners Institute for Education and Research, Box 1524, Mail Stop 23301A, Minneapolis, MN 55440-1524.
| | - Alan R Sinaiko
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Matt F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Elyse O Kharbanda
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Nicole K Trower
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Heather M Tavel
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Nancy E Sherwood
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - David J Magid
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Karen L Margolis
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Patrick J O'Connor
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
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Sullivan PW, Campbell JD, Globe G, Ghushchyan VH, Bender B, Schatz M, Chon Y, Woolley JM, Magid DJ. Measuring the effect of asthma control on exacerbations and health resource use. J Allergy Clin Immunol 2015; 136:1409-11.e1-6. [PMID: 26073753 DOI: 10.1016/j.jaci.2015.04.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 04/23/2015] [Accepted: 04/23/2015] [Indexed: 11/28/2022]
Affiliation(s)
| | - Jonathan D Campbell
- Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy, University of Colorado, Aurora, Colo
| | | | - Vahram H Ghushchyan
- Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy, University of Colorado, Aurora, Colo; American University of Armenia, Yerevan, Armenia
| | - Bruce Bender
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | | | | | | | - David J Magid
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colo
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Affiliation(s)
- Comilla Sasson
- From the Department of Emergency Medicine (C.S.) and Colorado School of Public Health (C.S., D.M.), University of Colorado School of Medicine, Aurora, and the Institute for Health Research, Kaiser Permanente, and Colorado Cardiovascular Outcomes Research Consortium, Denver (D.M.) - all in Colorado; and the American Heart Association, Dallas (C.S.)
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49
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Masoudi FA, Go AS, Magid DJ, Cassidy-Bushrow AE, Gurwitz JH, Liu TI, Reynolds K, Smith DH, Reifler LM, Glenn KA, Fiocchi F, Goldberg R, Gupta N, Peterson PN, Schuger C, Vidaillet H, Hammill SC, Greenlee RT. Age and sex differences in long-term outcomes following implantable cardioverter-defibrillator placement in contemporary clinical practice: findings from the Cardiovascular Research Network. J Am Heart Assoc 2015; 4:e002005. [PMID: 26037083 PMCID: PMC4599538 DOI: 10.1161/jaha.115.002005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Patient sex and age may influence rates of death after receiving an implantable cardioverter-defibrillator for primary prevention. Differences in outcomes other than mortality and whether these differences vary by heart failure symptoms, etiology, and left ventricular ejection fraction are not well characterized. Methods and Results We studied 2954 patients with left ventricular ejection fraction ≤0.35 undergoing first-time implantable cardioverter-defibrillator for primary prevention within the Cardiovascular Research Network; 769 patients (26%) were women, and 2827 (62%) were aged >65 years. In a median follow-up of 2.4 years, outcome rates per 1000 patient-years were 109 for death, 438 for hospitalization, and 111 for heart failure hospitalizations. Procedure-related complications occurred in 8.36%. In multivariable models, women had significantly lower risks of death (hazard ratio 0.67, 95% CI 0.56 to 0.80) and heart failure hospitalization (hazard ratio 0.82, 95% CI 0.68 to 0.98) and higher risks for complications (hazard ratio 1.38, 95% CI 1.01 to 1.90) than men; patients aged >65 years had higher risks of death (hazard ratio 1.55, 95% CI 1.30 to 1.86) and heart failure hospitalization (hazard ratio 1.25, 95% CI 1.05 to 1.49) than younger patients. Age and sex differences were generally consistent in strata according to symptoms, etiology, and severity of left ventricular systolic dysfunction, except the higher risk of complications in women, which differed by New York Heart Association classification (P=0.03 for sex–New York Heart Association interaction), and the risk of heart failure hospitalization in older patients, which differed by etiology of heart failure (P=0.05 for age–etiology interaction). Conclusions The burden of adverse outcomes after receipt of an implantable cardioverter-defibrillator for primary prevention is substantial and varies according to patient age and sex. These differences in outcome generally do not vary according to baseline heart failure characteristics.
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Affiliation(s)
- Frederick A Masoudi
- University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M., D.J.M., P.N.P.) Institute for Health Research, Kaiser Permanente Colorado, Denver, CO (F.A.M., D.J.M., L.M.R., K.A.G., P.N.P.)
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA (A.S.G.) Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, CA (A.S.G.)
| | - David J Magid
- University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M., D.J.M., P.N.P.) Institute for Health Research, Kaiser Permanente Colorado, Denver, CO (F.A.M., D.J.M., L.M.R., K.A.G., P.N.P.)
| | | | - Jerry H Gurwitz
- Meyers Primary Care Institute, Worcester, MA (J.H.G., R.G.) University of Massachusetts Medical School, Worcester, MA (J.H.G., R.G.)
| | - Taylor I Liu
- Department of Cardiac Electrophysiology, Kaiser Permanente Northern California, Santa Clara, CA (T.I.L.)
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - David H Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR (D.H.S.)
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO (F.A.M., D.J.M., L.M.R., K.A.G., P.N.P.)
| | - Karen A Glenn
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO (F.A.M., D.J.M., L.M.R., K.A.G., P.N.P.)
| | - Frances Fiocchi
- American College of Cardiology Foundation, Washington, DC (F.F.)
| | - Robert Goldberg
- Meyers Primary Care Institute, Worcester, MA (J.H.G., R.G.) University of Massachusetts Medical School, Worcester, MA (J.H.G., R.G.)
| | - Nigel Gupta
- Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA (N.G.)
| | - Pamela N Peterson
- University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M., D.J.M., P.N.P.) Institute for Health Research, Kaiser Permanente Colorado, Denver, CO (F.A.M., D.J.M., L.M.R., K.A.G., P.N.P.) Denver Health Medical Center, Denver, CO (P.N.P.)
| | - Claudio Schuger
- Henry Ford Hospital Heart and Vascular Institute, Detroit, MI (C.S.)
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Sandhu A, Ho PM, Asche S, Magid DJ, Margolis KL, Sperl-Hillen J, Rush B, Price DW, Ekstrom H, Tavel H, Godlevsky O, O'Connor PJ. Recidivism to uncontrolled blood pressure in patients with previously controlled hypertension. Am Heart J 2015; 169:791-7. [PMID: 26027616 DOI: 10.1016/j.ahj.2015.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 03/17/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Control of hypertension has improved nationally with focus on identifying and treating elevated blood pressures (BPs) to guideline recommended levels. However, once BP control is achieved, the frequency in which BP falls out of control and the factors associated with BP recidivism is unknown. In this retrospective cohort study conducted at 2 large, integrated health care systems we sought to examine rates and predictors of BP recidivism in adults with controlled hypertension. No change for methods, results and conclusion. METHODS Patients with a prior diagnosis of hypertension based on a combination of International Classification of Diseases, Ninth Revision, codes, receipt of antihypertensive medications, and/or elevated BP readings were eligible to be included. We defined controlled hypertension as normotensive BP readings (<140/90 mmHg or <130/80 mmHg in those with diabetes) at 2 consecutive primary care visits. We then followed up patients for BP recidivism defined by the date of the second of 2 consecutive BP readings >140/90 mmHg (>130/80 mmHg for diabetes or chronic kidney disease) during a median follow-up period of 16.6 months. Cox proportional hazards regression assessed the association between patient characteristics, comorbidities, medication adherence, and provider medication management with time to BP recidivism. RESULTS A total of 23,321 patients with controlled hypertension were included in this study. The proportion of patients with hypertension recidivism was 24.1% over the 16.6-month study period. For those with BP recidivism, the median time to relapse was 7.3 months. In multivariate analysis, those with diabetes (hazard ratio [HR] 3.99, CI 3.67-4.33), high normal baseline BP (for systolic BP HR 1.03, CI 1.03-1.04), or low antihypertensive medication adherence (HR 1.20, CI 1.11-1.29) had significantly higher rates of hypertension recidivism. Limitations of this work include demographics of our patient sample, which may not reflect other communities in addition to the intrinsic limitations of office-based BP measurements. CONCLUSIONS Hypertensive recidivism occurs in a significant portion of patients with previously well-controlled BP and accounts for a substantial fraction of patients with poorly controlled hypertension. Systematic identification of those most at risk for recidivism and implementation of strategies to minimize hypertension recidivism may improve overall levels of BP control and hypertension-related quality measures.
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Affiliation(s)
- Amneet Sandhu
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Colorado, Aurora, CO.
| | - P Michael Ho
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Colorado, Aurora, CO; VA Eastern Colorado Health Care System, Denver, CO
| | - Steve Asche
- HealthPartners Institute for Education and Research, Bloomington, MN
| | - David J Magid
- Institute for Health Research, Kaiser Permanente of Colorado, Littleton, CO
| | - Karen L Margolis
- HealthPartners Institute for Education and Research, Bloomington, MN
| | | | - Bill Rush
- HealthPartners Institute for Education and Research, Bloomington, MN
| | - David W Price
- Institute for Health Research, Kaiser Permanente of Colorado, Littleton, CO
| | - Heidi Ekstrom
- HealthPartners Institute for Education and Research, Bloomington, MN
| | - Heather Tavel
- Institute for Health Research, Kaiser Permanente of Colorado, Littleton, CO
| | - Olga Godlevsky
- HealthPartners Institute for Education and Research, Bloomington, MN
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