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Chuzi S, Lindenauer PK, Faridi K, Priya A, Pekow PS, D'Aunno T, Mazor KM, Stefan MS, Spatz ES, Gilstrap L, Werner RM, Lagu T. Variation in Risk-Standardized Acute Admission Rates Among Patients With Heart Failure in Accountable Care Organizations: Implications for Quality Measurement. J Am Heart Assoc 2023; 12:e029758. [PMID: 37345796 PMCID: PMC10356066 DOI: 10.1161/jaha.122.029758] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/10/2023] [Indexed: 06/23/2023]
Abstract
Background Accountable care organizations (ACOs) aim to improve health care quality and reduce costs, including among patients with heart failure (HF). However, variation across ACOs in admission rates for patients with HF and associated factors are not well described. Methods and Results We identified Medicare fee-for-service beneficiaries with HF who were assigned to a Medicare Shared Savings Program ACO in 2017 and survived ≥30 days into 2018. We calculated risk-standardized acute admission rates across ACOs, assigned ACOs to 1 of 3 performance categories, and examined associations between ACO characteristics and performance categories. Among 1 232 222 beneficiaries with HF, 283 795 (mean age, 81 years; 54% women; 86% White; 78% urban) were assigned to 1 of 467 Medicare Shared Savings Program ACOs. Across ACOs, the median risk-standardized acute admission rate was 87 admissions per 100 people, ranging from 61 (minimum) to 109 (maximum) admissions per 100 beneficiaries. Compared to the overall average, 13% of ACOs performed better on risk-standardized acute admission rates, 72% were no different, and 14% performed worse. Most ACOs with better performance had fewer Black beneficiaries and were not hospital affiliated. Most ACOs that performed worse than average were large, located in the Northeast, had a hospital affiliation, and had a lower proportion of primary care providers. Conclusions Admissions are common among beneficiaries with HF in ACOs, and there is variation in risk-standardized acute admission rates across ACOs. ACO performance was associated with certain ACO characteristics. Future studies should attempt to elucidate the relationship between ACO structure and characteristics and admission risk.
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Affiliation(s)
- Sarah Chuzi
- Division of Cardiology, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population SciencesUniversity of Massachusetts Chan Medical School–BaystateSpringfieldMAUSA
| | - Kamal Faridi
- Department of Healthcare Delivery and Population SciencesUniversity of Massachusetts Chan Medical School–BaystateSpringfieldMAUSA
| | - Aruna Priya
- Department of Healthcare Delivery and Population SciencesUniversity of Massachusetts Chan Medical School–BaystateSpringfieldMAUSA
| | - Penelope S. Pekow
- Department of Healthcare Delivery and Population SciencesUniversity of Massachusetts Chan Medical School–BaystateSpringfieldMAUSA
| | - Thomas D'Aunno
- Wagner Graduate School of Public Service at New York UniversityNew YorkNYUSA
| | - Kathleen M. Mazor
- Division of Health Systems Science, Department of MedicineUniversity of Massachusetts Chan Medical SchoolWorcesterMAUSA
| | - Mihaela S. Stefan
- Department of MedicineUniversity of Massachusetts Chan Medical SchoolSpringfieldMAUSA
| | - Erica S. Spatz
- Section of Cardiovascular MedicineYale School of MedicineNew HavenCTUSA
- Department of EpidemiologyYale School of Public HealthNew HavenCTUSA
- Yale Center for Outcomes Research and EvaluationNew HavenCTUSA
| | - Lauren Gilstrap
- Heart and Vascular Center, Dartmouth Hitchcock Medical CenterThe Dartmouth Institute, Geisel School of Medicine at DartmouthLebanonNHUSA
| | - Rachel M. Werner
- Leonard Davis Institute of Health Economics and Perelman School of MedicineUniversity of Pennsylvania; Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPAUSA
| | - Tara Lagu
- Institute for Public Health and Medicine, Northwestern University Feinberg School of MedicineChicagoILUSA
- Division of Hospital Medicine, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoILUSA
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2
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Gilstrap L, Solomon N, Chiswell K, James O'Malley A, Skinner JS, Fonarow GC, Bhatt DL, Yancy CW, Devore AD. The Association Between Beta-blocker and Renin-Angiotensin System Inhibitor Use After Heart Failure With Reduced Ejection Fraction Hospitalization and Outcomes in Older Patients. J Card Fail 2023; 29:434-444. [PMID: 36516937 PMCID: PMC10798429 DOI: 10.1016/j.cardfail.2022.11.010] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Beta-blockers (BB) and renin-angiotensin system inhibitors (RASi) are foundational for the treatment of heart failure with reduced ejection fraction (HFrEF). However, given the increased risk of side effects in older patients, uncertainty remains as to whether, on net, older patients benefit as much as the younger patients studied in trials. METHODS AND RESULTS Using the Get With The Guidelines-Heart Failure registry linked with Medicare data, overlap propensity weighted Cox proportional hazard models were used to examine the association between BB and RASi use at hospital discharge and 30-day and 1-year outcomes among patients with HFrEF. Among the 48,711 patients (aged ≥65 years) hospitalized with HFrEF, there were significant associations between BB and/or RASi use at discharge and lower rates of 30-day and 1-year mortality, including those over age 85 (30-day hazard ratio 0.56, 95% confidence interval 0.45-0.70; 1-year hazard ratio 0.69, 95% confidence interval 0.61-0.78). In addition, the magnitude of benefit associated with BB and/or RASi use after discharge did not decrease with advancing age. Even among the oldest patients, those over age 85, with hypotension, renal insufficiency or frailty, BB and/or RASi use at discharge was still associated with lower 1-year mortality or readmission. CONCLUSIONS Among older patients hospitalized with HFrEF, BB and/or RASi use at discharge is associated with lower rates of 30-day and 1-year mortality across all age groups and the magnitude of this benefit does not seem to decrease with advancing age. These data suggest that, absent a clinical contraindication, BB and RASi should be considered in all patients hospitalized with HFrEF before or at hospital discharge, regardless of age.
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Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Nicole Solomon
- Duke University Clinical Research Institute, Durham, North Carolina
| | - Karen Chiswell
- Duke University Clinical Research Institute, Durham, North Carolina
| | - A James O'Malley
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jonathan S Skinner
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Gregg C Fonarow
- University of California Los Angles, Division of Cardiology, Los Angeles, California
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Division of Cardiovascular Medicine, Boston, Massachusetts
| | - Clyde W Yancy
- Northwestern University, Division of Cardiology, Chicago, Illinois
| | - Adam D Devore
- Duke University Clinical Research Institute, Durham, North Carolina.
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Paulenka Y, Gilstrap L, Yazdi M, Zuckerman R, Ortengren A. Disseminated Yersinia Enterocolitica after Orthotopic Heart Transplant. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.595] [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: 04/05/2023] Open
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4
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Johnson M, Nayak RK, Gilstrap L, Dusetzina SB. Estimation of Out-of-Pocket Costs for Guideline-Directed Medical Therapy for Heart Failure Under Medicare Part D and the Inflation Reduction Act. JAMA Cardiol 2023; 8:299-301. [PMID: 36630145 PMCID: PMC9857788 DOI: 10.1001/jamacardio.2022.5033] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 10/05/2022] [Accepted: 11/10/2022] [Indexed: 01/12/2023]
Abstract
This cross-sectional study estimates out-of-pocket costs of heart failure with reduced ejection fraction medication regimens in Medicare Part D under current law and the Inflation Reduction Act.
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Affiliation(s)
- Micah Johnson
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rahul K. Nayak
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Lauren Gilstrap
- Dartmouth Hitchcock Medical Center, The Dartmouth Institute Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
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5
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Bhambri R, Colavecchia AC, Bruno M, Chen Y, Alvir J, Roy A, Kemner J, Crowley A, Benjumea D, Gilstrap L. Real-World Characteristics of Patients with Wild-Type Transthyretin Amyloid Cardiomyopathy: An Analysis of Electronic Healthcare Records in the United States. Am J Cardiovasc Drugs 2023; 23:197-206. [PMID: 36780092 PMCID: PMC10006039 DOI: 10.1007/s40256-022-00563-4] [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] [Accepted: 12/14/2022] [Indexed: 02/14/2023]
Abstract
BACKGROUND Tafamidis was approved for the treatment of hereditary and wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) in May 2019, based on findings from the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT). METHODS This retrospective cohort study evaluated the factors associated with tafamidis prescription after diagnosis of ATTRwt-CM in the real world. Between May 2019 and December 2020, 430 patients with 6 months' database activity were indexed from the de-identified US Optum electronic healthcare records at first diagnosis of ATTRwt-CM or prescription of tafamidis, then followed until last activity or death. Of these, 209 patients were prescribed tafamidis during follow-up, 167 (80%) within 1 month, 98% by 6 months, and 100% by 9 months. Median time from index to tafamidis prescription, calculated using the Kaplan-Meier method, was 5.8 months (95% confidence interval [CI] 2.4-not evaluable). RESULTS Factors associated with tafamidis prescription in a multivariable Cox proportional hazards regression (hazard ratio [95% CI]) included age ≥ 65 years (2.1 [1.07-4.05]), male sex (1.6 [1.07-2.28]), having heart failure/cardiomyopathy (2.4 [1.54-3.82]), and having had technetium-99m pyrophosphate myocardial scintigraphy (1.7 [1.28-2.28]). CONCLUSIONS The clinical characteristics of patients with ATTRwt-CM who were prescribed tafamidis in the real world were broadly comparable with those who took part in ATTR-ACT. Further studies are needed to evaluate hereditary and ATTRwt-CM patient populations in the real world and assess the long-term outcomes associated with disease management pathways. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov identifier: NCT01994889.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Lauren Gilstrap
- Cardiovascular Medicine Section, Dartmouth Health, Heart and Vascular Center, The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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6
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Goyal P, Zullo AR, Gladders B, Onyebeke C, Kwak MJ, Allen LA, Levitan EB, Safford MM, Gilstrap L. Real-world safety of neurohormonal antagonist initiation among older adults following a heart failure hospitalization. ESC Heart Fail 2023; 10:1623-1634. [PMID: 36807850 DOI: 10.1002/ehf2.14317] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 01/02/2023] [Accepted: 01/31/2023] [Indexed: 02/23/2023] Open
Abstract
AIMS To optimize guideline-directed medical therapy for heart failure, patients may require the initiation of multiple neurohormonal antagonists (NHAs) during and following hospitalization. The safety of this approach for older adults is not well established. METHODS AND RESULTS We conducted an observational cohort study of 207 223 Medicare beneficiaries discharged home following a hospitalization for heart failure with reduced ejection fraction (HFrEF) (2008-2015). We performed Cox proportional hazards regression to examine the association between the count of NHAs initiated within 90 days of hospital discharge (as a time-varying exposure) and all-cause mortality, all-cause rehospitalization, and fall-related adverse events over the 90 day period following hospitalization. We calculated inverse probability-weighted hazard ratios (IPW-HRs) with 95% confidence intervals (CIs) comparing initiation of 1, 2, or 3 NHAs vs. 0. The IPW-HRs for mortality were 0.80 [95% CI (0.78-0.83)] for 1 NHA, 0.70 [95% CI (0.66-0.75)] for 2, and 0.94 [95% CI (0.83-1.06)] for 3. The IPW-HRs for readmission were 0.95 [95% CI (0.93-0.96)] for 1 NHA, 0.89 [95% CI (0.86-0.91)] for 2, and 0.96 [95% CI (0.90-1.02)] for 3. The IPW-HRs for fall-related adverse events were 1.13 [95% CI (1.10-1.15)] for 1 NHA, 1.25 [95% CI (1.21-1.30)] for 2, and 1.64 [95% CI (1.54-1.76)] for 3. CONCLUSIONS Initiating 1-2 NHAs among older adults within 90 days of HFrEF hospitalization was associated with lower mortality and lower readmission. However, initiating 3 NHAs was not associated with reduced mortality or readmission and was associated with a significant risk for fall-related adverse events.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY, 10063, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Department of Pharmacy, Lifespan-Rhode Island Hospital, Providence, RI, USA
| | - Barbara Gladders
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Chukwuma Onyebeke
- Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY, 10063, USA
| | - Min Ji Kwak
- Department of Internal Medicine, McGovern Medical School, Houston, TX, USA
| | - Larry A Allen
- Division of Cardiology, University of Colorado Schools of Medicine, Aurora, CO, USA
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY, 10063, USA
| | - Lauren Gilstrap
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH, USA
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7
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Gilstrap L, Cohen A, Ouellet GM, Goyal P, Gladders B, Flint D, Skinner J. The association between beta-blockers and outcomes in patients with heart failure and concurrent Alzheimer's disease and related dementias. J Am Geriatr Soc 2023; 71:404-413. [PMID: 36240493 DOI: 10.1111/jgs.18086] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/11/2022] [Accepted: 09/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Contemporary patients with heart failure with reduced ejection fraction (HFrEF) are older and have a higher prevalence of cognitive impairment than those studied in trials. The risk/benefit trade-off of routine beta-blocker (BB) use in patients with HFrEF and Alzheimer's disease and related dementias (ADRD) has not been explored. This study aimed to determine the association between BB use and outcomes among patients with HFrEF and ADRD. METHODS Using a random 40% sample of Medicare Parts A, B, and D data we identified patients with ≥1 hospitalization for HFrEF between 2008 and 2018. Each patient was classified based on BB use prior to admission and after discharge. Outcomes include 90-day and 1-year mortality and readmission. RESULTS Between 2008 and 2018, we identified 357,030 patients hospitalized with HFrEF; 12.7% had ADRD. Patients with HFrEF and ADRD had higher 90-day and 1-year mortality compared to patients with HFrEF-only. Among patients admitted on a BB, 60.5% of patients with HFrEF-only were continued on therapy after discharge, compared to 56.8% of patients with HFrEF and ADRD. Discontinuing BB was associated with a 2.2-fold higher risk of 90-day mortality (p < 0.001) among patients with HF-only and a 2.- fold higher risk of 90-day mortality (p < 0.001) among patients with HFrEF + ADRD. Not starting a BB was associated with a 1.8-fold higher risk of 90-day mortality (p < 0.001) among patients with HFrEF-only and a 1.7-fold higher risk of 90-day mortality (p < 0.001) among patients with HFrEF + ADRD. Similar risks were seen at 1 year. CONCLUSIONS BB therapy is associated with significantly lower short and long-term mortality rates among all patients with HFrEF; the magnitude of these associated benefits appear at least as large in patients with HFrEF and ADRD compared to patients with HFrEF-only.
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Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, New Hampshire, USA.,Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA
| | - Andrew Cohen
- Section of Geriatrics, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Gregory M Ouellet
- Section of Geriatrics, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Parag Goyal
- Department of Medicine, Weil Cornell Medicine, New York, New York, USA
| | - Barbara Gladders
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, New Hampshire, USA
| | - Danette Flint
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, New Hampshire, USA.,Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA
| | - Jonathan Skinner
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA.,Department of Economics, Dartmouth College, Hanover, New Hampshire, USA
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8
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Gilstrap L, Zipkin RJ, Barnes JA, King A, O'Malley AJ, Gaziano TA, Tosteson ANA. Sacubitril/valsartan vs ACEi/ARB at hospital discharge and 5-year survival in older patients with heart failure with reduced ejection fraction: A decision analysis approach. Am Heart J 2022; 250:23-28. [PMID: 35525261 DOI: 10.1016/j.ahj.2022.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 08/31/2021] [Revised: 03/23/2022] [Accepted: 04/17/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND In clinical trials, sacubitril/valsartan has demonstrated significant survival benefits compared to angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEi/ARB). Whether older patients with heart failure with reduced ejection fraction (HFrEF) benefit as much, due to higher rates of comorbidities, frailty and drug discontinuation, is unknown. METHODS AND RESULTS Using a cohort of Medicare beneficiaries hospitalized with HFrEF between 2016 and 2018, we determined all-cause mortality and HF-readmission rates among patients not given ACEi/ARB or sacubitril/valsartan at hospital discharge, by age. We then used risk reductions from the SOLVD, PARADIGM-HF and PIONEER-HF trials to estimate the benefits of ACEi/ARB and sacubitril/valsartan. We then incorporated age-specific estimates of drug discontinuation from Medicare. A Markov decision process model was used to simulate 5-year survival and estimate number needed to treat, comparing discharge on ACEi/ARB vs sacubitril/valsartan by age. After accounting for drug discontinuation rates, which were surprisingly slightly higher among those discharged on ACEi/ARB (2.3%/month vs 1.9%/month), there was a small but significant survival advantage to discharge on sacubitril/valsartan over 5 years (+0.81 months [95% CI 0.80, 0.81]). The benefit of sacubitril/valsartan over ACEi/ARB did not decrease with increasing age - the number needed to treat among 66 to 74-year-old patients was 84 and among 85+ year-old patients was 67. CONCLUSIONS Even after accounting for "real world" rates of drug discontinuation, discharge on sacubitril/valsartan after conferred a small, but significant, survival advantage which does not appear to wane with increasing age.
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Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Ronnie J Zipkin
- Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Ashleigh King
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Alistair James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Thomas A Gaziano
- Brigham and Women's Hospital, Cardiovascular Medicine, Boston, MA; Harvard Medical School, Boston, MA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
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9
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Kavuri SK, Ullah A, Iyoha E, Ballur K, Gilstrap L, Mattox SN. Oncocytic Papillary Cystadenoma, an Unusual Variant Presenting as a Laryngeal Ventricular Cyst. Curr Health Sci J 2022; 48:353-355. [PMID: 36815090 PMCID: PMC9940932 DOI: 10.12865/chsj.48.03.15] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/18/2022] [Indexed: 02/24/2023]
Abstract
Cystadenoma arising from the larynx is a rare benign minor salivary gland tumor that can show mucinous or papillary morphology. The epithelial lining of the salivary gland tumor can present with oncocytic features, which is attributed to an increased number of mitochondria. We present a rare case of oncocytic papillary cystadenoma (OPC) of the larynx which has a combination of these features. The WHO defines OPC tumors as entities which closely resemble Warthin tumor, but lack its classic lymphoid component. The immunohistochemical profile and molecular genetic features are largely unknown. We present an 84-year-old female, former smoker, who presented with progressive dysphonia, dysphagia, and shortness of breath. Laryngoscopy revealed a large, smooth mass originating from the ventricle of the right vocal fold. Subsequent biopsy demonstrated cyst wall fragments lined by a bilayer of large columnar to cuboidal oncocytic cells that had granular eosinophilic cytoplasm, round to oval nuclei with finely dispersed chromatin, and small but distinct nucleoli. The surrounding stroma was slightly fibrotic with scant lymphoid elements. No nuclear pleomorphism, increased mitosis, or necrosis was identified. In the larynx, benign salivary gland tumors are rare and less frequent than malignant neoplasms. Awareness of rare benign entities like OPC help ensure proper management and aid in avoiding unnecessary therapy.
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Affiliation(s)
| | - Asad Ullah
- 1Medical College of Georgia, Augusta University, GA, USA
| | - Ehiremen Iyoha
- 1Medical College of Georgia, Augusta University, GA, USA
| | - Kalyani Ballur
- 1Medical College of Georgia, Augusta University, GA, USA
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10
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Gilstrap L, Zhou W, Alsan M, Nanda A, Skinner JS. Trends in Mortality Rates Among Medicare Enrollees With Alzheimer Disease and Related Dementias Before and During the Early Phase of the COVID-19 Pandemic. JAMA Neurol 2022; 79:342-348. [PMID: 35226041 PMCID: PMC8886452 DOI: 10.1001/jamaneurol.2022.0010] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE The COVID-19 pandemic fundamentally altered the delivery of health care in the United States. The associations between these COVID-19-related changes and outcomes in vulnerable patients, such as among persons with Alzheimer disease and related dementias (ADRD), are not yet well understood. OBJECTIVE To determine the association between regional rates of COVID-19 infection and excess mortality among individuals with ADRD. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study used data from beneficiaries of 100% fee-for-service Medicare Parts A and B between January 1, 2019, and December 31, 2020, to assess age- and sex-adjusted mortality rates. Participants were 53 640 888 Medicare enrollees 65 years of age or older categorized into 4 prespecified cohorts: enrollees with or without ADRD and enrollees with or without ADRD residing in nursing homes. EXPOSURES Monthly COVID-19 infection rates by hospital referral region between January and December 2020. MAIN OUTCOMES AND MEASURES Mortality rates from March through December 2020 were compared with those from March through December 2019. Excess mortality was calculated by comparing mortality rates in 2020 with rates in 2019 for specific, predetermined groups. Means were compared using t tests, and 95% CIs were estimated using the delta method. RESULTS This cross-sectional study included 26 952 752 Medicare enrollees in 2019 and 26 688 136 enrollees in 2020. In 2019, the mean (SD) age of community-dwelling beneficiaries without ADRD was 74.1 (8.8) years and with ADRD was 82.6 (8.4) years. The mean (SD) age of nursing home residents with ADRD (83.6 [8.4] years) was similar to that for patients without ADRD (79.7 [8.8] years). Among patients diagnosed as having ADRD in 2019, 63.5% were women, 2.7% were Asian, 9.2% were Black, 5.7% were Hispanic, 80.7% were White, and 1.7% were identified as other (included all races or ethnicities other than those given); the composition did not change appreciably in 2020. Compared with 2019, adjusted mortality in 2020 was 12.4% (95% CI, 12.1%-12.6%) higher among enrollees without ADRD and 25.7% (95% CI, 25.3%-26.2%) higher among all enrollees with ADRD, with even higher percentages for Asian (36.0%; 95% CI, 32.6%-39.3%), Black (36.7%; 95% CI, 35.2%-38.2%), and Hispanic (40.1%; 95% CI, 37.9%-42.3%) populations with ADRD. The hospital referral region in the lowest quintile for COVID-19 infections in 2020 had no excess mortality among enrollees without ADRD but 8.8% (95% CI, 7.5%-10.2%) higher mortality among community-dwelling enrollees with ADRD and 14.2% (95% CI, 12.2%-16.2%) higher mortality among enrollees with ADRD living in nursing homes. CONCLUSIONS AND RELEVANCE The results of this cross-sectional study suggest that the COVID-19 pandemic may be associated with excess mortality among older adults with ADRD, especially for Asian, Black, and Hispanic populations and people living in nursing homes, even in areas with low COVID-19 prevalence.
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Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, New Hampshire,The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Weiping Zhou
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Marcella Alsan
- National Bureau of Economic Research, Cambridge, Massachusetts,Harvard Kennedy School, Boston, Massachusetts
| | - Anoop Nanda
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jonathan S. Skinner
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire,National Bureau of Economic Research, Cambridge, Massachusetts
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Khan J, Ullah A, Matolo N, Waheed A, Nama N, Sharma N, Ballur K, Gilstrap L, Singh SG, Ghleilib I, White J, Cason FD. Prognostic Value of Lymph Node Ratio in Cutaneous Melanoma: A Systematic Review. Cureus 2021; 13:e19117. [PMID: 34868763 PMCID: PMC8627641 DOI: 10.7759/cureus.19117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Accepted: 10/29/2021] [Indexed: 12/23/2022] Open
Abstract
The prognosis of cutaneous melanoma (CM) is based on the histological characteristics of the primary tumor, such as Breslow depth, ulceration, and mitotic rate. The lymph node ratio (LNR) is the ratio of the involved lymph nodes (LNs) divided by the total number of LNs removed during regional LN dissection. LNR is a prognostic factor for many solid tumors; however, controversies exist regarding CM. This study sought to analyze the role of LNR as a prognostic factor in CM. An extensive literature search was conducted using PubMed, Google Scholar, Medline, and the Cochrane Central Registry of Controlled Trials from January 1966 to July 2015. The keywords included in the search were CM and inclusion of the ratio of positive to the total number of LNs as a prognostic factor. The outcomes analyzed included the number of patients with positive LNs, type of survival analysis, and results from the multivariate analysis. A total of 11 studies involving 12,011 patients with positive LNs were evaluated. No previous randomized controlled trials, meta-analyses, or systematic reviews were identified in the Cochrane database on the prognostic value of LNR in CM. The primary electronic database search resulted in 333 full-text articles. The LN location examined was the cervical, axillary, and inguinal regions in all studies except for one that examined only the inguinal region. All studies except three studied the prognostic value of the LNR as a categorical variable rather than a continuous variable. LNR was categorized as A (≤0.1), B (0.11-0.25), and C (>0.25). All studies identified LNR as an independent predictor of overall survival (OS), disease-free survival (DFS), or disease-specific survival (DSS). The hazard ratio (HR) and confidence interval (CI) associated with either DFS or OS were available only in a few studies. Moreover, pooled HR for OS was 2.08 (95% CI: 1.48 2.92), for DFS was 1.364 (95% CI: 0.92-2.02), and for DSS was 1.643 (95% CI: 0.89-3.0). The LNR provides superior prognostic stratification among patients with CM. Additional adequately powered prospective studies are needed to further define the role of LNR and be included in the staging system of CM and direct adjuvant therapy.
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Affiliation(s)
- Jaffar Khan
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Asad Ullah
- Pathology, Medical College of Georgia - Augusta University, Augusta, USA
| | - Nathaniel Matolo
- Surgical Oncology, San Joaquin General Hospital, French Camp, USA
| | - Abdul Waheed
- Surgery, San Joaquin General Hospital, French Camp, USA
| | - Noor Nama
- Obstetrics and Gynaecology, Bolan Medical College Complex Hospital Quetta, Quetta, PAK
| | | | - Kalyani Ballur
- Pathology and Laboratory Medicine, Medical College of Georgia - Augusta University, Augusta, USA
| | - Lauren Gilstrap
- Pathology, Medical College of Georgia - Augusta University, Augusta, USA
| | - Sohni G Singh
- Surgery, San Joaquin General Hospital, French Camp, USA
| | - Intisar Ghleilib
- Pathology and Laboratory Medicine, Medical College of Georgia - Augusta University, Augusta, USA
| | - Joseph White
- Pathology, Medical College of Georgia - Augusta University, Augusta, USA
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Gilstrap L, King A, Tomlin S, Austin AM. Variation in early diffusion of sacubitril/valsartan and implications for understanding novel drug diffusion. Am J Manag Care 2021; 27:524-530. [PMID: 34889576 DOI: 10.37765/ajmc.2021.88791] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES In the PARADIGM-HF trial, sacubitril/valsartan demonstrated a 20% reduction in mortality and heart failure hospitalization compared with standard angiotensin-converting enzyme inhibitor therapy. Despite this and a class I indication, drug diffusion has been much slower than anticipated. This study aims to examine the variation in early diffusion of sacubitril/valsartan and describe the factors associated with high and low rates of early use. STUDY DESIGN Annual, cross-sectional analyses between January 2016 and December 2018. METHODS We created a nationally representative cohort of Medicare fee-for-service beneficiaries with heart failure with reduced ejection fraction fully enrolled in parts A, B, and D for at least 1 year between 2016 and 2018. Sacubitril/valsartan use was determined using National Drug Codes. We generated age, sex, and race-adjusted rates of sacubitril/valsartan prescribing by hospital referral region from 2016 to 2018. We also examined the factors associated with high and low rates of early use. RESULTS Early use rates of sacubitril/valsartan were low: 1.9% in 2016, 3.3% in 2017, and 4.0% in 2018. Even after controlling for out-of-pocket co-payments, there was substantial geographic variation in early use, with most early use concentrated in the Northeast and South. CONCLUSIONS There has been substantial variation in the early diffusion of sacubitril/valsartan. In addition to drug cost, geographic prescribing patterns appear to play a major role in early drug diffusion.
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Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, 1 Medical Center Rd, Lebanon, NH 03766.
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13
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Panezai MS, Ullah A, Ballur K, Gilstrap L, Khan J, Tareen B, Kakar M, Khan J, Rasheed A, Waheed A, Ghleilib I, White J, Cason FD. Frequency of Celiac Disease in Patients With Chronic Diarrhea. Cureus 2021; 13:e20495. [PMID: 35047307 PMCID: PMC8760010 DOI: 10.7759/cureus.20495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Celiac disease (CD) is an immune-mediated disease caused by ingesting gluten-containing foods and is characterized mainly by malabsorptive diarrhea. Furthermore, distinguishing between mild disease and asymptomatic individuals is critical and necessitates a high level of clinical suspicion. Short stature, delayed puberty, bone abnormalities, neurological problems, and intestinal cancer can all be consequences of a delayed diagnosis. This study aimed to determine the prevalence of celiac disease among our community's recurrent diarrhea patients. METHODS This was a cross-sectional study aimed at determining the frequency of celiac disease in patients with chronic diarrhea. One hundred eighty-eight patients between the ages of 18 and 60 years who had chronic diarrhea lasting greater than three months were enrolled in this study. Stratification was utilized to control for modifiers. A p-value of ≤ 0.05 was considered significant. RESULTS A total of 74.5% of patients (n=140) were male, while 25.5% (n=48) were female with a mean age of 38.48±10.85 years. The average duration of celiac disease symptoms was 8.17± 3.75 months. Celiac disease was found in 12.2% (n=23) of the individuals. Also, 21% of individuals with a positive family history of CD devolved CD, compared to those without prior CD family history (p=0.01). CONCLUSIONS In individuals with chronic diarrhea for more than three months, the prevalence of celiac disease was determined to be 12.2% (n=23). There was a statistically significant difference between those with a positive family history of CD and those who did not have the condition.
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Affiliation(s)
| | - Asad Ullah
- Pathology, Medical College of Georgia, Augusta University, Augusta, USA
| | - Kalyani Ballur
- Clinical Oncology, Medical College of Georgia, Augusta University, Augusta, USA
| | - Lauren Gilstrap
- Pathology, Medical College of Georgia, Augusta University, Augusta, USA
| | - Jaffar Khan
- Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Bisma Tareen
- Internal Medicine, Bolan Medical College, Quetta, PAK
| | - Mirwais Kakar
- Gastroenterology, Bolan Medical College, Quetta, PAK
| | - Javeria Khan
- Gastroenterology, Holy Family Hospital, Rawalpindi, PAK
| | - Amna Rasheed
- Internal Medicine, Touro University California, Vallejo, USA
| | - Abdul Waheed
- Surgery, San Joaquin General Hospital, French Camp, USA
| | - Intisar Ghleilib
- Pathology and Laboratory Medicine, Medical College of Georgia, Augusta University, Augusta, USA
| | - Joseph White
- Pathology, Medical College of Georgia, Augusta University, Augusta, USA
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14
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Power JR, Alexandre J, Choudhary A, Ozbay B, Hayek S, Asnani A, Tamura Y, Aras M, Cautela J, Thuny F, Gilstrap L, Arangalage D, Ewer S, Huang S, Deswal A, Palaskas NL, Finke D, Lehman L, Ederhy S, Moslehi J, Salem JE. Electrocardiographic Manifestations of Immune Checkpoint Inhibitor Myocarditis. Circulation 2021; 144:1521-1523. [PMID: 34723640 DOI: 10.1161/circulationaha.121.055816] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John R Power
- University of California San Diego Health (J.R.P.)
| | | | | | - Benay Ozbay
- Basaksehir Cam and Sakura State Hospital, Istanbul, Turkey (B.O.)
| | - Salim Hayek
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor (S. Hayek)
| | - Aarti Asnani
- Beth Israel Deaconess Medical Center, Boston, MA (A.C., A.A.)
| | - Yuichi Tamura
- International University of Health and Welfare Mita Hospital, Tokyo, Japan (Y.T.)
| | - Mandar Aras
- University of California, San Francisco (M.A.)
| | - Jennifer Cautela
- Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France (J.C., F.T.)
| | - Franck Thuny
- Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France (J.C., F.T.)
| | | | | | - Steven Ewer
- University of Wisconsin Hospital, Madison (S. Ewer)
| | - Shi Huang
- Vanderbilt University Medical Center, Nashville, TN (S. Huang, J.M.)
| | - Anita Deswal
- University of Texas MD Anderson Cancer Center, Houston (A.D., N.L.P.)
| | | | - Daniel Finke
- University of Heidelberg, Germany (D.F., L.L.).,Assistance Publique-Hôpitaux de Paris, University of Paris, France (D.F.)
| | | | - Stephane Ederhy
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France (S. Ederhy, J.-E.S.)
| | - Javid Moslehi
- Vanderbilt University Medical Center, Nashville, TN (S. Huang, J.M.)
| | - Joe-Elie Salem
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France (S. Ederhy, J.-E.S.)
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15
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Gilstrap L, Austin AM, Gladders B, Goyal P, O'Malley J, Barnato A, Tosteson ANA, Skinner JS. Reply to: Comment on: The association between neurohormonal therapy and mortality in older adults with HFrEF. J Am Geriatr Soc 2021; 70:306-307. [PMID: 34626425 DOI: 10.1111/jgs.17488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/19/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, Lebanon, New Hampshire, USA.,Geisel School of Medicine at Dartmouth, The Dartmouth Institute, Hanover, New Hampshire, USA
| | - Andrea M Austin
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute, Hanover, New Hampshire, USA
| | - Barbara Gladders
- Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, Lebanon, New Hampshire, USA
| | - Parag Goyal
- Weill Cornell Medical Center, New York, New York, USA
| | - James O'Malley
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute, Hanover, New Hampshire, USA
| | - Amber Barnato
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute, Hanover, New Hampshire, USA
| | - Anna N A Tosteson
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute, Hanover, New Hampshire, USA
| | - Jonathan S Skinner
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute, Hanover, New Hampshire, USA
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16
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Gilstrap L, Austin AM, Gladders B, Goyal P, O'Malley AJ, Barnato A, Tosteson ANA, Skinner JS. Cover. J Am Geriatr Soc 2021. [DOI: 10.1111/jgs.17499] [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: 11/26/2022]
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17
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Gilstrap L, Wadhera RK, Austin AM, Kearing S, Joynt Maddox KE, Yeh RW. Association Between Diagnosis Code Expansion and Changes in 30-Day Risk-Adjusted Outcomes for Cardiovascular Diseases. J Am Heart Assoc 2021; 10:e020668. [PMID: 34387091 PMCID: PMC8475018 DOI: 10.1161/jaha.120.020668] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In January 2011, Centers for Medicare and Medicaid Services expanded the number of inpatient diagnosis codes from 9 to 25, which may influence comorbidity counts and risk-adjusted outcome rates for studies spanning January 2011. This study examines the association between (1) limiting versus not limiting diagnosis codes after 2011, (2) using inpatient-only versus inpatient and outpatient data, and (3) using logistic regression versus the Centers for Medicare and Medicaid Services risk-standardized methodology and changes in risk-adjusted outcomes. METHODS AND RESULTS Using 100% Medicare inpatient and outpatient files between January 2009 and December 2013, we created 2 cohorts of fee-for-service beneficiaries aged ≥65 years. The acute myocardial infarction cohort and the heart failure cohort had 578 728 and 1 595 069 hospitalizations, respectively. We calculate comorbidities using (1) inpatient-only limited diagnoses, (2) inpatient-only unlimited diagnoses, (3) inpatient and outpatient limited diagnoses, and (4) inpatient and outpatient unlimited diagnoses. Across both cohorts, International Classification of Diseases, Ninth Revision (ICD-9) diagnoses and hierarchical condition categories increased after 2011. When outpatient data were included, there were no significant differences in risk-adjusted readmission rates using logistic regression or the Centers for Medicare and Medicaid Services risk standardization. A difference-in-differences analysis of risk-adjusted readmission trends before versus after 2011 found that no significant differences between limited and unlimited models for either cohort. CONCLUSIONS For studies that span 2011, researchers should consider limiting the number of inpatient diagnosis codes to 9 and/or including outpatient data to minimize the impact of the code expansion on comorbidity counts. However, the 2011 code expansion does not appear to significantly affect risk-adjusted readmission rate estimates using either logistic or risk-standardization models or when using or excluding outpatient data.
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Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center Lebanon NH.,The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of Medicine Hanover NH
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research Beth Israel Deaconess Medical Center Boston MA.,The CardioVascular InstituteCardiovascular MedicineBeth Israel Deaconess Medical Center Boston MA
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of Medicine Hanover NH
| | - Stephen Kearing
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center Lebanon NH
| | - Karen E Joynt Maddox
- Cardiovascular Division Washington University School of Medicine in St. Louis MO.,Center for Health Economics and Policy Washington University in St. Louis MO
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research Beth Israel Deaconess Medical Center Boston MA.,The CardioVascular InstituteCardiovascular MedicineBeth Israel Deaconess Medical Center Boston MA
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18
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Gilstrap L, Austin AM, O'Malley AJ, Gladders B, Barnato AE, Tosteson A, Skinner J. Association Between Beta-Blockers and Mortality and Readmission in Older Patients with Heart Failure: an Instrumental Variable Analysis. J Gen Intern Med 2021; 36:2361-2369. [PMID: 34100232 PMCID: PMC8342662 DOI: 10.1007/s11606-021-06901-7] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 04/30/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND The demographics of heart failure are changing. The rate of growth of the "older" heart failure population, specifically those ≥ 75, has outpaced that of any other age group. These older patients were underrepresented in the early beta-blocker trials. There are several reasons, including a decreased potential for mortality benefit and increased risk of side effects, why the risk/benefit tradeoff may be different in this population. OBJECTIVE We aimed to determine the association between receipt of a beta-blocker after heart failure discharge and early mortality and readmission rates among patients with heart failure and reduced ejection fraction (HFrEF), specifically patients aged 75+. DESIGN AND PARTICIPANTS We used 100% Medicare Parts A and B and a random 40% sample of Part D to create a cohort of beneficiaries with ≥ 1 hospitalization for HFrEF between 2008 and 2016 to run an instrumental variable analysis. MAIN MEASURE The primary measure was 90-day, all-cause mortality; the secondary measure was 90-day, all-cause readmission. KEY RESULTS Using the two-stage least squared methodology, among all HFrEF patients, receipt of a beta-blocker within 30-day of discharge was associated with a - 4.35% (95% CI - 6.27 to - 2.42%, p < 0.001) decrease in 90-day mortality and a - 4.66% (95% CI - 7.40 to - 1.91%, p = 0.001) decrease in 90-day readmission rates. Even among patients ≥ 75 years old, receipt of a beta-blocker at discharge was also associated with a significant decrease in 90-day mortality, - 4.78% (95% CI - 7.19 to - 2.40%, p < 0.001) and 90-day readmissions, - 4.67% (95% CI - 7.89 to - 1.45%, p < 0.001). CONCLUSION Patients aged ≥ 75 years who receive a beta-blocker after HFrEF hospitalization have significantly lower 90-day mortality and readmission rates. The magnitude of benefit does not appear to wane with age. Absent a strong contraindication, all patients with HFrEF should attempt beta-blocker therapy at/after hospital discharge, regardless of age.
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Affiliation(s)
- Lauren Gilstrap
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. .,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Barbara Gladders
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Anna Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jonathan Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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19
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Gilstrap L, Austin AM, Gladders B, Goyal P, O'Malley AJ, Barnato A, Tosteson ANA, Skinner JS. The association between neurohormonal therapy and mortality in older adults with heart failure with reduced ejection fraction. J Am Geriatr Soc 2021; 69:2811-2820. [PMID: 34129234 DOI: 10.1111/jgs.17310] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 02/18/2021] [Revised: 05/10/2021] [Accepted: 05/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Neurohormonal therapy, which includes beta-blockers and angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACEi/ARBs), is the cornerstone of heart failure with reduced ejection fraction (HFrEF) treatment. While neurohormonal therapies have demonstrated efficacy in randomized clinical trials, older patients, which now comprise the majority of HFrEF patients, were underrepresented in those original trials. This study aimed to determine the association between short- (30 day) and long-term (1 year) mortality and the use of neurohormonal therapy in HFrEF patients, across the age spectrum. DESIGN/SETTING/PARTICIPANTS This is a population-based, retrospective, cohort study between January 2008 and December 2015. We used 100% Medicare Parts A and B and a random 40% sample of Part D to create a cohort of 295,494 fee-for-service beneficiaries with at least one hospitalization for HFrEF between 2008 and 2015. All analyses were performed between May 2019 and July 2020. EXPOSURE We used Part D data to determine exposure to beta-blocker and ACEi and ARB therapy. RESULTS We found that in 295,494 patients admitted for HFrEF between 2008 and 2015, the average age was 80 years, 54% were female and 17% were non-white. The baseline mortality rate was higher among those aged ≥85, but the mortality benefits of neurohormonal therapy were preserved across the age spectrum. Among those ≥85 years old, the hazard ratio for death within 30 days was 0.59 (95% confidence interval [CI] 0.56-0.62; p < 0.001) for beta-blockers and 0.47 (95% CI 0.44-0.49; p < 0.001) for ACEi/ARBs. The hazard ratio for death within 1 year was 0.37-0.56 (95% CI 0.35-0.58; p < 0.001) for beta-blockers and 0.38-0.53 (95% CI 0.37-0.55; p < 0.001) for ACEi/ARB. CONCLUSION At a population level, neurohormonal therapy was associated with lower short- and long-term mortality across the age spectrum.
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Affiliation(s)
- Lauren Gilstrap
- Heart and Vascular Center, Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,The Dartmouth Institute, Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Andrea M Austin
- The Dartmouth Institute, Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Barbara Gladders
- Heart and Vascular Center, Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Parag Goyal
- Division of Cardiology, Weill Cornell Medical Center, New York, New York, USA
| | - A James O'Malley
- The Dartmouth Institute, Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Amber Barnato
- The Dartmouth Institute, Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Anna N A Tosteson
- The Dartmouth Institute, Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Jonathan S Skinner
- The Dartmouth Institute, Geisel School of Medicine, Hanover, New Hampshire, USA
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20
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Power J, Meijers W, Fenioux C, Tamura Y, Asnani A, Alexandre J, Cautela J, Aras M, Lehmann L, Perl M, Narezkina A, Gilstrap L, Ederhy S, Moslehi J, Salem J. Predictors of steroid-refractory immune checkpoint inhibitor associated myocarditis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3272] [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: 11/14/2022] Open
Abstract
Abstract
Background/Introduction
Immune checkpoint inhibitor (ICI)-associated myocarditis has a high mortality rate of approximately 50%. Clinical decompensation often occurs despite first-line treatment with corticosteroids. Factors associated with steroid failure are currently unknown.
Purpose
To identify predictors of steroid failure in patients with ICI-associated myocarditis.
Methods
We developed a web-based registry to collect and study 157 cases with clinical manifestations of ICI-associated myocarditis across 16 countries. Steroid failure was defined as patients who were escalated to immunomodulators after ≥1mg/kg daily dose of prednisone or had in-hospital death due to myocarditis despite ≥1mg/kg daily dose of prednisone. Steroid response was defined as all other patients treated with steroids without escalation to immunomodulators and without death due to myocarditis. A multivariate logistic model accounting for age and sex was used to predict association with steroid failure.
Results
Compared to steroid responsive cases, steroid failure was more likely to result in fulminant myocarditis (56.7% vs 19.6%, OR=5.37 [2.62–10.98] p<0.001) and all-cause in-hospital mortality (49.1% vs 12.9%, OR=6.50 [2.86–14.73] p<0.001) with shorter time from presentation to death (27.5 vs 43.0 days HR: 2.56 [1.45–4.50] p=0.001). When adjusting for age and sex, cases were more likely to be steroid-refractory if they were female (46.7% vs 30.1%, OR=2.77 [1.31–5.85] p=0.007), higher body mass index (27.2 vs 22.0, OR=1.09 [1.01–1.18] p=0.012), had higher intake creatine kinase (2800.5 vs 528.0 U/L, OR=1.48 [1.14–1.90] p=0.003) had higher intake troponin T (1.40 vs 0.25 ng/mL OR=1.63 [1.00–2.64] p=0.049), or had one or more concomitant non-cardiac immune-related adverse event (90.0% vs 74.2%, OR=3.10 [1.14–8.25] p<0.026). The only immune-related adverse events independently associated with steroid failure in myocarditis were myasthenia gravis-like syndrome (26.7% vs 8.2%, OR=3.84 [1.47–10.10] p=0.006) and myositis (45.0% vs 24.7%, OR=2.38 [1.16–4.92] p=0.018). Steroid failure was not significantly associated with cardiovascular or autoimmune history but was associated with a history of thymoma (12.0% vs 2.6%, OR=18.86 [0.10–356.7] p=0.05)
Conclusion(s)
Features such as female sex, high body mass index, and pre-existing thymoma as well as findings of elevated cardiac biomarkers and other non-cardiac immune-related adverse events – particularly myositis and myasthenia gravis-like syndrome – may represent a steroid-refractory phenotype of ICI-associated myocarditis. These results suggest that a multidisciplinary approach to diagnosing concomitant non-cardiac immune related adverse events is key to risk-stratifying ICI-associated myocarditis.
Forrest Plot
Funding Acknowledgement
Type of funding source: Private hospital(s). Main funding source(s): National Institutes of Health
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Affiliation(s)
- J Power
- Vanderbilt University Medical Center, Nashville, United States of America
| | - W Meijers
- Vanderbilt University Medical Center, Nashville, United States of America
| | | | - Y Tamura
- International University of Health and Welfare, Narita, Japan
| | - A Asnani
- Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, United States of America
| | | | - J Cautela
- Hospital Nord of Marseille, Marseille, France
| | - M Aras
- University of California San Francisco, San Francisco, United States of America
| | - L Lehmann
- University of Heidelberg, Heidelberg, Germany
| | - M Perl
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - A Narezkina
- University of California San Diego, San Diego, United States of America
| | - L Gilstrap
- Dartmouth-Hitchcock Health, Lebanon, United States of America
| | - S Ederhy
- Sorbonne University, Paris, France
| | - J Moslehi
- Vanderbilt University Medical Center, Nashville, United States of America
| | - J Salem
- Sorbonne University, Paris, France
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Abstract
Background:
Atrial fibrillation (AF) accounts for substantial resource utilization that is expected to increase as the US population ages. Management strategies for AF vary widely based on patient preference, physician specialty training, available resources, and other factors, but the impact that geography has on treatment variations for AF is unknown.
Objective:
We seek to evaluate differences in AF patient characteristics and management between urban and non-urban Medicare beneficiaries.
Methods:
Our cohort included all Medicare fee-for-service beneficiaries meeting the CMS chronic conditions warehouse definition of AF from 2013-2017. Beneficiaries were designated as urban and non-urban by rural-urban commuting area codes. AF procedures were tabulated based on CPT codes. The use of AF related medications was tabulated based on prescriptions for drugs of interest in Medicare Part D.
Results:
During our period of interest, Medicare AF patients were average age 79 yrs, and 52% were female. Urban patients were more likely to be black and have chronic kidney disease, diabetes, and ischemic heart disease. The average CHADS2VA2SC score was high (4.90 SD 1.71) and not meaningfully different between urban and non-urban groups. Most advanced interventions for AF increased over time driven mostly by increases in AF ablation (Figure). However, compared with non-urban patients, urban patients were more likely to undergo AF ablation (1.81 vs 1.42%, p<0.001), Watchman implantation (0.15 vs 0.11%, p<0.001), and cardioversion (0.06 vs 0.05%, p=0.015). Non-urban patients were more likely to be prescribed amiodarone (7.08 vs 6.09%, p=0.002) and warfarin (8.84 vs 7.40%, p<0.001) compared with urban patients and were less likely to be prescribed a direct oral anticoagulant.
Conclusions:
Despite urban and non-urban Medicare patients with AF being similar with regard to demographic and clinical characteristics, treatment of AF varied in important ways between these groups. In general, urban patients were more likely to receive interventional care for AF which, in some cases, has known associated benefits with regard to quality of life, morbidity, and mortality. Further work is needed to understand differences in outcomes between these two groups and to develop policy solutions to reduce treatment disparities.
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Abstract
Background:
Immune checkpoint inhibitors (ICIs), including programmed cell death-1 (PD-1), programmed cell death ligand-1 (PD-L1) and cytotoxic lymphocyte antigen-4 (CTLA-4) inhibitors, are increasingly used in treatment of advanced stage cancers due to a well-established mortality benefit. ICI therapy is associated with immune mediated toxicity which may impact any organ system. Cardiovascular toxicities are rare based on existing data, but associated with high mortality rates.
Objectives:
The aim of this study is to determine whether preexisting cardiac conditions and/or cardiac therapies are associated with an increased or decreased risk of developing cardiotoxicity after ICI exposure.
Methods:
All patients treated with ICI therapy from March 2011 through October 2019 at our institution were identified. Demographic information, treatment dates, pre-treatment cardiac conditions and comorbidities, cancer types, pre-treatment cardiac biomarkers, and pre-treatment cardio-protective medication use were determined for each patient. New cardiac diagnoses after ICI exposure were identified in the medical record. Multivariate logistic regression was used determine the association between preexisting cardiac conditions and/or cardiac therapies and the development of cardiotoxicity after ICI exposure.
Results:
There were 902 patients identified with 1071 ICI exposures. The majority of exposures were to a PD-1 inhibitor (70%), with the most common drugs being pembrolizumab (42.8%) and nivolumab (26.5%). Eighty-nine new cardiac diagnoses were coded after initiation of ICI therapy. Sixteen events occurred within 30 days of initial exposure to an ICI and likely represent new cases of immune checkpoint inhibitor associated cardiotoxicity (incidence 1.5%). Of these events, one was confirmed as myocarditis, seven were heart failure without confirmation of myocarditis, three were arrhythmia, one was pericarditis, three were myocardial infarction and one was ventricular tachyarrhythmia/sudden cardiac death, without confirmed myocarditis or heart failure. There was an additional case of myocarditis identified within 90 days of initial exposure to ICI therapy, and a third case identified 115 days following exposure. All three patients who developed myocarditis died, consistent with the known high mortality rate of ICI associated myocarditis. One of the patients who developed myocarditis received pembrolizumab, one nivolumab and one cemiplimab (all PD-1 inhibitors). A history of heart failure increased the odds of developing a cardiac toxicity by 2.3 fold (95% CI 1.4 to 3.3, p<0.001) and prior beta-blocker exposure decreased the odds by 1.8 fold (95% -2.9 to -0.7, p=0.002).
Conclusion:
A history of heart failure is associated with an increased odds of developing cardiotoxicity after ICI exposure while prior beta blocker exposure appears to be protective.
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Gilstrap L, Skinner JS, Gladders B, O'Malley AJ, Barnato AE, Tosteson ANA, Austin AM. Opportunities and Challenges of Claims-Based Quality Assessment: The Case of Postdischarge β-Blocker Treatment in Patients With Heart Failure With Reduced Ejection Fraction. Circ Cardiovasc Qual Outcomes 2020; 13:e006180. [PMID: 32148101 DOI: 10.1161/circoutcomes.119.006180] [Citation(s) in RCA: 4] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND To combat the high cost and increasing burden of quality reporting, the Medicare Payment Advisory (MedPAC) has recommended using claims data wherever possible to measure clinical quality. In this article, we use a cohort of Medicare beneficiaries with heart failure with reduced ejection fraction and existing quality metrics to explore the impact of changes in quality metric methodology on measured quality performance, the association with patient outcomes, and hospital rankings. METHODS AND RESULTS We used 100% Medicare Parts A and B and a random 40% sample of Part D from 2008 to 2015 to create (1) a cohort of 295 494 fee-for-service beneficiaries with ≥1 hospitalization for heart failure with reduced ejection fraction and (2) a cohort of 1079 hospitals with ≥11 heart failure with reduced ejection fraction admissions in 2014 and 2015. We used Part D data to calculate β-blocker use after discharge and β-blocker use over time. We then varied the quality metric methodologies to explore the impact on measured performance. We then used multivariable time-to-event analyses to explore the impact of metric methodology on the association between quality performance and patient outcomes and Kendall's Tau to describe impact of quality metric methodology on hospital rankings. We found that quality metric methodology had a significant impact on measured quality performance. The association between quality performance and readmissions was sensitive to changes in methodology but the association with 1-year mortality was not. Changes in quality metric methodology also had a substantial impact on hospital quality rankings. CONCLUSIONS This article highlights how small changes in quality metric methodology can have a significant impact on measured quality performance, the association between quality performance and utilization-based outcomes, and hospital rankings. These findings highlight the need for standardized quality metric methodologies, better case-mix adjustment and cast further doubt on the use of utilization-based outcomes as quality metrics in chronic diseases.
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Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH (L.G., B.G.).,The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH.,Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (L.G.)
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Barbara Gladders
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH (L.G., B.G.)
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH.,Department of Biomedical Data Science (A.J.O.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
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Unlu O, Kennel P, Schumacher R, Gilstrap L, Maurer MS, Rich MW, Makam A, Goyal P. Heart Failure Guidelines are Evidence-Based, but are They Patient-Centered? J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.193] [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: 11/29/2022]
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Gilstrap L, Aaron M, Wild R, Beaulieu N, Chernew M, Landrum MB. Abstract 224: Recent Trends in Coronary Artery Disease Quality Performance and Implications for Clinical Practice in the Era of Alternative Payment Models. Circ Cardiovasc Qual Outcomes 2019. [DOI: 10.1161/hcq.12.suppl_1.224] [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:
In light of recent shifts away from fee-for-service and toward alternative payment models (APM), national trends in quality performance for common cardiac conditions, such as CAD, are important for identifying areas for quality improvement and also for determining physician/health system reimbursement.
Methods:
Using Medicare data from 2010-2013, we created a cohort of patients with CAD using a combination of chronic condition warehouse (CCW) flags, ICD-9 and CPT codes. We the determined national performance trends for the 2011 ACC/AHA CAD performance measures. For drug use metrics, we used 80% of days covered after the index event as the threshold.
Results:
From 2010-2013, performance trends for testing (annual LDL) and post-MI metrics (beta blocker use, P2Y12 use and cardiac rehab) were flat (p=ns). Among patients with CAD and another comorbidity such as heart failure or diabetes, neurohormonal therapy use increased (p<0.001,
Figure 1
).
Conclusion:
The rate of neurohormonal therapy use in patients with CAD and another comorbidity improved while testing and post-MI performance in patients with CAD alone changed little. The reasons for this and may relate to an increased emphasis on complex, costly patients in APMs. Whether these trends impact longer-term patient outcomes should be explored.
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Zeitler E, Gilstrap L, Slotwiner D, Al-Khatib S. COVERAGE WITH EVIDENCE DEVELOPMENT: WHERE ARE WE NOW? J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)33616-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Gilstrap L, Chernew M, Nguyen C, Alam S, Bai B, Landrum MB. Abstract 35: Trends in Statin Use and Adherence and the Impact of the 2013 Cholesterol Guidelines. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.35] [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:
In 2013, the ACC/AHA updated the cholesterol treatment guidelines. At the time, it was estimated that an additional 13 million Americans would quality for statin therapy. To date, the real-world implications of this guideline change have not been well studied. This study aims to better understand trends in statin use and adherence, by gender, and the impact of guideline change.
Methods:
This is a retrospective, observational study using medical and pharmacy claims from 2009 to 2014 from a large, national, commercial insurer. Considering all beneficiaries aged 18-65 with ≥1 year of continuous enrollment, we created annual cross sectional populations of statin-eligible patients and divided them into 3 statin benefit groups (SBG). In descending order of risk, the groups were: (1) atherosclerotic cardiovascular disease (ASCVD); (2) diabetes and (3) hyperlipidemia. Patients were assigned to the highest risk group that they qualified for.
Results:
Statin use rates among those with ASCVD increased until 2012 and then plateaued
(Figure 1a
). Use rates among those with diabetes, were flat until 2011 and then increased. Use rates among those with hyperlipidemia steadily rose from 2009-2014. Statin adherence rates among those with ASCVD increased from 2009-2014 (
Figure 1b
). Adherence rates among those with diabetes, decreased from 2009-2011 and then rose significantly from 2011-2014. Adherence rates among those with hyperlipidemia also rose steadily from 2009-2014. The most significant gender gap in treatment, for both use and adherence, was between men and women with ASCVD. There was with little change in this treatment gap, in any risk group, over the time period observed.
Conclusion:
The 2013 cholesterol guidelines have not yet had a significant effect on statin use or adherence. Recently improving trends in statin use and adherence, especially among patients with diabetes, appear to predate the 2013 guideline change. A significant gender gap in statin treatment remains, especially among those in the highest risk group.
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Roberts ET, Hatfield LA, McWilliams JM, Chernew ME, Done N, Gerovich S, Gilstrap L, Mehrotra A. Changes In Hospital Utilization Three Years Into Maryland's Global Budget Program For Rural Hospitals. Health Aff (Millwood) 2018; 37:644-653. [PMID: 29608370 PMCID: PMC5993431 DOI: 10.1377/hlthaff.2018.0112] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In a substantial shift in payment policy, the State of Maryland implemented a global budget program for acute care hospitals in 2010. Goals of the program include controlling hospital use and spending. Eight rural hospitals entered the program in 2010, while urban and suburban hospitals joined in 2014. Prior analyses, which focused on urban and suburban hospitals, did not find consistent evidence that Maryland's program had contributed to changes in hospital use after two years. However, these studies were limited by short follow-up periods, may have failed to isolate impacts of Maryland's payment change from other state trends, and had limited generalizability to rural settings. To understand the effects of Maryland's global budget program on rural hospitals, we compared changes in hospital use among Medicare beneficiaries served by affected rural hospitals versus an in-state control population from before to after 2010. By 2013-three years after the rural program began-there were no differential changes in acute hospital use or price-standardized hospital spending among beneficiaries served by the affected hospitals, versus the within-state control group. Our results suggest that among Medicare beneficiaries, global budgets in rural Maryland hospitals did not reduce hospital use or price-standardized spending as policy makers had anticipated.
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Affiliation(s)
- Eric T Roberts
- Eric T. Roberts ( ) is an assistant professor in the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, in Pennsylvania
| | - Laura A Hatfield
- Laura A. Hatfield is an associate professor in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - J Michael McWilliams
- J. Michael McWilliams is the Warren Alpert Foundation Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School
| | - Michael E Chernew
- Michael E. Chernew is the Leonard D. Schaeffer Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School
| | - Nicolae Done
- Nicolae Done is a postdoctoral fellow at Boston University School of Medicine
| | - Sule Gerovich
- Sule Gerovich is a senior researcher at Mathematica Policy Research in Baltimore, Maryland
| | - Lauren Gilstrap
- Lauren Gilstrap is a research fellow in the Department of Health Care Policy, Harvard Medical School
| | - Ateev Mehrotra
- Ateev Mehrotra is an associate professor in the Department of Health Care Policy, Harvard Medical School
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Stevenson LW, Schneiweiss S, Gilstrap L. Propensity to match or mismatch patients and therapies? Eur J Heart Fail 2017; 20:355-358. [DOI: 10.1002/ejhf.983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/02/2017] [Accepted: 08/04/2017] [Indexed: 11/11/2022] Open
Affiliation(s)
| | | | - Lauren Gilstrap
- Cardiovascular Division; Brigham and Women's Hospital; Boston MA USA
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Niehaus E, Tabtabai S, Sarswat N, Stone JR, Gilstrap L, Maurer M, Witteles R, Estep J, Baran D, Zucker M, Feltrin G, Seldin D, Semigran M. NEED FOR RENAL REPLACEMENT THERAPY AFTER CARDIAC TRANSPLANTATION IN PATIENTS WITH AL AMYLOIDOSIS IS ASSOCIATED WITH POOR SURVIVAL. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60895-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sarswat N, Niehaus E, Tabtabai S, Stone J, Gilstrap L, Mauer M, Witteles R, Estep J, Baran D, Zucker M, Guiseppe F, Seldin D, Semigran M. Pre-transplant Chemotherapy Does Not Affect Cardiac Transplant Survival in Light-Chain Amyloid Patients. J Heart Lung Transplant 2014. [DOI: 10.1016/j.healun.2014.01.171] [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: 11/29/2022] Open
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Fletcher GF, Berra K, Fletcher BJ, Gilstrap L, Wood MJ. The Integrated Team Approach to the Care of the Patient with Cardiovascular Disease. Curr Probl Cardiol 2012; 37:369-97. [DOI: 10.1016/j.cpcardiol.2012.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Gilstrap L, Fernandez-Golarz C, Cantu S, Rosenfield H, Scott N, Wood M. THE CHALLENGE OF CARDIAC PREVENTION IN AN ACADEMIC MEDICAL CENTER. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)61189-3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Roberts S, Bawdon R, Sobhi S, Dax J, Gilstrap L, Wimberly D. The maternal-fetal transfer of bisheteroypiperazine (U-87201-E) in the ex vivo human placenta. Am J Obstet Gynecol 1995; 172:88-91. [PMID: 7531400 DOI: 10.1016/0002-9378(95)90089-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The purpose of this study was to elucidate the maternal-fetal transfer of bisheteroypiperazine (U-87201-E), a nonnucleoside reverse transcriptase inhibitor of human immunodeficiency virus-1. STUDY DESIGN Placentas from normal term deliveries were used in this study to determine the maternal-fetal transfer of bisheteroypiperazine. The studies were conducted at several concentrations with the circulation either open-open or closed-closed. RESULTS In this study we determined that the clearance index of bisheteroypiperazine was 0.72 +/- 0.17 at maternal concentrations of 1.0 and 20.0 micrograms/ml. This is at least twice the clearance index of 3'-azido-2',3'-dideoxythymidine and more than five times greater than that of 2',3'-dideoxyinosine. CONCLUSIONS Bisheteroypiperazine crosses the maternal-fetal membranes by simple diffusion, in some instances almost equivalent to the reference compound antipyrine. Placental tissue concentrations were equivalent at all maternal concentrations, suggesting saturation. This high rate of maternal-fetal transfer suggests that it may be an effective prophylactic drug for fetuses of human immunodeficiency virus-infected mothers.
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Affiliation(s)
- S Roberts
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center
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