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Solomon MD, Demaria A, Nishimura R, Philip F. Discordant Aortic Stenosis Parameters in Real-World Data: Do Not Ignore a Low Aortic Valve Area. J Am Coll Cardiol 2024; 83:e153. [PMID: 38599723 DOI: 10.1016/j.jacc.2023.12.041] [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] [Received: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 04/12/2024]
Affiliation(s)
- Matthew D Solomon
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA; Kaiser Permanente Oakland Medical Center, Oakland, California, USA.
| | - Anthony Demaria
- University of California at San Diego, San Diego, California, USA
| | | | - Femi Philip
- Kaiser Permanente Roseville Medical Center, Roseville, California, USA
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2
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Solomon MD, Liang DH, Miller DC. Fate of the unoperated ascending thoracic aortic aneurysm-patient selection and the importance of the denominator. Eur Heart J 2024; 45:733-734. [PMID: 38087827 DOI: 10.1093/eurheartj/ehad794] [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: 03/03/2024] Open
Affiliation(s)
- Matthew D Solomon
- Department of Cardiology, Kaiser Permanente Northern California, 3600 Broadway, Oakland, CA 94611, USA
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94611, USA
| | - David H Liang
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
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3
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Solomon MD, Tabada G, Sung SH, Allen A, Mishell JM, Rassi AN, McNulty E, Philip F, Lange DC, Ambrosy AP, Zaroff JG, Krishnaswami A, Lee C, DeMaria A, Nishimura R, Go AS. Physician assessment of aortic stenosis severity, quantitative parameters, and long-term outcomes: Results from the KP-VALVE project. Am Heart J 2023; 266:32-47. [PMID: 37553045 DOI: 10.1016/j.ahj.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 05/22/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Contemporary outcomes for aortic stenosis (AS) and the association between physician-assessed AS severity and quantitative parameters is poorly understood. We aimed to evaluate AS natural history, compare outcomes for physicians' AS assessment vs. quantitative parameters, and identify AS parameters with the most explanatory power. METHODS We ascertained physician-assessed AS severity, echocardiographic parameters, and clinical data for 546,769 patients from 2008-2018, examined multivariable associations of physician-assessed AS severity and number of quantitative severe AS parameters with death, cardiovascular hospitalization, and aortic valve replacement, and estimated the relative contribution of different quantitative AS parameters on outcomes. RESULTS Among 49,604 AS patients (mean [SD] age 77 [11] years), 17.6% had moderate, 3.6% moderate-severe, and 9.4% severe AS. During median 3.7 [IQR 1.7-6.8] years, physician-assessed AS severity strongly correlated with outcomes, with moderate AS patients tracking closest to mild AS, and moderate-to-severe AS patients more comparable to severe AS. Although the number of quantitative severe AS parameters strongly predicted outcomes (adjusted HR [95% CI] for death 1.40 [1.34-1.46], 1.70 [1.56-1.85], and 1.78 [1.63-1.94] for 1, 2, and 3 parameters, respectively), aortic valve area <1.0 cm2 was the most frequent severe AS parameter, explained the largest relative contribution (67%), and was common in patients classified as moderate (21%) or moderate-severe (56%) AS. CONCLUSIONS Physician-assessed AS severity predicts outcomes, with cumulative effects for each severe AS parameter. Moderate AS includes a wide spectrum of patients, with discordant AVA <1.0 cm2 being both common and predictive. Better identification of non-classical severe AS phenotypes may improve outcomes.
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Affiliation(s)
- Matthew D Solomon
- Kaiser Permanente Northern California Division of Research, Oakland, CA; Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA.
| | - Grace Tabada
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Sue Hee Sung
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Amanda Allen
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Jacob M Mishell
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Andrew N Rassi
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Edward McNulty
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Femi Philip
- Department of Cardiology, Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - David C Lange
- Department of Cardiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Andrew P Ambrosy
- Kaiser Permanente Northern California Division of Research, Oakland, CA; Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Jonathan G Zaroff
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Ashok Krishnaswami
- Department of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, CA
| | - Catherine Lee
- Kaiser Permanente Northern California Division of Research, Oakland, CA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Anthony DeMaria
- Department of Cardiology, University of California at San Diego, San Diego, CA
| | - Rick Nishimura
- Department of Cardiology, The Mayo Clinic, Rochester, MN
| | - Alan S Go
- Kaiser Permanente Northern California Division of Research, Oakland, CA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, CA
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4
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Ambrosy AP, Go AS, Leong TK, Garcia EA, Chang AJ, Slade JJ, McNulty EJ, Mishell JM, Rassi AN, Ku IA, Lange DC, Philip F, Galper BZ, Berry N, Solomon MD. Temporal trends in the prevalence and severity of aortic stenosis within a contemporary and diverse community-based cohort. Int J Cardiol 2023; 384:107-111. [PMID: 37119944 DOI: 10.1016/j.ijcard.2023.04.047] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Data on the epidemiology of aortic stenosis (AS) are primarily derived from single center experiences and administrative claims data that do not delineate by degree of disease severity. METHODS An observational cohort study of adults with echocardiographic AS was conducted January 1st, 2013-December 31st, 2019 at an integrated health system. The presence/grade of AS was based on physician interpretation of echocardiograms. RESULTS A total of 66,992 echocardiogram reports for 37,228 individuals were identified. The mean ± standard deviation (SD) age was 77.5 ± 10.5, 50.5% (N = 18,816) were women, and 67.2% (N = 25,016) were non-Hispanic whites. The age-standardized AS prevalence increased from 589 (95% Confidence Interval [CI] 580-598) to 754 (95% CI 744-764) cases per 100,000 during the study period. The age-standardized AS prevalences were similar in magnitude among non-Hispanic whites (820, 95% CI 806-834), non-Hispanic blacks (728, 95% CI 687-769), and Hispanics (789, 95% CI 759-819) and substantially lower for Asian/Pacific Islanders (511, 95% CI 489-533). Finally, the distribution of AS by degree of severity remained relatively unchanged over time. CONCLUSIONS AND RELEVANCE The population prevalence of AS has grown considerably over a short timeframe although the distribution of AS severity has remained stable.
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Affiliation(s)
- Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA; Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA; Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Thomas K Leong
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Elisha A Garcia
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Alex J Chang
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Justin J Slade
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Edward J McNulty
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Jacob M Mishell
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Andrew N Rassi
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Ivy A Ku
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - David C Lange
- Department of Cardiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Femi Philip
- Department of Cardiology, Kaiser Permanente Sacramento Medical Center, Sacramento, CA, USA
| | - Benjamin Z Galper
- Department of Cardiology, Mid-Atlantic Permanente Medical Group, McLean, VA, USA
| | - Natalia Berry
- Department of Cardiology, Mid-Atlantic Permanente Medical Group, McLean, VA, USA
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
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Vinson DR, Rauchwerger AS, Karadi CA, Shan J, Warton EM, Zhang JY, Ballard DW, Mark DG, Hofmann ER, Cotton DM, Durant EJ, Lin JS, Sax DR, Poth LS, Gamboa SH, Ghiya MS, Kene MV, Ganapathy A, Whiteley PM, Bouvet SC, Babakhanian L, Kwok EW, Solomon MD, Go AS, Reed ME. Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial). Trials 2023; 24:246. [PMID: 37004068 PMCID: PMC10064588 DOI: 10.1186/s13063-023-07230-2] [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: 07/11/2022] [Accepted: 03/08/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION ClinicalTrials.gov NCT05009225 . Registered on 17 August 2021.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, USA.
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Chandu A Karadi
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Judy Shan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jennifer Y Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Erik R Hofmann
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Dale M Cotton
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Edward J Durant
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Modesto Medical Center, Modesto, CA, USA
| | - James S Lin
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Dana R Sax
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Luke S Poth
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | - Stephen H Gamboa
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Meena S Ghiya
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South San Francisco Medical Center, San Francisco, CA, USA
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Leandro Medical Center, San Leandro, CA, USA
| | - Anuradha Ganapathy
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Patrick M Whiteley
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Sean C Bouvet
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | | | | | - Matthew D Solomon
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Cardiology, Oakland Medical Center, Oakland, CA, USA
| | - Alan S Go
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Solomon MD, Liang DH, Go AS. Natural History and Intervention Thresholds for Ascending Thoracic Aortic Aneurysm-Not an Easy Nut to Crack-Reply. JAMA Cardiol 2023; 8:512-513. [PMID: 36920363 DOI: 10.1001/jamacardio.2023.0156] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Affiliation(s)
- Matthew D Solomon
- Kaiser Permanente Oakland Medical Center, Oakland, California.,Kaiser Permanente Division of Research, Oakland, California
| | | | - Alan S Go
- Kaiser Permanente Division of Research, Oakland, California
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Slade JJ, Ambrosy AP, Leong TK, Sung SH, Garcia EA, Ku IA, Solomon MD, McNulty EJ, Rassi AN, Lange DC, Philip F, Go AS, Mishell JM. Outcomes of Adults with Severe Aortic Stenosis Undergoing Urgent or Emergent vs. Elective Transcatheter Aortic Valve Replacement Within an Integrated Health Care Delivery System. Structural Heart 2023. [PMID: 37520133 PMCID: PMC10382976 DOI: 10.1016/j.shj.2023.100166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Background Transcatheter aortic valve replacement (TAVR) may be used to urgently or emergently treat severe aortic stenosis, but outcomes for this high-risk population have not been well-characterized. We sought to describe the incidence, clinical characteristics, and outcomes of patients undergoing urgent or emergent vs. elective TAVR. Methods We identified all adults who received TAVR for primary aortic stenosis between 2013 and 2019 within an integrated health care delivery system in Northern California. Elective or urgent/emergent procedure status was based on standard Society of Thoracic Surgeons definitions. Data were obtained from electronic health records, the Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry, and state/national reporting databases. Logistic regression and Cox proportional hazard models were performed. Results Among 1564 eligible adults that underwent TAVR, 81 (5.2%) were classified as urgent/emergent. These patients were more likely to have heart failure (63.0% vs. 47.4%), reduced left ventricular ejection fraction (21.0% vs. 11.8%), or a prior aortic valve balloon valvuloplasty (13.6% vs. 5.0%) and experienced higher unadjusted rates of 30-day and 1-year morbidity and mortality. Urgent/emergent TAVR status was independently associated with non-improved quality of life at 30-days (hazard ratio, 4.87; p < 0.01) and acute kidney injury within 1-year post-TAVR (hazard ratio, 2.11; p = 0.01). There was not a significant difference in adjusted 1-year mortality with urgent/emergent TAVR. Conclusions Urgent/emergent TAVR status was uncommon and associated with high-risk clinical features and higher unadjusted rates of short- and long-term morbidity and mortality. Procedure status may be useful to identify patients less likely to experience significant short term improvement in health-related quality of life post-TAVR.
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Solomon MD, Tabada GH, Sung SH, Allen A, Mishell JM, Rassi AN, McNulty EJ, Philip F, Lange DC, Ambrosy AP, Zaroff JG, Krishnaswami A, Lee C, DeMaria AN, Go AS. PHYSICIAN ASSESSMENT OF AORTIC STENOSIS SEVERITY AND LONG-TERM OUTCOMES: RESULTS FROM THE KP-VALVE PROJECT. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02393-8] [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: 03/07/2023]
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Solomon MD, Go AS, Tabada G, Allen A, Garcia E, Philip F, DeMaria AN, Lee C. QUANTITATIVE AORTIC STENOSIS PARAMETERS AND LONG-TERM OUTCOMES: RESULTS FROM THE KP-VALVE PROJECT. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02436-1] [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: 03/06/2023]
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Yap EN, Dusendang JR, Ng KP, Keny HV, Webb CA, Weyker PD, Thoma MS, Solomon MD, Herrinton LJ. Risk of cardiac events after elective versus urgent or emergent noncardiac surgery: Implications for quality measurement and improvement. J Clin Anesth 2023; 84:110994. [PMID: 36356394 DOI: 10.1016/j.jclinane.2022.110994] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/10/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Patient populations differ for elective vs urgent and emergent surgery. The effect of this difference on surgical outcome is not well understood and may be important for improving surgical safety. Our primary hypothesis was that there is an association of surgical acuity with risk of postoperative cardiac events. Secondarily, we examined elective vs urgent and emergent patients separately to understand patient characteristics that are associated with postoperative cardiac events. METHODS We performed a retrospective cohort study of patients ≥65 years undergoing noncardiac elective or urgent/emergent surgery. Logistic regression estimated the association of surgical acuity with a postoperative cardiac event, which was defined as myocardial infarction or cardiac arrest within 30 days of surgery. For the secondary analysis, we modeled the outcome after stratifying by acuity. RESULTS The study included 161,177 patients with 1014 cardiac events. The unadjusted risk of a postoperative cardiac event was 3.2 per 1000 among elective patients and 28.7 per 1000 among urgent and emergent patients (adjusted odds ratio 4.10, 95% confidence interval 3.56-4.72). After adjustment, increased age, higher baseline cardiac risk, peripheral vascular disease, hypertension, worse American Society of Anesthesiologist (ASA) physical classification, and longer operative time were associated with a postoperative cardiac event. Higher baseline cardiac risk was more strongly associated with postoperative cardiac events in elective patients. In contrast, worse ASA physical classification was more strongly associated with postoperative cardiac events in urgent and emergent patients. Black patients had higher odds of a postoperative cardiac event only in urgent and emergent patients compared to White patients. CONCLUSIONS Quality measurement and improvement to address postoperative cardiac risk should consider patients based on surgical acuity.
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Affiliation(s)
- Edward N Yap
- Department of Anesthesia, The Permanente Medical Group, USA; Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA.
| | - Jennifer R Dusendang
- Division of Research, Kaiser Permanente Northern California, The Permanente Medical Group, USA
| | - Kevin P Ng
- Department of Anesthesia, The Permanente Medical Group, USA
| | - Hemant V Keny
- Department of Surgery, The Permanente Medical Group, USA
| | - Christopher A Webb
- Department of Anesthesia, The Permanente Medical Group, USA; Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA
| | - Paul D Weyker
- Department of Anesthesia, The Permanente Medical Group, USA
| | - Mark S Thoma
- Department of Anesthesia, The Permanente Medical Group, USA; Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, The Permanente Medical Group, USA; Department of Cardiology, The Permanente Medical Group, USA
| | - Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, The Permanente Medical Group, USA
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11
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Yap EN, Dusendang JR, Ng KP, Keny HV, Solomon MD, Cohn BR, Corley DA, Herrinton LJ. Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery. Popul Health Manag 2022; 25:712-720. [PMID: 36095257 DOI: 10.1089/pop.2022.0147] [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] [Indexed: 12/31/2022] Open
Abstract
Limited sample size, incomplete measures, and inadequate risk adjustment adversely influence accurate health care quality measurements, surgical quality measurements, and accurate comparisons among hospitals. Since these measures are linked to resources for quality improvement and reimbursement, improving the accuracy of measurement has substantial implications for patients, clinicians, hospital administrators, insurers, and purchasers. The team examined risk-adjusted differences of postoperative cardiac events among 20 geographically dispersed, community-based medical centers within an integrated health care system and compared it with the National Surgical Quality Improvement Program (NSQIP) hospital-specific differences. The exposure included the hospital at which patients received noncardiac surgical care, with stratification of patients by the acuity of surgery (elective vs. urgent/emergent). Among 157,075 surgery patients, the unadjusted risk of cardiac event per 1000 ranged among hospitals from 2.1 to 6.9 for elective surgery and from 10.3 to 44.5 for urgent/emergent surgery. Across the 20 hospitals, hospital rankings estimated in the present analysis differed significantly from ranking reported by NSQIP (P for difference: elective, P = 0.0001; urgent/emergent, P < 0.0001) with significantly and substantially lower variation after risk adjustment. Current surgical quality measures may not adequately account for limitations of sample size, data capture, adequate risk adjustment, and surgical acuity in a given hospital, particularly for rare outcomes. These differences have implications for quality reporting and may introduce bias into hospital comparisons, particularly for hospitals with incomplete capture of their patients' baseline risk and acuity.
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Affiliation(s)
- Edward N Yap
- Department of Anesthesia, The Permanente Medical Group, Oakland, California, USA.,Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA
| | - Jennifer R Dusendang
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Kevin P Ng
- Department of Anesthesia, The Permanente Medical Group, Oakland, California, USA
| | - Hemant V Keny
- Department of Surgery, The Permanente Medical Group, Oakland, California, USA
| | - Matthew D Solomon
- Department of Cardiology, and The Permanente Medical Group, Oakland, California, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Bradley R Cohn
- Department of Anesthesia, The Permanente Medical Group, Oakland, California, USA
| | - Douglas A Corley
- Department of Gastroenterology, The Permanente Medical Group, Oakland, California, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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12
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Solomon MD, Leong T, Sung SH, Lee C, Allen JG, Huh J, LaPunzina P, Lee H, Mason D, Melikian V, Pellegrini D, Scoville D, Sheikh AY, Mendoza D, Naderi S, Sheridan A, Hu X, Cirimele W, Gisslow A, Leung S, Padilla K, Bloom M, Chung J, Topic A, Vafaei P, Chang R, Miller DC, Liang DH, Go AS. Association of Thoracic Aortic Aneurysm Size With Long-term Patient Outcomes: The KP-TAA Study. JAMA Cardiol 2022; 7:1160-1169. [PMID: 36197675 PMCID: PMC9535537 DOI: 10.1001/jamacardio.2022.3305] [Citation(s) in RCA: 14] [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: 04/19/2022] [Accepted: 08/09/2022] [Indexed: 12/15/2022]
Abstract
Importance The risk of adverse events from ascending thoracic aorta aneurysm (TAA) is poorly understood but drives clinical decision-making. Objective To evaluate the association of TAA size with outcomes in nonsyndromic patients in a large non-referral-based health care delivery system. Design, Setting, and Participants The Kaiser Permanente Thoracic Aortic Aneurysm (KP-TAA) cohort study was a retrospective cohort study at Kaiser Permanente Northern California, a fully integrated health care delivery system insuring and providing care for more than 4.5 million persons. Nonsyndromic patients from a regional TAA safety net tracking system were included. Imaging data including maximum TAA size were merged with electronic health record (EHR) and comprehensive death data to obtain demographic characteristics, comorbidities, medications, laboratory values, vital signs, and subsequent outcomes. Unadjusted rates were calculated and the association of TAA size with outcomes was evaluated in multivariable competing risk models that categorized TAA size as a baseline and time-updated variable and accounted for potential confounders. Data were analyzed from January 2018 to August 2021. Exposures TAA size. Main Outcomes and Measures Aortic dissection (AD), all-cause death, and elective aortic surgery. Results Of 6372 patients with TAA identified between 2000 and 2016 (mean [SD] age, 68.6 [13.0] years; 2050 female individuals [32.2%] and 4322 male individuals [67.8%]), mean (SD) initial TAA size was 4.4 (0.5) cm (828 individuals [13.0% of cohort] had initial TAA size 5.0 cm or larger and 280 [4.4%] 5.5 cm or larger). Rates of AD were low across a mean (SD) 3.7 (2.5) years of follow-up (44 individuals [0.7% of cohort]; incidence 0.22 events per 100 person-years). Larger initial aortic size was associated with higher risk of AD and all-cause death in multivariable models, with an inflection point in risk at 6.0 cm. Estimated adjusted risks of AD within 5 years were 0.3% (95% CI, 0.3-0.7), 0.6% (95% CI, 0.4-1.3), 1.5% (95% CI, 1.2-3.9), 3.6% (95% CI, 1.8-12.8), and 10.5% (95% CI, 2.7-44.3) in patients with TAA size of 4.0 to 4.4 cm, 4.5 to 4.9 cm, 5.0 to 5.4 cm, 5.5 to 5.9 cm, and 6.0 cm or larger, respectively, in time-updated models. Rates of the composite outcome of AD and all-cause death were higher than for AD alone, but a similar inflection point for increased risk was observed at 6.0 cm. Conclusions and Relevance In a large sociodemographically diverse cohort of patients with TAA, absolute risk of aortic dissection was low but increased with larger aortic sizes after adjustment for potential confounders and competing risks. Our data support current consensus guidelines recommending prophylactic surgery in nonsyndromic individuals with TAA at a 5.5-cm threshold.
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Affiliation(s)
- Matthew D. Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Thomas Leong
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - J. Geoff Allen
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Joseph Huh
- Department of Cardiothoracic Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | - Paul LaPunzina
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Hon Lee
- Department of Cardiothoracic Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Duncan Mason
- Department of Cardiothoracic Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Vicken Melikian
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Daniel Pellegrini
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - David Scoville
- Department of Cardiothoracic Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Ahmad Y. Sheikh
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Dorinna Mendoza
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Sahar Naderi
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Ann Sheridan
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Xinge Hu
- Department of Cardiology, Kaiser Permanente Fremont Medical Center, Fremont, California
| | - Wendy Cirimele
- Department of Cardiothoracic Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | - Anne Gisslow
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Sandy Leung
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Kristine Padilla
- Department of Cardiothoracic Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Michael Bloom
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Josh Chung
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Adrienne Topic
- Department of Cardiology, WellSpan Health Good Samaritan Hospital, Lebanon, Pennsylvania
| | - Paniz Vafaei
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Robert Chang
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - D. Craig Miller
- Department of Cardiovascular Surgery, Stanford University School of Medicine, Stanford, California
| | - David H. Liang
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- 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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Go AS, Leong TK, Sung SH, Wei R, Harrison TN, Gupta N, Baker N, Goldstein B, Ataher Q, Solomon MD, Reynolds K. Thromboembolism after treatment with 4-factor prothrombin complex concentrate or plasma for warfarin-related bleeding. J Thromb Thrombolysis 2022; 54:470-479. [PMID: 35984591 PMCID: PMC9553785 DOI: 10.1007/s11239-022-02695-5] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2022] [Indexed: 11/26/2022]
Abstract
Limited data exist in large, representative populations about whether the risk of thromboembolic events varies after receiving four-factor human prothrombin complex concentrate (4F-PCC) versus treatment with human plasma for urgent reversal of oral vitamin K antagonist therapy. We conducted a multicenter observational study to compare the 45-day risk of thromboembolic events in adults with warfarin-associated major bleeding after treatment with 4F-PCC (Kcentra®) or plasma. Hospitalized patients in two large integrated healthcare delivery systems who received 4F-PCC or plasma for reversal of warfarin due to major bleeding from January 1, 2008 to March 31, 2020 were identified and were matched 1:1 on potential confounders and a high-dimensional propensity score. Arterial and venous thromboembolic events were identified up to 45 days after receiving 4F-PCC or plasma from electronic health records and adjudicated by physician review. Among 1119 patients receiving 4F-PCC and a matched historical cohort of 1119 patients receiving plasma without a recent history of thromboembolism, mean (SD) age was 76.7 (10.5) years, 45.6% were women, and 9.4% Black, 14.6% Asian/Pacific Islander, and 15.7% Hispanic. The 45-day risk of thromboembolic events was 3.4% in those receiving 4F-PCC and 4.1% in those receiving plasma (P = 0.26; adjusted hazard ratio 0.76; 95% confidence interval 0.49-1.16). The adjusted risk of all-cause death at 45 days post-treatment was lower in those receiving 4F-PCC compared with plasma. Among a large, ethnically diverse cohort of adults treated for reversal of warfarin-associated bleeding, receipt of 4F-PCC was not associated with an excess risk of thromboembolic events at 45 days compared with plasma therapy.
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Affiliation(s)
- Alan S Go
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
- Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, CA, USA.
- Department of Medicine, Stanford University, Palo Alto, CA, USA.
| | - Thomas K Leong
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Nigel Gupta
- Department of Cardiac Electrophysiology, Southern CA Permanente Medical Group, Los Angeles, CA, USA
| | - Nicole Baker
- Clinical Epidemiology, CSL Behring, King of Prussia, PA, USA
| | - Brahm Goldstein
- Clinical Epidemiology, CSL Behring, King of Prussia, PA, USA
| | - Quazi Ataher
- Clinical Epidemiology, CSL Behring, King of Prussia, PA, USA
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Kristi Reynolds
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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Solomon MD, Escobar GJ, Lu Y, Schlessinger D, Steinman JB, Steinman L, Lee C, Liu VX. Risk of severe COVID-19 infection among adults with prior exposure to children. Proc Natl Acad Sci U S A 2022; 119:e2204141119. [PMID: 35895714 PMCID: PMC9388132 DOI: 10.1073/pnas.2204141119] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/27/2022] [Indexed: 12/14/2022] Open
Abstract
Susceptibility and severity of COVID-19 infection vary widely. Prior exposure to endemic coronaviruses, common in young children, may protect against SARS-CoV-2. We evaluated risk of severe COVID-19 among adults with and without exposure to young children in a large, integrated healthcare system. Adults with children 0-5 years were matched 1:1 to adults with children 6-11 years, 12-18 years, and those without children based upon a COVID-19 propensity score and risk factors for severe COVID-19. COVID-19 infections, hospitalizations, and need for intensive care unit (ICU) were assessed in 3,126,427 adults, of whom 24% (N = 743,814) had children 18 years or younger, and 8.8% (N = 274,316) had a youngest child 0-5 years. After 1:1 matching, propensity for COVID-19 infection and risk factors for severe COVID-19 were well balanced between groups. Rates of COVID-19 infection were slightly higher for adults with exposure to older children (incident risk ratio, 1.09, 95% confidence interval, [1.05-1.12] and IRR 1.09 [1.05-1.13] for adults with children 6-11 and 12-18, respectively), compared to those with children 0-5 years, although no difference in rates of COVID-19 illness requiring hospitalization or ICU admission was observed. However, adults without exposure to children had lower rates of COVID-19 infection (IRR 0.85, [0.83-0.87]) but significantly higher rates of COVID-19 hospitalization (IRR 1.49, [1.29-1.73]) and hospitalization requiring ICU admission (IRR 1.76, [1.19-2.58]) compared to those with children aged 0-5. In a large, real-world population, exposure to young children was associated with less severe COVID-19 illness. Endemic coronavirus cross-immunity may play a role in protection against severe COVID-19.
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Affiliation(s)
- Matthew D. Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612
- Department of Cardiology, Kaiser Oakland Medical Center, Oakland, CA 94611
| | - Gabriel J. Escobar
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612
| | - Yun Lu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612
| | - David Schlessinger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612
| | | | - Lawrence Steinman
- Department of Pediatrics, Stanford University, Stanford, CA 94305
- Department of Neurology, Stanford University, Stanford, CA 94305
- Department of Neurological Sciences, Stanford University, Stanford, CA 94305
| | - Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612
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15
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Shah AI, Alabaster A, Dontsi M, Rana JS, Solomon MD, Krishnaswami A. Comparison of coronary revascularization strategies in older adults presenting with acute coronary syndromes. J Am Geriatr Soc 2022; 70:2235-2245. [DOI: 10.1111/jgs.17794] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/13/2022] [Accepted: 03/12/2022] [Indexed: 01/01/2023]
Affiliation(s)
- Ahmed Ijaz Shah
- Division of Cardiology Kaiser Permanente Oakland Medical Center Oakland California USA
| | - Amy Alabaster
- Division of Research Kaiser Permanente Oakland California USA
| | - Makdine Dontsi
- Division of Research Kaiser Permanente Oakland California USA
| | - Jamal S. Rana
- Division of Cardiology Kaiser Permanente Oakland Medical Center Oakland California USA
- Division of Research Kaiser Permanente Oakland California USA
| | - Matthew D. Solomon
- Division of Cardiology Kaiser Permanente Oakland Medical Center Oakland California USA
- Division of Research Kaiser Permanente Oakland California USA
| | - Ashok Krishnaswami
- Division of Cardiology Kaiser Permanente San Jose Medical Center San Jose California USA
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16
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Gupta N, Yang J, Reynolds K, Lenane J, Garcia E, Sung SH, Harrison TN, Solomon MD, Go AS. Diagnostic Yield, Outcomes, and Resource Utilization With Different Ambulatory Electrocardiographic Monitoring Strategies. Am J Cardiol 2022; 166:38-44. [PMID: 34953575 DOI: 10.1016/j.amjcard.2021.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 08/22/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/01/2022]
Abstract
Accurate diagnosis of arrhythmias is improved with longer monitoring duration but can risk delayed diagnosis. We compared diagnostic yield, outcomes, and resource utilization by arrhythmia monitoring strategy in 330 matched adults (mean age 64 years, 40% women, and 30% non-White) without previously documented atrial fibrillation or atrial flutter (AF/AFL) who received ambulatory electrocardiographic monitoring by 14-day Zio XT (patch-based continuous monitor), 24-hour Holter, or 30-day event monitor (external loop recorder) between October 2011 and May 2014. Patients were matched by age, gender, site, likelihood of receiving Zio XT patch, and indication for monitoring, and subsequently followed for monitoring results, management changes, clinical outcomes, and resource utilization. AF/AFL ≥30 seconds was noted in 6% receiving Zio XT versus 0% by Holter (p = 0.04) and 3% by event monitor (p = 0.07). Nonsustained ventricular tachycardia was noted in 24% for Zio XT patch versus 8% (p <0.001) for Holter and 4% (p <0.001) for event monitor. No significant differences between monitoring strategies in outcomes or resource utilization were observed. Prolonged monitoring with 14-day Zio XT patch or 30-day event monitor was superior to 24-hour Holter in detecting new AF/AFL but not different from each other. Documented nonsustained ventricular tachycardia was more frequent with Zio XT than 24-hour Holter and 30-day event monitor without apparent increased risk of adverse outcomes or excess utilization. In conclusion, additional efforts are needed to further personalize electrocardiographic monitoring strategies that optimize clinical management and outcomes.
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Affiliation(s)
- Nigel Gupta
- Department of Cardiac Electrophysiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern, California, Pasadena, California
| | - Judith Lenane
- iRhythm Technologies, Inc., San Francisco, California
| | - Elisha Garcia
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern, California, Pasadena, California
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Cardiology, Kaiser Oakland Medical Center, Oakland, California
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California; Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, California; Department of Medicine, Stanford University, Stanford, California.
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Lancaster EM, Gologorsky R, Hull MM, Okuhn S, Solomon MD, Avins AL, Adams JL, Chang RW. The natural history of large abdominal aortic aneurysms in patients without timely repair. J Vasc Surg 2021; 75:109-117. [PMID: 34324972 DOI: 10.1016/j.jvs.2021.07.125] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 12/29/2020] [Accepted: 07/15/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Contemporary data on the natural history of large abdominal aortic aneurysms (AAAs) in patients undergoing delayed or no repair are lacking. In this study, we examine the impact of large AAA size on the incidence of rupture and mortality. METHODS From a prospectively maintained aneurysm surveillance registry, patients with an unrepaired, large AAA (≥5.5 cm in men and ≥5.0 cm in women) at baseline (ie, index imaging) or who progressed to a large size from 2003 to 2017 were included, with follow-up through March 2020. Outcomes of interest obtained by manual chart review included rupture (confirmed by imaging/autopsy), probable rupture (timing/findings consistent with rupture without more likely cause of death), repair, reasons for either no or delayed (>1 year after diagnosis of large AAA) repair and total mortality. Cumulative incidence of rupture was calculated using a nonparametric cumulative incidence function, accounting for the competing events of death and aneurysm repair and was stratified by patient sex. RESULTS Of the 3248 eligible patients (mean age, 83.6 ± 9.1 years; 71.2% male; 78.1% white; and 32.0% current smokers), 1423 (43.8%) had large AAAs at index imaging, and 1825 progressed to large AAAs during the follow-up period, with a mean time to qualifying size of 4.3 ± 3.4 years. In total, 2215 (68%) patients underwent repair, of which 332 were delayed >1 year; 1033 (32%) did not undergo repair. The most common reasons for delayed repair were discrepancy in AAA measurement between surgeon and radiologist (34%) and comorbidity (20%), whereas the most common reasons for no repair were patient preference (48%) and comorbidity (30%). Among patients with delayed repair (mean time to repair, 2.6 ± 1.8 years), nine (2.7%) developed symptomatic aneurysms, and an additional 11 (3.3%) ruptured. Of patients with no repair, 94 (9.1%) ruptured. The 3-year cumulative incidence of rupture was 3.4% for initial AAA size 5.0 to 5.4 cm (women only), 2.2% for 5.5 to 6.0 cm, 6.0% for 6.1 to 7.0 cm, and 18.4% for >7.0 cm. Women with AAA size 6.1 to 7.0 cm had a 3-year cumulative incidence of rupture of 12.8% (95% confidence interval, 7.5%-19.6%) compared with 4.5% (95% confidence interval, 3.0%-6.5%) in men (P = .002). CONCLUSIONS In this large cohort of AAA registry patients over 17 years, annual rupture rates for large AAAs were lower than previously reported, with possible increased risk in women. Further analyses are ongoing to identify those at increased risk for aneurysm rupture and may provide targeted surveillance regimens and improve patient counseling.
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Affiliation(s)
| | - Rebecca Gologorsky
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, Calif
| | - Michaela M Hull
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif
| | - Steven Okuhn
- Division of Vascular Surgery, Department of Surgery, VA San Francisco Healthcare System, San Francisco, Calif
| | - Matthew D Solomon
- Department of Cardiology, The Permanente Medical Group, Oakland, Calif; Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif; Departments of Medicine, Epidemiology, and Biostatistics, University of California, San Francisco, Calif
| | - John L Adams
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif
| | - Robert W Chang
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif; Department of Vascular Surgery, Permanente Medical Group, South San Francisco, Calif.
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Solomon MD, Nguyen-Huynh M, Leong TK, Alexander J, Rana JS, Klingman J, Go AS. Changes in Patterns of Hospital Visits for Acute Myocardial Infarction or Ischemic Stroke During COVID-19 Surges. JAMA 2021; 326:82-84. [PMID: 34076670 PMCID: PMC8173470 DOI: 10.1001/jama.2021.8414] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [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] [Indexed: 01/12/2023]
Abstract
This study evaluates changes in rates of patients hospitalized for acute myocardial infarction (AMI) or suspected stroke during COVID-19 surges in the US as a measure of willingness to seek care during the pandemic.
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Affiliation(s)
- Matthew D. Solomon
- Department of Cardiology, Kaiser Permanente Northern California, Oakland, California
| | - Mai Nguyen-Huynh
- Department of Neurology, Kaiser Permanente Northern California, Walnut Creek, California
| | - Thomas K. Leong
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Janet Alexander
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jamal S. Rana
- Department of Cardiology, Kaiser Permanente Northern California, Oakland, California
| | - Jeffrey Klingman
- Department of Neurology, Kaiser Permanente Northern California, Walnut Creek, California
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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Ambrosy AP, Malik UI, Thomas RC, Parikh RV, Tan TC, Goh CH, Selby VN, Solomon MD, Avula HR, Fitzpatrick JK, Skarbinski J, Philip S, Granowitz C, Bhatt DL, Go AS. Rationale and design of the pragmatic randomized trial of icosapent ethyl for high cardiovascular risk adults (MITIGATE). Am Heart J 2021; 235:54-64. [PMID: 33516752 PMCID: PMC7843090 DOI: 10.1016/j.ahj.2021.01.018] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/25/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The MITIGATE study aims to evaluate the real-world clinical effectiveness of pre-treatment with icosapent ethyl (IPE), compared with usual care, on laboratory-confirmed viral upper respiratory infection (URI)-related morbidity and mortality in adults with established atherosclerotic cardiovascular disease (ASCVD). BACKGROUND IPE is a highly purified and stable omega-3 fatty acid prescription medication that is approved for cardiovascular risk reduction in high-risk adults on statin therapy with elevated triglycerides. Preclinical data and clinical observations suggest that IPE may have pleiotropic effects including antiviral and anti-inflammatory properties that may prevent or reduce the downstream sequelae and cardiopulmonary consequences of viral URIs. METHODS MITIGATE is a virtual, electronic health record-based, open-label, randomized, pragmatic clinical trial enrolling ∼16,500 participants within Kaiser Permanente Northern California - a fully integrated and learning health care delivery system with 21 hospitals and >255 ambulatory clinics serving ∼4.5 million members. Adults ≥50 years with established ASCVD and no prior history of coronavirus disease 2019 (COVID-19) will be prospectively identified and pre-randomized in a 1:10 allocation ratio (∼ 1,500 IPE: ∼15,000 usual care) stratified by age and previous respiratory health status to the intervention (IPE 2 grams by mouth twice daily with meals) vs the control group (usual care) for a minimum follow-up duration of 6 months. The co-primary endpoints are moderate-to-severe laboratory-confirmed viral URI and worst clinical status due to a viral URI at any point in time. CONCLUSION The MITIGATE study will inform clinical practice by providing evidence on the real-world clinical effectiveness of pretreatment with IPE to prevent and/or reduce the sequelae of laboratory-confirmed viral URIs in a high-risk cohort of patients with established ASCVD.
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Affiliation(s)
- Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA.
| | - Umar I Malik
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Rachel C Thomas
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Rishi V Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Choon H Goh
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Van N Selby
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Harshith R Avula
- Department of Cardiology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA
| | - Jesse K Fitzpatrick
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Infectious Disease, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Departments of Medicine (Nephrology), Epidemiology, and Biostatistics, University of California, San Francisco, San Francisco, CA; Department of Medicine (Nephrology), Stanford University, Palo Alto, CA
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Sachdeva A, Hung YY, Solomon MD, McNulty EJ. Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention for Chronic Total Occlusion. Am J Cardiol 2020; 132:44-51. [PMID: 32762964 DOI: 10.1016/j.amjcard.2020.06.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 04/17/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 11/29/2022]
Abstract
The optimal duration of dual antiplatelet therapy (DAPT) after treatment of chronic total occlusions (CTO) with percutaneous coronary intervention (PCI) is unknown. We aimed to determine if extended (> 12 months) DAPT was associated with a net clinical benefit. The study population included patients who underwent successful CTO PCI within Kaiser Permanente Northern California between 2009 and 2016. Baseline demographic, clinical, and procedural characteristics were compared for patients on DAPT ≤ versus > 12 months. Clinical outcomes (death, myocardial infarction (MI), and ≥ Academic Research Consortium type 3a bleeding) were compared beginning 12 months after PCI using Cox proportional hazards models. We also adjudicated individual causes of death. 1,069 patients were followed for a median of 3.6 years (Interquartile Range = 2.2 to 5.5) following CTO PCI. Patients on DAPT ≤ 12 months (n = 597, 56%) were more likely to have anemia, end stage renal disease, and previous MI. After adjustment for between group differences, > 12 months of DAPT was associated with lower death or MI (hazard ratio [HR]: 0.66; 95% confidence interval [CI]: 0.47 to 0.93) and lower death (HR: 0.54; 95% CI: 0.36 to 0.82). There were no associations with MI (HR: 0.91; 95% CI: 0.55 to 1.5) or bleeding (HR 1.1; 95% CI: 0.50 to 2.4), but a numerically higher proportion of patients on shorter v. longer DAPT died of a cardiovascular cause (37% vs 20%, p = 0.10). In conclusion, > 12 months of DAPT was associated with lower death or MI, without an increase in bleeding. Prospective studies are needed to evaluate the optimal duration of DAPT in this unique subgroup.
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Affiliation(s)
- Amit Sachdeva
- Division of Cardiology, Kaiser Permanente Northern California, Walnut Creek, California; Division of Research, Kaiser Permanente Northern California, Oakland, California.
| | - Yun-Yi Hung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Division of Cardiology, Kaiser Permanente Northern California, Oakland, California
| | - Edward J McNulty
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Division of Cardiology, Kaiser Permanente Northern California, San Francisco, California
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21
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Lancaster EM, Gologorsky RC, Hull MM, Okuhn S, Solomon MD, Avins AL, Adams JL, Chang RW. The Natural History of Large Abdominal Aortic Aneurysms in Patients Without Timely Repair: Implications for Rupture and Mortality. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.07.003] [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: 11/16/2022]
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22
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Solomon MD, McNulty EJ, Rana JS, Leong TK, Lee C, Sung SH, Ambrosy AP, Sidney S, Go AS. The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction. N Engl J Med 2020; 383:691-693. [PMID: 32427432 DOI: 10.1056/nejmc2015630] [Citation(s) in RCA: 470] [Impact Index Per Article: 117.5] [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: 12/15/2022]
Affiliation(s)
| | - Edward J McNulty
- Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Jamal S Rana
- Kaiser Permanente Oakland Medical Center, Oakland, CA
| | | | | | - Sue-Hee Sung
- Kaiser Permanente Northern California, Oakland, CA
| | - Andrew P Ambrosy
- Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | | | - Alan S Go
- Kaiser Permanente Northern California, Oakland, CA
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Abstract
Importance A deceleration in the rate of decrease of heart disease (HD) mortality between 2011 and 2014 has been reported. In the context of the rapid increase in the population of adults aged 65 years and older, extending the examination of HD mortality through 2017 has potentially important implications for public health and medical care. Objective To examine changes in the age-adjusted mortality rate and the number of deaths within subcategories of HD from 2011 to 2017 in conjunction with the change in the size of the US population during the same period. Design, Setting, and Participants In this quality improvement study, the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) data set was used to identify national changes in the US population aged 65 years and older and in the age-adjusted mortality rates and number of deaths that were listed with an underlying cause of HD, coronary heart disease (CHD), heart failure, and other HDs from January 1, 2011, to December 31, 2017. Main Outcomes and Measures Changes from 2011 to 2017 in the US population and in age-adjusted mortality rates and number of deaths that were listed with an underlying cause of HD, CHD, heart failure (both as an underlying and a contributing cause), and other HDs overall, by sex and race/ethnicity. Results The total size of this population of US adults aged 65 years and older increased 22.9% from 41.4 million to 50.9 million between January 1, 2011, and December 31, 2017, while the population of adults younger than 65 years increased by only 1.7%. During this period, the age-adjusted mortality rate decreased 5.0% for HD and 14.9% for CHD while increasing 20.7% for heart failure and 8.4% for other HDs. The number of deaths increased 8.5% for HD, 38.0% for heart failure, and 23.4% for other HDs while decreasing 2.5% for CHD. A total of 80% of HD deaths occurred in the group of adults aged 65 years and older. Conclusions and Relevance The substantial increase in the growth rate of the group of adults aged 65 years and older who have the highest risk of HD was associated with an increase in the number of HD deaths in this group despite a slowly declining HD mortality rate in the general population. With the number of adults aged 65 years and older projected to increase an additional 44% from 2017 to 2030, innovative and effective approaches to prevent and treat HD, particularly the substantially increasing rates of heart failure, are needed.
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Affiliation(s)
- Stephen Sidney
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland.,Department of Epidemiology, University of California, San Francisco.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California.,Department of Biostatistics, University of California, San Francisco.,Department of Medicine, University of California, San Francisco
| | - Marc G Jaffe
- Department of Endocrinology, Kaiser Permanente Northern California, South San Francisco, California
| | - Matthew D Solomon
- Department of Cardiology, Kaiser Permanente Northern California, Oakland
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente Northern California, San Francisco
| | - Jamal S Rana
- Division of Research, Kaiser Permanente Northern California, Oakland.,Department of Cardiology, Kaiser Permanente Northern California, Oakland.,Department of Medicine, University of California, San Francisco
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Solomon MD, Leong TK, Levin E, Rana JS, Jaffe MG, Sidney S, Sung SH, Lee C, DeMaria A, Go AS. Cumulative Adherence to Secondary Prevention Guidelines and Mortality After Acute Myocardial Infarction. J Am Heart Assoc 2020; 9:e014415. [PMID: 32131689 PMCID: PMC7335507 DOI: 10.1161/jaha.119.014415] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background The survival benefit associated with cumulative adherence to multiple clinical and lifestyle-related guideline recommendations for secondary prevention after acute myocardial infarction (AMI) is not well established. Methods and Results We examined adults with AMI (mean age 68 years; 64% men) surviving at least 30 (N=25 778) or 90 (N=24 200) days after discharge in a large integrated healthcare system in Northern California from 2008 to 2014. The association between all-cause death and adherence to 6 or 7 secondary prevention guideline recommendations including medical treatment (prescriptions for β-blockers, renin-angiotensin-aldosterone system inhibitors, lipid medications, and antiplatelet medications), risk factor control (blood pressure <140/90 mm Hg and low-density lipoprotein cholesterol <100 mg/dL), and lifestyle approaches (not smoking) at 30 or 90 days after AMI was evaluated with Cox proportional hazard models. To allow patients time to achieve low-density lipoprotein cholesterol <100 mg/dL, this metric was examined only among those alive 90 days after AMI. Overall guideline adherence was high (35% and 34% met 5 or 6 guidelines at 30 days; and 31% and 23% met 6 or 7 at 90 days, respectively). Greater guideline adherence was independently associated with lower mortality (hazard ratio, 0.57 [95% CI, 0.49-0.66] for those meeting 7 and hazard ratio, 0.69 [95% CI, 0.61-0.78] for those meeting 6 guidelines versus 0 to 3 guidelines in 90-day models, with similar results in the 30-day models), with significantly lower mortality per each additional guideline recommendation achieved. Conclusions In a large community-based population, cumulative adherence to guideline-recommended medical therapy, risk factor control, and lifestyle changes after AMI was associated with improved long-term survival. Full adherence was associated with the greatest survival benefit.
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Affiliation(s)
- Matthew D Solomon
- Division of Research Kaiser Permanente Northern California Oakland CA.,Division of Cardiology Kaiser Permanente Oakland Medical Center Oakland CA
| | - Thomas K Leong
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Eleanor Levin
- Division of Cardiology Kaiser Permanente Santa Clara Medical Center Santa Clara CA
| | - Jamal S Rana
- Division of Research Kaiser Permanente Northern California Oakland CA.,Division of Cardiology Kaiser Permanente Oakland Medical Center Oakland CA
| | - Marc G Jaffe
- Division of Endocrinology Kaiser Permanente South San Francisco Medical Center San Francisco CA
| | - Stephen Sidney
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Sue Hee Sung
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Catherine Lee
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Anthony DeMaria
- Division of Cardiology University of California at San Diego CA
| | - Alan S Go
- Division of Research Kaiser Permanente Northern California Oakland CA.,Departments of Epidemiology, Biostatistics and Medicine University of California San Francisco CA.,Departments of Medicine, Health Research and Policy Stanford University Palo Alto CA
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Solomon MD, Tabada G, Allen A, Sung SH, Go AS. NATURAL HISTORY OF AORTIC STENOSIS IN A LARGE INTEGRATED HEALTH CARE DELIVERY SYSTEM. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32767-4] [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: 11/28/2022]
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26
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Rana JS, Liu JY, Moffet HH, Karter AJ, Nasir K, Solomon MD, Jaffe MG, Ambrosy AP, Go AS, Sidney S. Risk of atherosclerotic cardiovascular disease by cardiovascular health metric categories in approximately 1 million patients. Eur J Prev Cardiol 2020; 28:e29-e32. [PMID: 33611408 DOI: 10.1177/2047487320905025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 11/15/2022]
Affiliation(s)
- Jamal S Rana
- Division of Cardiology, Kaiser Permanente Oakland Medical Center, USA
- Division of Research, Kaiser Permanente Northern California, USA
| | - Jennifer Y Liu
- Division of Research, Kaiser Permanente Northern California, USA
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, USA
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, USA
| | - Khurram Nasir
- Division of Cardiovascular Medicine, Yale University School of Medicine, USA
| | - Matthew D Solomon
- Division of Cardiology, Kaiser Permanente Oakland Medical Center, USA
- Division of Research, Kaiser Permanente Northern California, USA
| | - Marc G Jaffe
- Division of Endocrinology, Kaiser Permanente South San Francisco Medical Center, USA
| | - Andrew P Ambrosy
- Division of Research, Kaiser Permanente Northern California, USA
- Division of Cardiology, Kaiser Permanente San Francisco Medical Center, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, USA
| | - Stephen Sidney
- Division of Research, Kaiser Permanente Northern California, USA
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Go AS, Reynolds K, Yang J, Gupta N, Lenane J, Sung SH, Harrison TN, Liu TI, Solomon MD. Association of Burden of Atrial Fibrillation With Risk of Ischemic Stroke in Adults With Paroxysmal Atrial Fibrillation: The KP-RHYTHM Study. JAMA Cardiol 2019; 3:601-608. [PMID: 29799942 DOI: 10.1001/jamacardio.2018.1176] [Citation(s) in RCA: 165] [Impact Index Per Article: 33.0] [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: 12/25/2022]
Abstract
Importance Atrial fibrillation is a potent risk factor for stroke, but whether the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation independently influences the risk of thromboembolism remains controversial. Objective To determine if the burden of atrial fibrillation characterized using noninvasive, continuous ambulatory monitoring is associated with the risk of ischemic stroke or arterial thromboembolism in adults with paroxysmal atrial fibrillation. Design, Setting, and Participants This retrospective cohort study conducted from October 2011 and October 2016 at 2 large integrated health care delivery systems used an extended continuous cardiac monitoring system to identify adults who were found to have paroxysmal atrial fibrillation on 14-day continuous ambulatory electrocardiographic monitoring. Exposures The burden of atrial fibrillation was defined as the percentage of analyzable wear time in atrial fibrillation or flutter during the up to 14-day monitoring period. Main Outcomes and Measures Ischemic stroke and other arterial thromboembolic events occurring while patients were not taking anticoagulation were identified through November 2016 using electronic medical records and were validated by manual review. We evaluated the association of the burden of atrial fibrillation with thromboembolism while not taking anticoagulation after adjusting for the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) or CHA2DS2-VASc stroke risk scores. Results Among 1965 adults with paroxysmal atrial fibrillation, the mean (SD) age was 69 (11.8) years, 880 (45%) were women, 496 (25%) were persons of color, the median ATRIA stroke risk score was 4 (interquartile range [IQR], 2-7), and the median CHA2DS2-VASc score was 3 (IQR, 1-4). The median burden of atrial fibrillation was 4.4% (IQR ,1.1%-17.23%). Patients with a higher burden of atrial fibrillation were less likely to be women or of Hispanic ethnicity, but had more prior cardioversion attempts compared with those who had a lower burden. After adjusting for either ATRIA or CHA2DS2-VASc stroke risk scores, the highest tertile of atrial fibrillation burden (≥11.4%) was associated with a more than 3-fold higher adjusted rate of thromboembolism while not taking anticoagulants (adjusted hazard ratios, 3.13 [95% CI, 1.50-6.56] and 3.16 [95% CI, 1.51-6.62], respectively) compared with the combined lower 2 tertiles of atrial fibrillation burden. Results were consistent across demographic and clinical subgroups. Conclusions and Relevance A greater burden of atrial fibrillation is associated with a higher risk of ischemic stroke independent of known stroke risk factors in adults with paroxysmal atrial fibrillation.
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Affiliation(s)
- Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland.,Departments of Epidemiology, Biostatistics and Medicine, University of California-San Francisco, San Francisco.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Nigel Gupta
- Department of Cardiac Electrophysiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | | | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Taylor I Liu
- Department of Cardiac Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland.,Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, California
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28
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Solomon MD, Leong T, Sung SH, Lee C, Savitz S, Rana J, McNulty E, Go AS. DEVELOPMENT AND VALIDATION OF MODELS TO PREDICT LONG-TERM OUTCOMES AND RESOURCE UTILIZATION AFTER PERCUTANEOUS CORONARY INTERVENTION. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30729-6] [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: 11/25/2022]
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29
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Go AS, Hlatky MA, Liu TI, Fan D, Garcia EA, Sung SH, Solomon MD. Contemporary Burden and Correlates of Symptomatic Paroxysmal Supraventricular Tachycardia. J Am Heart Assoc 2018; 7:e008759. [PMID: 29982228 PMCID: PMC6064827 DOI: 10.1161/jaha.118.008759] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 05/28/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Contemporary data about symptomatic paroxysmal supraventricular tachycardia (PSVT) epidemiology are limited. We characterized prevalence and correlates of symptomatic PSVT within a large healthcare delivery system and estimated national PSVT burden. METHODS AND RESULTS We identified adults with an encounter for potential PSVT between 2010 and 2015 in Kaiser Permanente Northern California, excluding those with prior known atrial fibrillation or atrial flutter. We adjudicated medical records, ECGs, and other monitoring data to estimate positive predictive values for targeted International Classification of Diseases (ICD), 9th and 10th Revisions codes in inpatient, emergency department, and outpatient settings. Combinations of diagnosis codes and settings were used to calculate PSVT prevalence, and PSVT correlates were identified using multivariable regression. We estimated national rates by applying prevalence estimates in Kaiser Permanente to 2010 US Census data. The highest positive predictive values included codes for "PSVT" in the emergency department (82%), "unspecified cardiac dysrhythmia" in the emergency department (27%), "anomalous atrioventricular excitation" as a primary inpatient diagnosis (33%), and "unspecified paroxysmal tachycardia" as a primary inpatient diagnosis (23%). Prevalence of symptomatic PSVT was 140 per 100 000 (95% confidence interval, 100-179) and was higher for individuals who were older, women, white or black, or who had valvular heart disease, heart failure, diabetes mellitus, lung disease, or prior bleeding. We estimate the national prevalence of symptomatic PSVT to be 168 per 100 000 (95% confidence interval, 120-215). CONCLUSIONS Selected diagnostic codes in inpatient and emergency department settings may be useful to identify symptomatic PSVT episodes. We project that at least 0.168% of US adults experience symptomatic PSVT, and certain characteristics can identify people at higher risk.
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Affiliation(s)
- Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
- Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, CA
- Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Mark A Hlatky
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
- Department of Health Research and Policy, Stanford University, Stanford, CA
- Department of Medicine (Cardiovascular Medicine), Stanford University, Stanford, CA
| | - Taylor I Liu
- Department of Cardiac Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Elisha A Garcia
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA
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30
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Sidney S, Sorel ME, Quesenberry CP, Jaffe MG, Solomon MD, Nguyen-Huynh MN, Go AS, Rana JS. Comparative Trends in Heart Disease, Stroke, and All-Cause Mortality in the United States and a Large Integrated Healthcare Delivery System. Am J Med 2018; 131:829-836.e1. [PMID: 29625083 PMCID: PMC6005733 DOI: 10.1016/j.amjmed.2018.02.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 02/02/2018] [Revised: 02/08/2018] [Accepted: 02/09/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Heart disease and stroke remain among the leading causes of death nationally. We examined whether differences in recent trends in heart disease, stroke, and total mortality exist in the United States and Kaiser Permanente Northern California (KPNC), a large integrated healthcare delivery system. METHODS The main outcome measures were comparisons of US and KPNC total, age-specific, and sex-specific changes from 2000 to 2015 in mortality rates from heart disease, coronary heart disease, stroke, and all causes. The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research data system was used to determine US mortality rates. Mortality rates for KPNC were determined from health system, Social Security vital status, and state death certificate databases. RESULTS Declines in age-adjusted mortality rates were noted in KPNC and the United States for heart disease (36.3% in KPNC vs 34.6% in the United States), coronary heart disease (51.0% vs 47.9%), stroke (45.5% vs 38.2%), and all-cause mortality (16.8% vs 15.6%). However, steeper declines were noted in KPNC than the United States among those aged 45 to 65 years for heart disease (48.3% KPNC vs 23.6% United States), coronary heart disease (55.6% vs 35.9%), stroke (55.8% vs 26.0%), and all-cause mortality (31.5% vs 9.1%). Sex-specific changes were generally similar. CONCLUSIONS Despite significant declines in heart disease and stroke mortality, there remains an improvement gap nationally among those aged less than 65 years when compared with a large integrated healthcare delivery system. Interventions to improve cardiovascular mortality in the vulnerable middle-aged population may play a key role in closing this gap.
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Affiliation(s)
- Stephen Sidney
- Division of Research, Kaiser Permanente Northern California, Oakland.
| | - Michael E Sorel
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Marc G Jaffe
- Department of Endocrinology, Kaiser Permanente Northern California, South San Francisco
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland; Department of Cardiology, Kaiser Permanente Northern California, Oakland
| | - Mai N Nguyen-Huynh
- Department of Neurology, Kaiser Permanente Northern California, Walnut Creek
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland; Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco; Department of Health Research and Policy, Stanford University School of Medicine, Stanford, Calif
| | - Jamal S Rana
- Division of Research, Kaiser Permanente Northern California, Oakland; Department of Cardiology, Kaiser Permanente Northern California, Oakland; Department of Medicine, University of California, San Francisco, San Francisco
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Abstract
Metastasis of a nonvisceral leiomyosarcoma to the heart is rare. We present the case of a man with a history of an upper extremity cancerous lesion that was completely resected with appropriate surveillance monitoring, which then metastasized to the heart 14 years later, presenting as superior vena cava syndrome. Full evaluation found no other metastatic lesions, including no residual sarcoma at the former primary site. We include transthoracic echocardiography and computed tomography images of unusual presentation of the large mass extending from the caudal superior vena cava to the right atrium and into the right ventricle across the tricuspid valve.
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Affiliation(s)
- Cristina Martinez
- Department of Emergency Medicine, Alameda Health System - Highland Hospital, Oakland CA
| | - Jamal S Rana
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA; Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Matthew D Solomon
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Rana JS, Tabada GH, Solomon MD, Lo JC, Jaffe MG, Sung SH, Ballantyne CM, Go AS. Accuracy of the Atherosclerotic Cardiovascular Risk Equation in a Large Contemporary, Multiethnic Population. J Am Coll Cardiol 2017; 67:2118-2130. [PMID: 27151343 DOI: 10.1016/j.jacc.2016.02.055] [Citation(s) in RCA: 205] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/18/2016] [Accepted: 02/23/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND The accuracy of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Pooled Cohort Risk Equation for atherosclerotic cardiovascular disease (ASCVD) events in contemporary and ethnically diverse populations is not well understood. OBJECTIVES The goal of this study was to evaluate the accuracy of the 2013 ACC/AHA Pooled Cohort Risk Equation within a large, multiethnic population in clinical care. METHODS The target population for consideration of cholesterol-lowering therapy in a large, integrated health care delivery system population was identified in 2008 and followed up through 2013. The main analyses excluded those with known ASCVD, diabetes mellitus, low-density lipoprotein cholesterol levels <70 or ≥190 mg/dl, prior lipid-lowering therapy use, or incomplete 5-year follow-up. Patient characteristics were obtained from electronic medical records, and ASCVD events were ascertained by using validated algorithms for hospitalization databases and death certificates. We compared predicted versus observed 5-year ASCVD risk, overall and according to sex and race/ethnicity. We additionally examined predicted versus observed risk in patients with diabetes mellitus. RESULTS Among 307,591 eligible adults without diabetes between 40 and 75 years of age, 22,283 were black, 52,917 were Asian/Pacific Islander, and 18,745 were Hispanic. We observed 2,061 ASCVD events during 1,515,142 person-years. In each 5-year predicted ASCVD risk category, observed 5-year ASCVD risk was substantially lower: 0.20% for predicted risk <2.50%; 0.65% for predicted risk 2.50% to <3.75%; 0.90% for predicted risk 3.75% to <5.00%; and 1.85% for predicted risk ≥5.00% (C statistic: 0.74). Similar ASCVD risk overestimation and poor calibration with moderate discrimination (C statistic: 0.68 to 0.74) were observed in sex, racial/ethnic, and socioeconomic status subgroups, and in sensitivity analyses among patients receiving statins for primary prevention. Calibration among 4,242 eligible adults with diabetes was improved, but discrimination was worse (C statistic: 0.64). CONCLUSIONS In a large, contemporary "real-world" population, the ACC/AHA Pooled Cohort Risk Equation substantially overestimated actual 5-year risk in adults without diabetes, overall and across sociodemographic subgroups.
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Affiliation(s)
- Jamal S Rana
- Division of Cardiology, Kaiser Permanente Northern California, Oakland, California; Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Grace H Tabada
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Matthew D Solomon
- Division of Cardiology, Kaiser Permanente Northern California, Oakland, California; Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, Stanford University, Stanford, California
| | - Joan C Lo
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, University of California, San Francisco, San Francisco, California; Division of Endocrinology, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Marc G Jaffe
- Department of Medicine, University of California, San Francisco, San Francisco, California; Division of Endocrinology, Kaiser Permanente South San Francisco Medical Center, South San Francisco, California
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Christie M Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, and Center for Cardiovascular Disease Prevention, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, University of California, San Francisco, San Francisco, California; Departments of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California.
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Karter AJ, Parker MM, Solomon MD, Lyles CR, Adams AS, Moffet HH, Reed ME. Effect of Out-of-Pocket Cost on Medication Initiation, Adherence, and Persistence among Patients with Type 2 Diabetes: The Diabetes Study of Northern California (DISTANCE). Health Serv Res 2017; 53:1227-1247. [PMID: 28474736 DOI: 10.1111/1475-6773.12700] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [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: 01/30/2023] Open
Abstract
OBJECTIVE To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes. DATA SOURCES/SETTING Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006-2012. STUDY DESIGN Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence. DATA COLLECTION Adherence and OOP costs were based on pharmacy dispensing records and benefits. PRINCIPAL FINDINGS Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1-$10, and 3 percent when the medication was free of charge (p < .0001). Higher OOP cost was also strongly associated with inadequate secondary adherence (≥20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24 months). CONCLUSIONS Cost-sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control.
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Affiliation(s)
- Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,University of California San Francisco Medical School, San Francisco, CA
| | - Melissa M Parker
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Division of Cardiology, Kaiser Permanente Northern California, Oakland, CA.,Department of Medicine, Stanford University, Stanford, CA
| | - Courtney R Lyles
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Alyce S Adams
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Krishnaswami A, Ho WKW, Kwan WP, Tsou C, Rana JS, Solomon MD, Jiang SF, Jang JJ, Alloggiamento T, Praserthdam AW. A pilot study to assess the utility of five established variables to standardize exercise treadmill test reporting. Int J Cardiol 2017; 231:271-276. [PMID: 28189190 DOI: 10.1016/j.ijcard.2016.12.020] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 12/05/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND The prognostic utility of 5 established variables (functional capacity, Duke treadmill score, chronotropic response to exercise, heart rate recovery, and premature ventricular contractions) together after routine exercise treadmill testing (ETT) has not been determined. METHODS We assessed the combined prognostic ability of 5 established variables for the primary outcome (myocardial infarction [MI], coronary revascularization [CR] or all-cause mortality) and the secondary outcome of unnecessary downstream testing (defined as receipt of further noninvasive imaging without CR, MI, or death) compared with standard methods. Using a retrospective study design, 1857 consecutive patients were enrolled in the year 2014 and followed until December 31, 2015. Optimal discrimination and global fit statistics were assessed from logistic regression models. Classification and regression tree (CART) methodology was used for the final model. RESULTS The mean [SD] age was 56.0 [12.5]years; median comorbidities (2, IQR 2) with 26% having an equivocal report. Compared to other models, a model with age, sex, and the 5 established variables showed an improvement in discrimination for the primary [c-statistic 0.85 versus (0.69-0.79)] and secondary [c-statistic 0.73 versus (0.65-0.71)] outcomes with substantial improvement in global fit. The final, optimal, 10-fold cross-validated CART model had a c-statistic of 0.78. CONCLUSIONS The utility of the 5-established variables, based on the current study, resides in its ability to decrease unnecessary downstream testing and improve cardiovascular event prognostication. This is accomplished by removing the subjective interpretation of currently used ETT variables that can lead to an equivocal report.
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Affiliation(s)
- Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente, San Jose, CA, United States; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, United States.
| | - William K W Ho
- Department of Hospital Medicine, Kaiser Permanente, San Jose, CA, United States
| | - Walter P Kwan
- Division of Nuclear Medicine, Kaiser Permanente, San Jose, CA, United States
| | - Christine Tsou
- Department of Hospital Medicine, Kaiser Permanente, San Jose, CA, United States
| | - Jamal S Rana
- Division of Cardiology, Kaiser Permanente, Oakland, CA, United States; Division of Research, Kaiser Permanente Division of Research, Oakland, CA, United States
| | - Matthew D Solomon
- Division of Cardiology, Kaiser Permanente, Oakland, CA, United States; Division of Research, Kaiser Permanente Division of Research, Oakland, CA, United States; Stanford University School of Medicine, Stanford, CA, United States
| | - Sheng-Fang Jiang
- Division of Research, Kaiser Permanente Division of Research, Oakland, CA, United States
| | - James J Jang
- Division of Cardiology, Kaiser Permanente, San Jose, CA, United States
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Reed ME, Warton EM, Kim E, Solomon MD, Karter AJ. Value-Based Insurance Design Benefit Offsets Reductions In Medication Adherence Associated With Switch To Deductible Plan. Health Aff (Millwood) 2017; 36:516-523. [DOI: 10.1377/hlthaff.2016.1316] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Mary E. Reed
- Mary E. Reed ( ) is a research scientist in the Division of Research at Kaiser Permanente, in Oakland, California
| | - E. Margaret Warton
- E. Margaret Warton is a consulting data analyst in the Division of Research at Kaiser Permanente
| | - Eileen Kim
- Eileen Kim is chief of outpatient quality in the East Bay service area at Kaiser Permanente
| | - Matthew D. Solomon
- Matthew D. Solomon is a physician researcher in the Department of Cardiology at Kaiser Permanente
| | - Andrew J. Karter
- Andrew J. Karter is a research scientist in the Division of Research at Kaiser Permanente
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Solomon MD, Leong T, Sung SH, Inveiss A, Hernandez JB, White RM, Sosa MP, Rana J, McNulty E, Go AS. PREDICTORS OF LONG-TERM RESOURCE UTILIZATION AFTER INCIDENT PERCUTANEOUS CORONARY INTERVENTION. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)33434-4] [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: 10/20/2022]
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Solomon MD, Leong TK, Rana JS, Xu Y, Go AS. Community-Based Trends in Acute Myocardial Infarction From 2008 to 2014. J Am Coll Cardiol 2016; 68:666-668. [DOI: 10.1016/j.jacc.2016.03.607] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 03/01/2016] [Accepted: 03/08/2016] [Indexed: 11/27/2022]
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Solomon MD, Yang J, Sung SH, Livingston ML, Sarlas G, Lenane JC, Go AS. Incidence and timing of potentially high-risk arrhythmias detected through long term continuous ambulatory electrocardiographic monitoring. BMC Cardiovasc Disord 2016; 16:35. [PMID: 26883019 PMCID: PMC4756401 DOI: 10.1186/s12872-016-0210-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 02/02/2016] [Indexed: 11/18/2022] Open
Abstract
Background Ambulatory electrocardiographic (ECG) monitoring is the standard to screen for high-risk arrhythmias. We evaluated the clinical utility of a novel, leadless electrode, single-patient-use ECG monitor that stores up to 14 days of a continuous recording to measure the burden and timing of potentially high-risk arrhythmias. Methods We examined data from 122,815 long term continuous ambulatory monitors (iRhythm ZIO® Service, San Francisco) prescribed from 2011 to 2013 and categorized potentially high-risk arrhythmias into two types: (1) ventricular arrhythmias including non-sustained and sustained ventricular tachycardia and (2) bradyarrhythmias including sinus pauses >3 s, atrial fibrillation pauses >5 s, and high-grade heart block (Mobitz Type II or third-degree heart block). Results Of 122,815 ZIO® recordings, median wear time was 9.9 (IQR 6.8–13.8) days and median analyzable time was 9.1 (IQR 6.4–13.1) days. There were 22,443 (18.3 %) with at least one episode of non-sustained ventricular tachycardia (NSVT), 238 (0.2 %) with sustained VT, 1766 (1.4 %) with a sinus pause >3 s (SP), 520 (0.4 %) with a pause during atrial fibrillation >5 s (AFP), and 1486 (1.2 %) with high-grade heart block (HGHB). Median time to first arrhythmia was 74 h (IQR 26–149 h) for NSVT, 22 h (IQR 5–73 h) for sustained VT, 22 h (IQR 7–64 h) for SP, 31 h (IQR 11–82 h) for AFP, and 40 h (SD 10–118 h) for HGHB. Conclusions A significant percentage of potentially high-risk arrhythmias are not identified within 48-h of ambulatory ECG monitoring. Longer-term continuous ambulatory ECG monitoring provides incremental detection of these potentially clinically relevant arrhythmic events.
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Affiliation(s)
- Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA. .,Stanford University School of Medicine, Stanford, CA, USA. .,Department of Cardiology, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA.
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | | | | | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.,Stanford University School of Medicine, Stanford, CA, USA.,Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, CA, USA
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Rana JS, Liu JY, Moffet HH, Solomon MD, Go AS, Jaffe MG, Karter AJ. Metabolic Dyslipidemia and Risk of Coronary Heart Disease in 28,318 Adults With Diabetes Mellitus and Low-Density Lipoprotein Cholesterol <100 mg/dl. Am J Cardiol 2015; 116:1700-4. [PMID: 26428026 DOI: 10.1016/j.amjcard.2015.08.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 08/29/2015] [Accepted: 08/29/2015] [Indexed: 10/23/2022]
Abstract
The risk of future coronary heart disease (CHD) in subjects with diabetes and "metabolic dyslipidemia" (high triglyceride [TGs] and low high-density cholesterol levels) remains a matter of concern. Little is known regarding the risk of CHD for this phenotype with low-density lipoprotein cholesterol (LDL-C) levels <100 mg/dl. We analyzed a diabetes cohort of 28,318 members (aged 30 to 90 years) of Kaiser Permanente Northern California during 2002 to 2011 (192,356 person-years [p-y] follow-up), with LDL-C levels <100 mg/dl and without known CHD. We compared the incidence and hazard ratios (HRs) for CHD events in groups using Cox models: normal high-density lipoprotein (HDL) and TG (reference; n = 7,278, 25.7%); normal HDL and high TG (≥ 150 mg/dl; n = 4,484,15.8%); low HDL (≤ 50 mg/dl for women and ≤ 40 mg/dl for men) and normal TG (n = 4,048, 14.3%); low HDL and high TG (metabolic dyslipidemia; n = 12,508, 44%). Patients with metabolic dyslipidemia had the highest age-adjusted CHD events/1,000 p-y (12.7/1,000 p-y and 19.0/1,000 p-y for women and men, respectively). After multivariate adjustment for age, gender, ethnicity, hypertension, smoking, statin use, duration of diabetes, and hemoglobin A1c, we observed an increased CHD risk in women (HR 1.35, 95% confidence interval 1.14 to 1.60) and men (HR 1.62, 95% confidence interval 1.43 to 1.83) with metabolic dyslipidemia compared to those with normal HDL and TG. Even in subjects with an LDL-C <100 mg/dl, presence of metabolic dyslipidemia in adults with diabetes is associated with an increased risk of CHD. In conclusion, effective CHD prevention strategies are needed for adults with diabetes and metabolic dyslipidemia.
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Solomon MD, Leong TK, Sung SH, Inveiss A, Hernandez JB, White RM, Sosa M, McNulty EJ, Go AS. TCT-443 Cost and Utilization Among Patients After Incident Percutaneous Coronary Intervention. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.08.459] [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: 10/23/2022]
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Kazi DS, Leong TK, Chang TI, Solomon MD, Hlatky MA, Go AS. Association of spontaneous bleeding and myocardial infarction with long-term mortality after percutaneous coronary intervention. J Am Coll Cardiol 2015; 65:1411-20. [PMID: 25857906 DOI: 10.1016/j.jacc.2015.01.047] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [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: 03/12/2014] [Revised: 01/04/2015] [Accepted: 01/22/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND Platelet inhibition after percutaneous coronary intervention (PCI) reduces the risk of myocardial infarction (MI) but increases the risk of bleeding. MIs and bleeds during the index hospitalization for PCI are known to negatively affect long-term outcomes. The impact of spontaneous bleeding occurring after discharge on long-term mortality is unknown. OBJECTIVES This study sought to examine, in a real-world cohort, the association between spontaneous major bleeding or MI after PCI and long-term mortality. METHODS We conducted a retrospective cohort study of patients ≥30 years of age who underwent a PCI between 1996 and 2008 in an integrated healthcare delivery system. We used extended Cox regression to examine the associations of spontaneous bleeding and MI with all-cause mortality, after adjustment for time-updated demographics, comorbidities, periprocedural events, and longitudinal medication exposure. RESULTS Among 32,906 patients who had a PCI and survived the index hospitalization, 530 had bleeds and 991 had MIs between 7 and 365 days post-discharge. There were 4,048 deaths over a mean follow-up of 4.42 years. The crude annual death rate after a spontaneous bleed (9.5%) or MI (7.6%) was higher than among patients who experienced neither event (2.6%). Bleeding was associated with an increased rate of death (adjusted hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.30 to 2.00), similar to that after an MI (HR: 1.91; 95% CI: 1.62 to 2.25). The association of bleeding with death remained significant after additional adjustment for the longitudinal use of antiplatelet agents. CONCLUSIONS Spontaneous bleeding after a PCI was independently associated with higher long-term mortality, and conveyed a risk comparable to that of an MI during follow-up. This tradeoff between efficacy and safety bolsters the argument for personalizing antiplatelet therapy after PCI on the basis of the patient's long-term risk of both thrombotic and bleeding events.
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Affiliation(s)
- Dhruv S Kazi
- Division of Cardiology, San Francisco General Hospital, San Francisco, California; Department of Medicine (Cardiology), University of California San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California.
| | - Thomas K Leong
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Tara I Chang
- Department of Medicine, Stanford University, Stanford, California
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, Stanford University, Stanford, California
| | - Mark A Hlatky
- Department of Medicine, Stanford University, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California
| | - Alan S Go
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Health Research and Policy, Stanford University, Stanford, California
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Hlatky MA, Andersson C, Chang TI, Kazi D, Solomon MD, Go AS. Reply: Beta-blockers for angina: time to reassess the specific impact of drug therapy in coronary heart disease patients. J Am Coll Cardiol 2014; 64:2712. [PMID: 25524354 DOI: 10.1016/j.jacc.2014.10.003] [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] [Received: 09/22/2014] [Accepted: 10/07/2014] [Indexed: 11/26/2022]
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Chang TI, Montez-Rath ME, Shen JI, Solomon MD, Chertow GM, Winkelmayer WC. Thienopyridine use after coronary stenting in low income patients enrolled in medicare part D receiving maintenance dialysis. J Am Heart Assoc 2014; 3:e001356. [PMID: 25336465 PMCID: PMC4323824 DOI: 10.1161/jaha.114.001356] [Citation(s) in RCA: 10] [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 Coronary stenting in patients on dialysis has increased by nearly 50% over the past decade, despite heightened risks of associated stent thrombosis and bleeding relative to the general population. We examined clopidogrel, prasugrel or ticlopidine use after percutaneous coronary intervention (PCI) with stenting in patients on dialysis. We conducted 3-, 6-, and 12-month landmark analyses to test the hypothesis that thienopyridine discontinuation prior to those time points would be associated with higher risks of death, myocardial infarction, or repeat revascularization, and a lower risk of major bleeding episodes compared with continued thienopyridine use. METHODS AND RESULTS Using the US Renal Data System, we identified 8458 patients on dialysis with Medicare Parts A+B+D undergoing PCI with stenting between July 2007 and December 2010. Ninety-nine percent of all thienopyridine prescriptions were for clopidogrel. At 3 months, 82% of patients who received drug-eluting stents (DES) had evidence of thienopyridine use. These proportions fell to 62% and 40% at 6 and 12 months, respectively. In patients who received a bare-metal stent (BMS), 70%, 34%, and 26% of patients had evidence of thienopyridine use at 3, 6, and 12 months, respectively. In patients who received a DES, there was a suggestion of higher risks of death or myocardial infarction associated with thienopyridine discontinuation in the 3-, 6-, and 12-months landmark analyses, but no higher risk of major bleeding episodes. In patients who received a BMS, there were no differences in death or cardiovascular events, and possibly lower risk of major bleeding with thienopyridine discontinuation in the 3- and 6-month landmark analyses. CONCLUSIONS The majority of patients on dialysis who undergo PCI discontinue thienopyridines before 1 year regardless of stent type. While not definitive, these data suggest that longer-term thienopyridine use may be of benefit to patients on dialysis who undergo PCI with DES.
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Affiliation(s)
- Tara I Chang
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.)
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.)
| | - Jenny I Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA (J.I.S.)
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA (M.D.S.)
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.)
| | - Wolfgang C Winkelmayer
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.) Section of Nephrology, Baylor College of Medicine, Houston, TX 77030-3411 (W.C.W.)
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Andersson C, Shilane D, Go AS, Chang TI, Kazi D, Solomon MD, Boothroyd DB, Hlatky MA. Beta-Blocker Therapy and Cardiac Events Among Patients With Newly Diagnosed Coronary Heart Disease. J Am Coll Cardiol 2014; 64:247-52. [DOI: 10.1016/j.jacc.2014.04.042] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 04/23/2014] [Accepted: 04/25/2014] [Indexed: 10/25/2022]
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Solomon MD, Go AS, Shilane D, Boothroyd DB, Leong TK, Kazi DS, Chang TI, Hlatky MA. Comparative Effectiveness of Clopidogrel in Medically Managed Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2014; 63:2249-57. [DOI: 10.1016/j.jacc.2014.02.586] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 01/24/2014] [Accepted: 02/05/2014] [Indexed: 11/25/2022]
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Romley JA, Juday T, Solomon MD, Seekins D, Brookmeyer R, Goldman DP. Early HIV Treatment Led To Life Expectancy Gains Valued At $80 Billion For People Infected In 1996–2009. Health Aff (Millwood) 2014; 33:370-7. [DOI: 10.1377/hlthaff.2013.0623] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- John A. Romley
- John A. Romley is a research assistant professor of public policy at the University of Southern California, in Los Angeles
| | - Timothy Juday
- Timothy Juday was director of health economics and outcomes research in virology and immunoscience for Bristol-Myers Squibb at the time of this research. He is now senior director of health economics and outcomes research in virology for AbbVie, in Chicago, Illinois
| | - Matthew D. Solomon
- Matthew D. Solomon is a consulting assistant professor of medicine at Stanford University, in California
| | - Daniel Seekins
- Daniel Seekins is group medical director, virology external collaborations, for Bristol-Myers Squibb, in Plainsboro, New Jersey
| | - Ronald Brookmeyer
- Ronald Brookmeyer is a professor of biostatistics at the University of California, Los Angeles
| | - Dana P. Goldman
- Dana P. Goldman is the Leonard D. Schaeffer Chair and director of the Schaeffer Center for Health Policy and Economics, University of Southern California
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Solomon MD, Vijan S, Forma FM, Conrad RM, Summers NT, Lakdawalla DN. The impact of insulin type on severe hypoglycaemia events requiring inpatient and emergency department care in patients with type 2 diabetes. Diabetes Res Clin Pract 2013; 102:175-82. [PMID: 24188928 DOI: 10.1016/j.diabres.2013.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 04/14/2013] [Accepted: 09/22/2013] [Indexed: 11/16/2022]
Abstract
AIMS To evaluate the risk from different insulin types on severe hypoglycaemia (SHG) events requiring inpatient (IP) or emergency department (ED) care in patients with type 2 diabetes. METHODS Type 2 diabetes patients newly started on insulin in a large commercial claims database were evaluated for SHG events. Patients were classified into an insulin group based on their most frequently used insulin type. Multivariable Cox models assessed the association between insulin type and the risk of SHG events. RESULTS We identified 8626 patients (mean age 53.5 years; 55% female) with type 2 diabetes followed for an average of 4.0 years after insulin initiation. Of these, 161 (1.9%) had a SHG event at an average of 3.1y after insulin initiation. Patients with SHG events were slightly older (56.4 vs. 53.4 years), used a similar number of OADs (1.1 vs. 1.2) but had more co-morbidities compared with those without SHG events. In multivariate Cox models, premixed insulin (HR 2.12; p<0.01), isophane insulin (NPH) (HR 2.02; p<0.01), and rapid acting insulin (HR 2.75; p<0.01) had significantly higher risks of SHG events compared with glargine. No statistically significant difference in SHG events was seen with detemir (HR 1.20; p=0.73). CONCLUSIONS Among patients with type 2 diabetes, the use of newer basal insulin analogues was associated with lower rates of SHG events requiring IP or ED care compared with users of other insulin formulations. Future research should examine the impact of hypoglycaemia events of different severity levels.
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Lakdawalla D, Turakhia MP, Jhaveri M, Mozaffari E, Davis P, Bradley L, Solomon MD. Comparative effectiveness of antiarrhythmic drugs on cardiovascular hospitalization and mortality in atrial fibrillation. J Comp Eff Res 2013; 2:301-12. [PMID: 24236629 DOI: 10.2217/cer.13.19] [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] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To assess, through a systematic review, evidence for the effects of antiarrhythmic drugs (AADs) on cardiovascular (CV) hospitalization and mortality. MATERIALS & METHODS English language articles were identified using MEDLINE, EMBASE and the Cochrane Clinical Trial Registry and were screened for study applicability and methodological quality. RESULTS Out of 3526 identified studies, 38 were selected for analysis (19 evaluated individual AADs, 13 compared rate- versus rhythm-control strategies, and 6 evaluated multiple AADs but did not report outcomes for individual agents). None of the studies examining individual AADs employed the CV hospitalization end point used in ATHENA (the reference trial). There were no head-to-head comparisons of individual AADs on CV hospitalization. Most high-quality studies used multidrug rate- versus rhythm-control strategies. CONCLUSION Assessment of the comparative effectiveness of individual AADs on CV hospitalization and mortality end points is not possible with the current evidence.
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Affiliation(s)
- Darius Lakdawalla
- Leonard D Schaeffer Center for Health Policy & Economics, University of Southern California, 650 Childs Way, Los Angeles, CA 90089-90626, USA.
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Turakhia MP, Solomon MD, Jhaveri M, Davis P, Eber MR, Conrad R, Summers N, Lakdawalla D. Burden, timing, and relationship of cardiovascular hospitalization to mortality among Medicare beneficiaries with newly diagnosed atrial fibrillation. Am Heart J 2013; 166:573-80. [PMID: 24016509 DOI: 10.1016/j.ahj.2013.07.003] [Citation(s) in RCA: 16] [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: 02/04/2013] [Accepted: 07/01/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Limited data exist on the burden and relationship of cardiovascular (CV) hospitalization to mortality after newly diagnosed with atrial fibrillation (AF). METHODS Using a 20% sample of nationwide Medicare Part A and B claims data, we performed a retrospective cohort study of Medicare beneficiaries with newly diagnosed AF (2004-2008). Cox proportional hazards time-varying exposures were used to determine the risk of death among patients with CV hospitalization after AF diagnosis. RESULTS Of 228,295 patients (mean age 79.6 ± 7.4 years, 56% female), 57% had a CV hospitalization after diagnosis of AF (41% in the first year). The most common primary CV hospitalization diagnoses were AF/supraventricular arrhythmias (21%), heart failure (19%), myocardial infarction (11%), and stroke/transient ischemic attack (7.7%). Incidence rates per 1,000 person-years among patients with and without CV hospitalization were 114 and 87, respectively, for all-cause mortality. After adjustment for covariates and time to CV hospitalization, the hazard of mortality among newly diagnosed AF patients with CV hospitalization, compared with those without CV hospitalization, was higher (hazard ratio 1.22, 95% CI 1.20-1.24). CONCLUSIONS Cardiovascular hospitalization is common in the first year after AF diagnosis. Atrial fibrillation, heart failure, myocardial infarction, and stroke/transient ischemic attack account for half of primary hospitalization diagnosis. Cardiovascular hospitalization is independently associated with mortality, irrespective of time from diagnosis to first hospitalization, and represents a critical inflection point in survival trajectory. These findings highlight the importance of CV hospitalization as a marker of disease progression and poor outcomes. Efforts to clarify the determinants of hospitalization could inform interventions to reduce admissions and improve survival.
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Solomon MD, Tirupsur A, Hytopoulos E, Beggs M, Harrington DS, French C, Quertermous T. Clinical utility of a novel coronary heart disease risk-assessment test to further classify intermediate-risk patients. Clin Cardiol 2013; 36:621-7. [PMID: 23929798 PMCID: PMC4231217 DOI: 10.1002/clc.22185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Revised: 07/02/2013] [Indexed: 12/20/2022] Open
Abstract
Background Current coronary heart disease (CHD) risk assessments inadequately assess intermediate‐risk patients, leaving many undertreated and vulnerable to heart attacks. A novel CHD risk‐assessment (CHDRA) tool was developed for intermediate‐risk stratification using biomarkers and established risk factors to significantly improve CHD risk discrimination. Hypothesis Physicians will change their treatment plan in response to more information about a patient's CHD risk level provided by the CHDRA test. Methods A Web‐based survey of cardiology, internal medicine, family practice, and obstetrics/gynecology physicians (n = 206) was conducted to assess the CHDRA clinical impact. Each physician was shown 3 clinical vignettes representing community‐based cohort participants randomly selected from 8 total vignettes. For each, the physicians assessed the individual's CHD risk and selected preferred therapies based on the individual's comorbidities, physical examination, and laboratory results. The individual's CHDRA score was then provided and the physicians were queried for changes to their initial treatment plans. Results After obtaining the CHDRA result, 70% of the physician responses indicated a change to the patient's treatment plan. The revised lipid‐management plans agreed more often (74.6% of the time) with the current Adult Treatment Panel III guidelines than did the original plans (57.6% of the time). Most physicians (71.3%) agreed with the statement that the CHDRA result provided information that would impact their current treatment decisions. Conclusions The CHDRA test provided additional information to which physicians responded by more often applying appropriate therapy and actions aligned with guidelines, thus demonstrating the clinical utility of the test.
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Affiliation(s)
- Matthew D Solomon
- Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
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