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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 werematched 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 crossimmunity may play a role in protection against severe COVID-19. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The article offers information on the decrease in the number of patients presenting to hospitals because of emergency conditions such as acute myocardial infarction during the Covid-19 pandemic. It examined patient characteristics and weekly incidence rates of hospitalization for acute myocardial infarction.

Objectives: This study sought to examine the effectiveness of clopidogrel in real-world, medically managed patients with unstable angina (UA) or non–ST-segment elevation myocardial infarction (NSTEMI). Background: Although clinical trials have demonstrated the efficacy of clopidogrel to reduce cardiovascular (CV) morbidity and mortality in medically managed patients with UA or NSTEMI, the effectiveness of clopidogrel in actual clinical practice is less certain. Methods: A retrospective cohort study was conducted of Kaiser Permanente Northern California members without known coronary artery disease or prior clopidogrel use who presented with UA or NSTEMI between 2003 and 2008 and were medically managed (i.e., no percutaneous coronary intervention or coronary artery bypass grafting during the index hospitalization or within 7 days post-discharge). Over 2 years of follow-up, we measured the association between clopidogrel use and all-cause mortality, hospital stay for MI, and a composite endpoint of death or MI using propensity-matched multivariable Cox analyses. Results: We identified 16,365 patients with incident UA (35%) or NSTEMI (65%); 36% of these patients were prescribed clopidogrel within 7 days of discharge. In 8,562 propensity score–matched patients, clopidogrel users had lower rates of all-cause mortality (8.3% vs. 13.0%; p < 0.01; adjusted hazard ratio [HR]: 0.63; 95% confidence interval [CI]: 0.54 to 0.72) and the composite of death or MI (13.5% vs. 17.4%; p < 0.01; HR: 0.74, CI: 0.66 to 0.84), but not MI alone (6.7% vs. 7.2%; p = 0.30; HR: 0.93, CI: 0.78 to 1.11), compared with nonusers of clopidogrel. The association between clopidogrel use and the composite of death or MI was significant only among patients presenting with NSTEMI (HR: 0.67; CI: 0.59 to 0.76; pint < 0.01), not among those presenting with UA (HR: 1.25; CI: 0.94 to 1.67). Conclusions: In a large, community-based cohort of patients who were medically managed after UA/NSTEMI, clopidogrel use was associated with a lower risk of death and MI, particularly among patients with NSTEMI. [Copyright &y& Elsevier]

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. [Copyright &y& Elsevier]

Objectives: This study sought to compare use of evidence-based secondary preventive medications after coronary bypass surgery (CABG) and percutaneous coronary intervention (PCI). Background: Use of cardioprotective medication after coronary revascularization has been inconsistent and relatively low in older studies. Methods: We studied patients in a large integrated healthcare delivery system who underwent CABG or PCI for new onset coronary disease. We used data from health plan databases about prescriptions dispensed during the first year after initial coronary revascularization to identify patients who never filled a prescription and to calculate the medication possession ratio among patients who filled at least 1 prescription. We focused on angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARBs), beta-blockers, and statins. Results: Between 2000 and 2007, 8,837 patients with new onset coronary disease underwent initial CABG, and 14,516 underwent initial PCI. Patients receiving CABG were more likely than patients receiving PCI to not fill a prescription for a statin (7.1% vs. 4.8%, p < 0.0001) or for an ACEI/ARB (29.1% vs. 22.4%, p < 0.0001), but similar proportions never filled a prescription for a beta-blocker (6.4% vs. 6.1%). Among those who filled at least 1 prescription post-revascularization, patients receiving CABG had lower medication possession ratios than patients receiving PCI for ACEI/ARBs (69.4% vs. 77.8%, p < 0.0001), beta-blockers (76.1% vs. 80.6%, p < 0.0001), and statins (82.7% vs. 84.2%, p < 0.001). Conclusions: Patients who received CABG were generally less likely than patients who received PCI to fill prescriptions for secondary preventive medications and to use those medications consistently in the first year after the procedure. [ABSTRACT FROM AUTHOR]

The article focuses on the study conducted on the effect of cost sharing on the initiation of drug treatment for newly diagnosed chronically ill patients. A retrospective cohort study was conducted in 17,183 older adults with hypertension, hypercholesterolemia and diabetes, and with drug coverage from different health plans provided by their employers. The study reveals that the increased cost sharing hinders the initiation of medications for patients with chronic disease. However, it mentions that the case only has greater effects on patients who have less experience with prescription drugs. It suggests physicians and lawmakers to consider the effects of cost sharing on patients' behavior in order to encourage the development of a necessary care.

In this article the author reflect on a study on how often patients do not fill prescriptions by measuring primary nonadherence for a population of commercially insured outpatients. It found that almost one-quarter of all prescriptions written went unfilled and 8.3% of all new prescriptions went unfilled. After exploring multiple drug classes, the researchers found that the least filled class was pain medications. The authors comment on patient behavior and implications of the study for prescribing doctors.

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. 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. 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. The population prevalence of AS has grown considerably over a short timeframe although the distribution of AS severity has remained stable. • The prevalence of aortic stenosis has grown substantially. • The prevalence of aortic stenosis is lower for Asian/Pacific Islanders. • The distribution of aortic stenosis severity has not changed over time. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The optimal coronary revascularization strategy to maximize the patient‐centered outcome of days alive and out of hospital (DAOH), in multimorbid older (≥65‐years) adults after an acute coronary syndrome (ACS) is incompletely understood. Methods: Using Kaiser Permanente Northern California Health Plan databases, we identified 3871 patients ≥65‐years presenting with ACS between 1/1/2010–3/1/2018 who underwent coronary revascularization with either coronary artery bypass grafting (CABG, N = 1575) or multivessel percutaneous coronary intervention (PCI, N = 2296). Selection bias was accounted for through propensity score modeling techniques and inverse probability of treatment weighting. Cox proportional hazards models were fit to evaluate the association of revascularization type with outcomes. Primary Outcomes: Absolute DAOH and the relative risk of achieving ≥90%DAOH during three time intervals. Secondary Outcomes: All‐cause mortality, recurrent MI, stroke, rehospitalization, repeat revascularization, and dialysis initiation. Results: CABG (compared to PCI) was associated with greater absolute number of DAOH, significant after the first year (mean difference at 1‐year: +5.8 days, 95% confidence interval [CI], −1.6 to 13 days; 3‐years: +56 days, 95%CI, +25 to +88 days; 5‐years: + 131 days, 95%CI, +57 to +205 days). The relative risk of achieving ≥90% DAOH significantly favored CABG after the first year (1‐year:1.02, 95%CI, 0.98–1.05; 3‐years:1.06, 95%CI 1.002–1.11, 5‐years:1.12, 95%CI, 1.03–1.22), and was related to lower incidences of all‐cause mortality, repeat revascularization, rehospitalization, incident dialysis, and nonfatal MI with CABG. Conclusions: In older adults with multivessel or left main coronary artery disease who presented with ACS, CABG, after the first year, was associated with a greater absolute number of DAOH—a geriatric and patient‐centered outcome, compared to PCI. CABG patients also had a higher probability of achieving ≥90%DAOH—with lower all‐cause mortality, recurrent MI, repeat revascularization, new dialysis, and rehospitalization rates. Future randomized trials should study the impact of optimal revascularization strategies on the quality of life of older adults with multimorbidity. See related editorial by Hanna et al. in this issue. [ABSTRACT FROM AUTHOR]

In late 2009 US guidelines for HIV treatment were revised to recommend the initiation of combination antiretroviral therapy (cART) earlier in the course of the disease. We analyzed the life expectancy gains of people infected with HIV between the introduction of cART in 1996 and the 2009 guideline revisions. Compared to people who initiated cART late (defined as having a CD4 cell count of less than 350 per cubic millimeter of blood), those who initiated treatment early (with a CD4 count of 350-500) could expect to live 6.1 years longer, and the earliest initiators (with a CD4 count of more than 500) could expect an extra 9.0 years of life. The total value of life expectancy gains to the early and earliest initiators of treatment was $80 billion, with each life-year valued at $150,000. The value of the survival gains was more than double the increase in drug manufacturers' revenues from early cART initiation. Our results clarify the economic implications of adherence to treatment guidelines. [ABSTRACT FROM AUTHOR]

Background. The specialist's role in caring for managed care patients is likely to grow. Thus, assessing the correlates of patient satisfaction with specialty care is essential. Objective. To examine the association between characteristics of eye care practices and satisfaction with eye care among working age patients with open-angle glaucoma (OAG) or diabetic retinopathy (DR). Subjects/Study Setting. A total of 913 working age patients with OAG or DR enrolled in six commercial managed care health plans. The patients were treated in 144 different eye care practices. Study Design. We used a patient survey to obtain information on patient characteristics and satisfaction with eye care, measured by scores on satisfaction subscales of the 18-item Patient Satisfaction Questionnaire. We used a survey of eye care practices to obtain information on practice characteristics, including provider specialties, practice organization, financial features, and utilization and quality management systems. We estimated logistic regression models to assess the association of patient and practice characteristics with high levels of patient satisfaction. Principal Findings. Treatment in a practice with a glaucoma specialist (for OAG patients) or a retina specialist (for DR patients) was associated with higher satisfaction, whereas treatment in a practice that obtained a high proportion of its revenues from capitation payments or in a group practice where providers obtained a high proportion of their incomes from bonuses was associated with lower satisfaction. Conclusions. Many eye care patients prefer to be treated by specialists with expertise in their conditions. Financial arrangement features of eye care practices also are associated with patient satisfaction with care. The most likely mechanisms underlying these associations are effects on provider behavior and satisfaction, which in turn influence patient satisfaction. Managed care plans and provider groups should aim to minimize the negative impact of managed care features on patient satisfaction. [ABSTRACT FROM AUTHOR]

Context: With drug spending rising rapidly for working-aged adults, many employers and health insurance providers have changed benefits packages to encourage use of fewer or less expensive drugs. It is unknown how these initiatives affect drug costs. Objective: To examine how innovations in benefits packages, such as those that include multitier formularies and mandatory generic substitution, affect total cost to insurance providers for generic and brand drugs and out-of-pocket payments to beneficiaries. Design and Participants: Retrospective study from 1997 to 1999 linking claims data of 420 786 primary beneficiaries aged 18 through 64 years who worked at large firms (n = 25) with health insurance benefits that included outpatient drugs. Main Outcome Measures: Overall drug costs; generic, single-source brand, and multisource brand costs; and drug expenditures by health insurance providers and out-of-pocket costs for beneficiaries. Results: For a 1-tier plan with a $5 co-payment for all drugs, the average annual spending was $725 per member. Doubling co-payments to $10 for all drugs reduced the annual average drug cost from $725 to $563 per member (22.3%, P<.001). Doubling co-payments in a 2-tier plan from $5 for generics and $10 for brand drugs to $10 for generics and $20 for brand drugs reduced costs from $678 to $455 (32.9%, P<.001). Adding an additional co-payment of $30 for nonpreferred brand drugs to a 2-tier plan ($10 generics; $20 brand) lowered overall drug spending by 4% (P<.001). Requiring mandatory generic substitution in a 2-tier plan reduced drug spending by 8% (P<.001). Doubling co-payments in a 2-tier plan increased the fraction beneficiaries' paid out-of-pocket from 17.6% to 25.6%. Conclusions: Adding an additional level of co-payment, increasing existing co-payments or coinsurance rates, and requiring mandatory generic substitution all reduced plan payments and overall drug spending among working-age enrollees with employer-provided drug... [ABSTRACT FROM AUTHOR]

Introduction: While coronary disease is common in end-stage renal disease, there are few studies of thienopyridine use after PCI in this population. Guidelines recommend 1 to 12 months of thienopyridine use depending on stent type, but are based on patients without advanced kidney disease. However, patients on dialysis often have more severe coronary disease and higher risks of bleeding. We hypothesized that in patients on dialysis undergoing PCI with stenting: 1) most will discontinue thienopyridines prior to 1 year; 2) discontinuation of thienopyridines prior to 6 months post-PCI will associate with higher risks of death or MI, but a lower risk of bleeding. Methods: Using the US Renal Data System, we identified patients on dialysis with Medicare Parts A+B+D (with low-income subsidy) who had PCI with stenting between 7/07 and 12/09. Thienopyridine discontinuation was defined as >30-day gap in supply. We performed a landmark analysis, selecting patients who were event-free at 6 months after PCI, and categorized them as having discontinued thienopyridines or not at that point. We propensity-matched patients for discontinued vs. continued use and fit Cox models to examine death, death or MI, and hospitalized bleeding. Results: We identified 4686 patients, 66% of whom received a drug-eluting stent [DES]. At 90-days, 78% of DES and 65% of bare metal stent (BMS) patients used a thienopyridine; this proportion fell to 64% and 48% at 6 months, and 42% and 29% at 1 year. Overall rates of death and MI were high (Table). In the matched cohorts, patients who discontinued thienopyridine use prior to 6 months (vs. continued use) had no significant differences in long-term outcomes (Table). Conclusions: In patients on dialysis who undergo PCI with stenting, most use thienopyridines for <1 year. Continued thienopyridine use at 6 months was not associated with a significant benefit or with higher bleeding risk. Our study highlights the need for future trials to determine the optimal duration of thienopyridine use after PCI in this high-risk population. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Enrollment in high-deductible health plans is increasing out-of-pocket spending. But innovative plans that pair deductibles with value-based insurance designs can help preserve low-cost access to high-value treatments for patients by aligning coverage with clinical value. Among adults in high-deductible health plans who were prescribed medications for chronic conditions, we examined what impact a value-based pharmacy benefit that offered free chronic disease medications had on medication adherence. Overall, we found that the value-based plan offset reductions in medication adherence associated with switching to a deductible plan. The value-based plan appeared particularly beneficial for patients who started with low levels of medication adherence. Patients with additional clinical complexity or vulnerable populations living in neighborhoods with lower socioeconomic status, however, did not show adherence improvements and might not be taking advantage of value-based insurance design provisions. Additional efforts may be needed to educate patients about their nuanced benefit plans to help overcome initial confusion about these complex plans. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background The effectiveness of beta-blockers for preventing cardiac events has been questioned for patients who have coronary heart disease (CHD) without a prior myocardial infarction (MI). Objectives The purpose of this study was to assess the association of beta-blockers with outcomes among patients with new-onset CHD. Methods We studied consecutive patients discharged after the first CHD event (acute coronary syndrome or coronary revascularization) between 2000 and 2008 in an integrated healthcare delivery system who did not use beta-blockers in the year before entry. We used time-varying Cox regression models to determine the hazard ratio (HR) associated with beta-blocker treatment and used treatment-by-covariate interaction tests (pint) to determine whether the association differed for patients with or without a recent MI. Results A total of 26,793 patients were included, 19,843 of whom initiated beta-blocker treatment within 7 days of discharge from their initial CHD event. Over an average of 3.7 years of follow-up, 6,968 patients had an MI or died. Use of beta-blockers was associated with an adjusted HR for mortality of 0.90 (95% confidence limits [CL]: 0.84 to 0.96), and an adjusted HR for death or MI of 0.92 (CL: 0.87 to 0.97). The association between beta-blockers and outcomes differed significantly between patients with and without a recent MI (HR for death: 0.85 vs. 1.02, pint = 0.007; and HR for death or MI: 0.87 vs. 1.03, pint = 0.005). Conclusions Use of beta-blockers among patients with new-onset CHD was associated with a lower risk of cardiac events only among patients with a recent MI. [ABSTRACT FROM AUTHOR]

Background: Randomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality.Objective: To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population.Design: Observational treatment comparison using propensity score matching and Cox proportional hazards models.Setting: United States, 1992 to 2008.Patients: Medicare beneficiaries aged 66 years or older.Intervention: Multivessel CABG or multivessel PCI.Measurements: The CABG-PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up.Results: Among 105 156 propensity score-matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P ≤ 0.002 for each) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-years (range, -0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI.Limitation: Treatments were chosen by patients and physicians rather than being randomly assigned.Conclusion: Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease.Primary Funding Source: National Heart, Lung, and Blood Institute. [ABSTRACT FROM AUTHOR]

Background: Randomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality. Objective: To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population. Design: Observational treatment comparison using propensity score matching and Cox proportional hazards models. Setting: United States, 1992 to 2008. Patients: Medicare beneficiaries aged 66 years or older. Intervention: Multivessel CABG or multivessel PCI. Measurements: The CABG-PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up. Results: Among 105 156 propensity score-matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P = 0.002 for each) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-years (range, -0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI. Limitation: Treatments were chosen by patients and physicians rather than being randomly assigned. Conclusion: Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease. Primary Funding Source: National Heart, Lung, and Blood Institute. [ABSTRACT FROM AUTHOR]

Despite data that traditional laboratory-based outcome measures in dialysis are improving over time, population-based data indicate that mortality rates are not improving in parallel. With increased focus on performance measures based on laboratory-based outcomes (e.g., hematocrit, albumin, and parathyroid hormone), less emphasis has been placed on other markers, some of which may be stronger predictors of mortality. We performed a systematic review to interpret the predictive value of laboratory-based outcome measures in dialysis. We identified studies with data regarding the predictive value of laboratory-based outcomes for mortality in dialysis. We calculated the sample size-weighted pooled relative risk of death with dichotomized “high” vs. “low” levels of each measure. We rank-ordered predictors by scaling the pooled relative risk of each measure by its pooled standard deviation. There were 5171 titles, of which 128 (representing 44 laboratory-based outcomes) were selected. Nine were significantly associated with mortality, in order of decreasing scaled effect size: (1) tumor necrosis factor-α, (2) hematocrit, (3) interleukin-6, (4) troponin T, (5) Kt/Vurea, (6) prealbumin, (7) urea reduction ratio, (8) serum albumin, and (9) C-reactive protein. Other oft-cited measures such as calcium phosphate product and parathyroid hormone were not significantly associated with mortality in pooled analysis. Quality improvement efforts to improve traditional laboratory-based outcomes in end-stage renal disease are necessary, but likely insufficient, to improve overall mortality in dialysis. Renewed consideration of cardiovascular, inflammatory, and nutritional markers that are especially strong predictors of mortality may have important implications for risk stratification and targeted therapeutic interventions. [ABSTRACT FROM AUTHOR]

Context Many health plans have instituted more cost sharing to discourage use of more expensive pharmaceuticals and to reduce drug spending. Objective To determine how changes in cost sharing affect use of the most commonly used drug classes among the privately insured and the chronically ill. Design, Setting, and Participants Retrospective US study conducted from 1997 to 2000, examining linked pharmacy claims data with health plan benefit designs from 30 employers and 52 health plans. Participants were 528 969 privately insured beneficiaries aged 18 to 64 years and enrolled from 1 to 4 years (960 791 person-years). Main Outcome Measure Relative change in drug days supplied (per member, per year) when co-payments doubled in a prototypical drug benefit plan. Results Doubling co-payments was associated with reductions in use of 8 therapeutic classes. The largest decreases occurred for nonsteroidal anti-inflammatory drugs (NSAIDs) (45%) and antihistamines (44%). Reductions in overall days supplied of antihyperlipidemics (34%), antiulcerants (33%), antiasthmatics (32%), antihypertensives (26%), antidepressants (26%), and antidiabetics (25%) were also observed. Among patients diagnosed as having a chronic illness and receiving ongoing care, use was less responsive to co-payment changes. Use of antidepressants by depressed patients declined by 8%; use of antihypertensives by hypertensive patients decreased by 10%. Larger reductions were observed for arthritis patients taking NSAIDs (27%) and allergy patients taking antihistamines (31%). Patients with diabetes reduced their use of antidiabetes drugs by 23%. Conclusions The use of medications such as antihistamines and NSAIDs, which are taken intermittently to treat symptoms, was sensitive to co-payment changes. Other medications—antihypertensive, antiasthmatic, antidepressant, antihyperlipidemic, antiulcerant, and antidiabetic agents—also demonstrated significant price responsiveness. The reduction in use ... [ABSTRACT FROM AUTHOR]

Introduction: The American Heart Association (AHA) overall cardiovascular health (CVH) metric categorizes 7 targeted cardiovascular disease risk factors and health behaviors as "ideal," "intermediate," or "poor" for adults. We examined the association between these CVH categories and subsequent healthcare utilization in a large, diverse population. Methods: Kaiser Permanente Northern California (KPNC) is an integrated health care delivery system caring for >4.4 million members. We assessed 6 AHA metrics (smoking, physical activity, body mass index, blood pressure, total cholesterol, and blood glucose), each graded on a scale of 0 to 2, with 2 indicating "ideal" status, 1 "intermediate" status, and 0 "poor" status. Points were summed across health metrics to define three overall CVH categories: Poor (0-6), Intermediate (7-9) and Ideal (10-12). Individual-level health care utilization and costs (in 2015) were extracted from administrative databases for hospital, outpatient, pharmacy, emergency department (ED) and other services. We calculated average cost per patient from the total population, and then we determined costs for each service relative to the 'average cost per patient', across CVH categories and stratified by age categories. Results: Among 991,698 adult members (57.0% female) with all 6 metrics, 194,003 (19.6%) were age 18-39, 554,129 (55.9%) age 40-64, and 243,566 (24.6%) age ≥65 years. Poor CVH was present in 21.2%, intermediate CVH in 52.6% and ideal CVH in 26.2%. Overall costs increased monotonically across age categories, but better overall CVH was associated with lower relative cost in each age group (p<0.001 for trend; Figure). Conclusions: In a large real-world population, adults with ideal CVH had significantly lower total health care costs. Future research should consider pragmatic trials to test the clinical and cost-effectiveness of upstream wellness and prevention interventions to improve CVH. [ABSTRACT FROM AUTHOR]

Introduction: The Kaiser Permanente ASCVD Risk Estimator (KPARE) was developed to address the systematic overestimation of actual ASCVD risk by the ACC/AHA ASCVD Pooled Cohort Equation (ACC/AHA PCE) in contemporary populations. We evaluated the accuracy and generalizability of KPARE for estimating 10-year ASCVD risk in eligible primary prevention, community-based populations in the U.S. and Canada, as compared with the ACC/AHA PCE. Methods: We identified adults 40-79 years old in 3 contemporary U.S. populations (Kaiser Permanente Northern California (KPNC), Southern California (KPSC) and Northwest (KPNW), as well as adults 66-79 years old in Ontario, Canada who had LDL-C 70-189 mg/dL, no known ASCVD, diabetes or lipid-lowering therapy and had complete follow-up. Non-fatal and fatal ASCVD events were ascertained from health system electronic health records and death certificates using validated algorithms. We examined observed ASCVD event rates within deciles of predicted 10-year risk using the KPARE vs. the ACC/AHA PCE predicted risk, and calculated metrics of discrimination and calibration. Results: In eligible primary prevention validation cohorts of KPNC (N=151,409), KPSC (N=246,815), KPNW (N=46,784), and Ontario, Canada (N=60,612 adults), the KPARE showed both better discrimination and calibration (Figure) compared to the ACC/AHA PCE to predict 10-year risk of ASCVD events, with c-statistics of 0.78, 0.78, 0.79, and 0.65, respectively. Categorical net reclassification index showed the KPARE improved ASCVD risk prediction over the ACC/AHA PCE by 23% in the KPNC validation cohort, 24% in KPSC, 33% in KPNW, and 25% in Ontario, Canada. Results were similar when stratified by race-gender subgroups. Conclusions: The new Kaiser Permanente ASCVD Risk Estimator provides more accurate ASCVD risk estimates in various community populations than the ACC/AHA PCE and may provide greater utility in shared decision-making for primary prevention strategies. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]