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ImportanceBlack adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown.ObjectiveTo compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals.Design, Setting, and ParticipantsPatients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022.ExposuresHospitals caring for high proportions of Black patients.Main Outcomes and MeasuresQuality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients.ResultsThis study included 422 483 patients (224 270 male [53.1%] and 284 618 White [67.4%]) with a mean age of 73.0 years. Among 480 hospitals participating in GWTG-HF, 96 were classified as hospitals with high proportions of Black patients. Quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of 14 GWTG-HF measures, including use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91; 95% CI, 0.65-1.27), evidence-based β-blockers (94.7% vs 93.7%; OR, 1.02; 95% CI, 0.82-1.28), angiotensin receptor neprilysin inhibitors at discharge (14.3% vs 16.8%; OR, 0.74; 95% CI, 0.54-1.02), anticoagulation for atrial fibrillation/flutter (88.8% vs 87.5%; OR, 1.05; 95% CI, 0.76-1.45), and implantable cardioverter-defibrillator counseling/placement/prescription at discharge (70.9% vs 71.0%; OR, 0.75; 95% CI, 0.50-1.13). Patients at high-proportion Black hospitals were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; 95% CI, 0.53-0.86), receive cardiac resynchronization device placement/prescription (50.6% vs 53.8%; OR, 0.63; 95% CI, 0.42-0.95), or an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; 95% CI, 0.50-0.97). Overall defect-free HF care was similar between both groups of hospitals (82.6% vs 83.4%; OR, 0.89; 95% CI, 0.67-1.19) and there were no significant within-hospital differences in quality for Black patients vs White patients. Among Medicare beneficiaries, the risk-adjusted hazard ratio (HR) for 30-day readmissions was higher at high-proportion Black vs other hospitals (HR, 1.14; 95% CI, 1.02-1.26), but similar for 30-day mortality (HR 0.92; 95% CI,0.84-1.02).Conclusions and RelevanceQuality of care for HF was similar across 11 of 14 measures at hospitals caring for high proportions of Black patients compared with other hospitals, as was overall defect-free HF care. There were no significant within-hospital differences in quality for Black patients vs White patients.

ImportanceDeclines in cardiovascular mortality have stagnated in the US over the past decade, in part related to worsening risk factor control in older adults. Little is known about how the prevalence, treatment, and control of cardiovascular risk factors have changed among young adults aged 20 to 44 years.ObjectiveTo determine if the prevalence of cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, obesity, and tobacco use), treatment rates, and control changed among adults aged 20 to 44 years from 2009 through March 2020, overall and by sex and race and ethnicity.Design, Setting, and ParticipantsSerial cross-sectional analysis of adults aged 20 to 44 years in the US participating in the National Health and Nutrition Examination Survey (2009-2010 to 2017–March 2020).Main Outcomes and MeasuresNational trends in the prevalence of hypertension, diabetes, hyperlipidemia, obesity, and smoking history; treatment rates for hypertension and diabetes; and blood pressure and glycemic control in those receiving treatment.ResultsAmong 12 924 US adults aged 20 to 44 years (mean age, 31.8 years; 50.6% women), the prevalence of hypertension was 9.3% (95% CI, 8.1%-10.5%) in 2009-2010 and 11.5% (95% CI, 9.6%-13.4%) in 2017-2020. The prevalence of diabetes (from 3.0% [95% CI, 2.2%-3.7%] to 4.1% [95% CI, 3.5%-4.7%]) and obesity (from 32.7% [95% CI, 30.1%-35.3%] to 40.9% [95% CI, 37.5%-44.3%]) increased from 2009-2010 to 2017-2020, while the prevalence of hyperlipidemia decreased (from 40.5% [95% CI, 38.6%-42.3%] to 36.1% [95% CI, 33.5%-38.7%]). Black adults had high rates of hypertension across the study period (2009-2010: 16.2% [95% CI, 14.0%-18.4%]; 2017-2020: 20.1% [95% CI, 16.8%-23.3%]), and significant increases in hypertension were observed among Mexican American adults (from 6.5% [95% CI, 5.0%-8.0%] to 9.5% [95% CI, 7.3%-11.7%]) and other Hispanic adults (from 4.4% [95% CI, 2.1%-6.8%] to 10.5% [95% CI, 6.8%-14.3%]), while Mexican American adults had a significant rise in diabetes (from 4.3% [95% CI, 2.3%-6.2%] to 7.5% [95% CI, 5.4%-9.6%]). The percentage of young adults treated for hypertension who achieved blood pressure control did not significantly change (from 65.0% [95% CI, 55.8%-74.2%] in 2009-2010 to 74.8% [95% CI, 67.5%-82.1%] in 2017-2020], while glycemic control among young adults receiving treatment for diabetes remained suboptimal throughout the study period (2009-2010: 45.5% [95% CI, 27.7%-63.3%]) to 2017-2020: 56.6% [95% CI, 39.2%-73.9%]).Conclusions and RelevanceIn the US, diabetes and obesity increased among young adults from 2009 to March 2020, while hypertension did not change and hyperlipidemia declined. There was variation in trends by race and ethnicity.

High lipid concentrations are a modifiable risk factor for cardiovascular disease. Little is known about how population-level lipid concentrations, as well as trends in lipid control, have changed over the past decade among US adults.To determine whether lipid concentrations and rates of lipid control changed among US adults and whether these trends differed by sex and race and ethnicity, from 2007 to 2018.Serial cross-sectional analysis of 33 040 US adults aged 20 years or older, weighted to be nationally representative, from the National Health and Nutrition Examination Surveys (2007-2008 to 2017-2018).Lipid concentrations among US adults and rates of lipid control among adults receiving statin therapy. Lipid control was defined as a total cholesterol concentration of 200 mg/dL or less.The mean age of the study population was 47.4 years, and 51.4% were women; of the 33 040 participants, 12.0% were non-Hispanic Black; 10.3%, Mexican American; 6.4%, other Hispanic American; 62.7%, non-Hispanic White; and 8.5%, other race and ethnicities (including non-Hispanic Asian. Among all US adults, age-adjusted total cholesterol improved significantly in the overall population from 197 mg/dL in 2007-2008 to 189 mg/dL in 2017-2018 (difference, -8.6 mg/dL [95% CI, -12.2 to -4.9 mg/dL]; P for trend.001), with similar patterns for men and women. Black, Mexican American, other Hispanic, and White adults experienced significant improvements in total cholesterol, but no significant change was observed for Asian adults. Among adults receiving statin therapy, age-adjusted lipid control rates did not significantly change from 78.5% in 2007-2008 to 79.5% in 2017-2018 (difference, 1.1% [95% CI, -3.7% to 5.8%]; P for trend = .27), and these patterns were similar for men and women. Across all racial and ethnic groups, only Mexican Americans experienced a significant improvement in age-adjusted lipid control (P for trend = .008). In 2015-2018, age-adjusted rates of lipid control were significantly lower for women than for men (OR, 0.54 [95% CI, 0.40 to 0.72]). In addition, when compared with White adults, rates of lipid control while taking statins were significantly lower among Black adults (OR, 0.66 [95% CI, 0.47 to 0.94]) and other Hispanic adults (OR, 0.59 [95% CI, 0.37 to 0.95]); no significant differences were observed for other racial and ethnic groups.In this serial cross-sectional study, lipid concentrations improved in the US adult population from 2007-2008 through 2017-2018. These patterns were observed across all racial and ethnic subgroups, with the exception of non-Hispanic Asian adults.

This study describes demographic characteristics and hospital bed capacities of the 5 New York City boroughs, and evaluates whether differences in testing for coronavirus disease 2019 (COVID-19), hospitalizations, and deaths have emerged as a signal of racial, ethnic, and financial disparities.

This comparative effectiveness research study uses Medicare claims data to examine the total number of days at home among intermediate-risk patients recovering from transcatheter aortic valve replacement (TAVR) vs patients recovering from surgical aortic valve replacement (SAVR).

Key Points Question What is the prevalence of angina among stable US outpatients with coronary artery disease (CAD)? Findings In a survey study of 1612 outpatient primary care patients with CAD in a large US integrated primary care network, 21.2% of surveyed patients reported experiencing angina at least once per month (daily or weekly, 12.5%; monthly, 8.7%). After multivariable adjustment, speaking a language other than Spanish or English, Black race, smoking, atrial fibrillation, and chronic obstructive pulmonary disease were associated with increased angina frequency. Meaning These findings suggest that angina is prevalent among US outpatients with CAD; proactive angina assessment in outpatient settings may identify patients with suboptimally controlled angina and may be associated with improved treatment and outcomes., This survey study examines the prevalence and frequency of angina among stable US outpatients with coronary artery disease., Importance Angina pectoris is associated with morbidity and mortality. Angina prevalence and frequency among contemporary US populations with coronary artery disease (CAD) remain incompletely defined. Objective To ascertain the angina prevalence and frequency among stable outpatients with CAD. Design, Setting, and Participants This cross-sectional survey study involved telephone-based administration of the Seattle Angina Questionnaire–7 (SAQ-7) between February 1, 2017, and July 31, 2017, to a nonconvenience sample of adults with established CAD who receive primary care through a large US integrated primary care network. Data analysis was performed from August 2017 to August 2019. Exposure SAQ-7 administration. Main Outcomes and Measures Angina prevalence and frequency were assessed using SAQ-7 question 2. Covariates associated with angina were assessed in univariable and multivariable regression. Results Of 4139 eligible patients, 1612 responded to the survey (response rate, 38.9%). The mean (SD) age of the respondents was 71.8 (11.0) years, 577 (35.8%) were women, 1447 (89.8%) spoke English, 147 (9.1%) spoke Spanish, 1336 (82.8%) were White, 76 (4.7%) were Black, 92 (5.7%) were Hispanic, 974 (60.4%) had Medicare, and 83 (5.2%) had Medicaid. Among respondents, 342 (21.2%) reported experiencing angina at least once monthly; among those, 201 (12.5%) reported daily or weekly angina, and 141 respondents (8.7%) reported monthly angina. The mean (SD) SAQ-7 score was 93.7 (13.7). After multivariable adjustment, speaking a language other than Spanish or English (odds ratio [OR], 5.07; 95% CI, 1.39-18.50), Black race (OR, 2.01; 95% CI, 1.08-3.75), current smoking (OR, 1.88; 95% CI, 1.27-2.78), former smoking (OR, 1.69; 95% CI, 1.13-2.51), atrial fibrillation (OR, 1.52; 95% CI, 1.02-2.26), and chronic obstructive pulmonary disease (OR, 1.61; 95% CI, 1.18-2.18) were associated with more frequent angina. Male sex (OR, 0.63; 95% CI, 0.47-0.86), peripheral artery disease (OR, 0.63; 95% CI, 0.44-0.90), and novel oral anticoagulant use (OR, 0.19; 95% CI, 0.08-0.48) were associated with less frequent angina. Conclusions and Relevance Among stable outpatients with CAD receiving primary care through an integrated primary care network, 21.2% of surveyed patients reported experiencing angina at least once monthly. Several objective demographic and clinical characteristics were associated with angina frequency. Proactive assessment of angina symptoms using validated assessment tools and estimation of patients at higher risk of suboptimally controlled angina may be associated with reduced morbidity.

IMPORTANCE: The US Centers for Medicare & Medicaid Services have implemented national value-based programs that incentivize hospitals to deliver better cardiovascular care. However, it is unclear how hospitals recognized for high-quality cardiovascular care by American Heart Association (AHA) and American College of Cardiology (ACC) national quality improvement initiatives (termed award hospitals) have performed under value-based programs. OBJECTIVE: To determine if hospitals that received awards for high-quality cardiovascular care from the AHA/ACC were less likely to be penalized under the Hospital Readmissions Reduction Program (HRRP) and the Hospital Value-Based Purchasing Program (VBP) compared with other hospitals. DESIGN, SETTING, AND PARTICIPANTS: This national cross-sectional study included data from short-term acute care hospitals in the United States that were participating in the HRRP or VBP in fiscal year 2018. EXPOSURES: Recognition awards for high-quality care from the AHA’s Get With The Guidelines–Heart Failure and ACC’s Chest Pain–MI (myocardial infarction) Registry national quality improvement initiatives. MAIN OUTCOMES AND MEASURES: Proportion of hospitals that received a financial penalty or financial reward under the HRRP or VBP, median payment adjustments, and hospital-level 30-day mortality rates. RESULTS: This study included 3175 hospitals participating in the HRRP and 2781 hospitals participating in the VBP in fiscal year 2018. Under the HRRP, a higher proportion of award hospitals received financial penalties compared with other hospitals (419 [85.5%] vs 2112 [78.7%]; P

IMPORTANCE: Cardiovascular disease is a major cause of death among homeless adults, with mortality rates that are substantially higher than in the general population. It is unknown whether differences in hospitalization-related care contribute to these disparities in cardiovascular outcomes. OBJECTIVE: To evaluate differences in intensity of care and mortality between homeless and nonhomeless individuals hospitalized for cardiovascular conditions (ie, acute myocardial infarction, stroke, cardiac arrest, or heart failure). DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study included all hospitalizations for cardiovascular conditions among homeless adults (n = 24 890) and nonhomeless adults (n = 1 827 900) 18 years or older in New York, Massachusetts, and Florida from January 1, 2010, to September 30, 2015. Statistical analysis was performed from February 6 to July 16, 2019. MAIN OUTCOMES AND MEASURES: Risk-standardized diagnostic and therapeutic procedure rates and in-hospital mortality rates. RESULTS: Of the 1 852 790 total hospitalizations for cardiovascular conditions across 525 hospitals, 24 890 occurred among patients who were homeless (11 452 women and 13 438 men; mean [SD] age, 65.1 [14.8] years) and 1 827 900 occurred among patients who were not homeless (850 660 women and 977 240 men; mean [SD] age, 72.1 [14.6] years). Most hospitalizations among homeless individuals were primarily concentrated among 11 hospitals. Homeless adults were more likely than nonhomeless adults to be black (38.6% vs 15.6%) and insured by Medicaid (49.3% vs 8.5%). After accounting for differences in demographics (age, sex, and race/ethnicity), insurance payer, and clinical comorbidities, homeless adults hospitalized for acute myocardial infarction were less likely to undergo coronary angiography compared with nonhomeless adults (39.5% vs 70.9%; P

The addition of a claims-based frailty metric to traditional comorbidity-based risk-adjustment models for acute myocardial infarction (AMI), heart failure (HF), and pneumonia improves the prediction of 30-day mortality and readmission. This may have important implications for hospitals that tend to care for frail populations and participate in Centers for MedicareMedicaid Services value-based payment programs, which use these risk-adjusted metrics to determine reimbursement.To determine whether the addition of frailty measures to traditional comorbidity-based risk-adjustment models improved prediction of outcomes for patients with AMI, HF, and pneumonia.A nationwide cohort study included Medicare fee-for-service beneficiaries 65 years and older in the United States between January 1 and December 1, 2016. Analysis began August 2018.Rates of mortality within 30 days of admission and 30 days of discharge, as well as 30-day readmission rates by frailty group. We evaluated the incremental effect of adding the Hospital Frailty Risk Score (HFRS) to current comorbidity-based risk-adjustment models for 30-day outcomes across all conditions.For 785 127 participants, there were 166 200 hospitalizations [21.2%] for AMI, 348 619 [44.4%] for HF, and 270 308 [34.4%] for pneumonia. The mean (SD) age at the time of hospitalization was 79.2 (8.9) years; 656 315 (83.6%) were white and 402 639 (51.3%) were women. The mean (SD) HFRS was 7.3 (7.4) for patients with AMI, 10.8 (8.3) for patients with HF, and 8.2 (5.7) for patients with pneumonia. Among patients hospitalized for AMI, an HFRS more than 15 (compared with an HFRS5) was associated with a higher risk of 30-day postadmission mortality (adjusted odds ratio [aOR], 3.6; 95% CI, 3.4-3.8), 30-day postdischarge mortality (aOR, 4.0; 95% CI, 3.7-4.3), and 30-day readmission (aOR, 3.0; 95% CI, 2.9-3.1) after multivariable adjustment for age, sex, race, and comorbidities. Similar patterns were observed for patients hospitalized with HF (30-day postadmission mortality: aOR, 3.5; 95% CI, 3.4-3.7; 30-day postdischarge mortality: aOR, 3.5; 95% CI, 3.3-3.6; and 30-day readmission: aOR, 2.9; 95% CI, 2.8-3.0) and among patients with pneumonia (30-day postadmission mortality: aOR, 2.5; 95% CI, 2.3-2.6; 30-day postdischarge mortality: aOR, 3.0; 95% CI, 2.9-3.2; and 30-day readmission: aOR, 2.8; 95% CI, 2.7-2.9). The addition of HFRS to traditional comorbidity-based risk-prediction models improved discrimination to predict outcomes for all 3 conditions.Among Medicare fee-for-service beneficiaries, frailty as measured by the HFRS was associated with mortality and readmissions among patients hospitalized for AMI, HF, or pneumonia. The addition of HFRS to traditional comorbidity-based risk-prediction models improved the prediction of outcomes for all 3 conditions.

IMPORTANCE: Medicaid expansion under the Patient Protection and Affordable Care Act led to one of the largest gains in health insurance coverage for nonelderly adults in the United States. However, its association with cardiovascular mortality is unclear. OBJECTIVE: To investigate the association of Medicaid expansion with cardiovascular mortality rates in middle-aged adults. DESIGN, SETTING, AND PARTICIPANTS: This study used a longitudinal, observational design, using a difference-in-differences approach with county-level data from counties in 48 states (excluding Massachusetts and Wisconsin) and Washington, DC, from 2010 to 2016. Adults aged 45 to 64 years were included. Data were analyzed from November 2018 to January 2019. EXPOSURES: Residence in a Medicaid expansion state. MAIN OUTCOMES AND MEASURES: Difference-in-differences of annual, age-adjusted cardiovascular mortality rates from before Medicaid expansion to after expansion. RESULTS: As of 2016, 29 states and Washington, DC, had expanded Medicaid eligibility, while 19 states had not. Compared with counties in Medicaid nonexpansion states, counties in expansion states had a greater decrease in the percentage of uninsured residents at all income levels (mean [SD], 7.3% [3.2%] vs 5.6% [2.7%]; P

Importance In a recent meta-analysis of randomized clinical trials, femoropopliteal artery revascularization with paclitaxel drug-coated devices was associated with increased long-term all-cause mortality compared with non-drug-coated devices. However, to our knowledge, these findings have not been replicated in other data sources and may be subject to confounding from missing data associated with patient withdrawal and loss to follow-up. Objective To evaluate differences in all-cause mortality between patients who were treated with drug-coated devices vs non-drug-coated devices for femoropopliteal artery revascularization. Design, setting, and participants This nationwide, multicenter retrospective cohort study included 16 560 Centers for Medicare and Medicaid Services beneficiaries who were admitted for femoropopliteal artery revascularization from January 1, 2016, to December 31, 2016. All-cause mortality was analyzed through September 30, 2017. Exposures Drug-coated devices (drug-eluting stent [DES] or drug-coated balloon [DCB]) compared with non-drug-coated devices (bare metal stent or uncoated percutaneous transluminal angioplasty balloon). Main outcomes and measures The primary outcome was all-cause mortality analyzed through the end of follow-up. Results Among 16 560 patients treated at 1883 hospitals, the mean (SD) age was 72.9 (11) years, 7734 (46.7%) were men, 12 232 (73.9%) were white, 8222 (49.7%) currently or had previously used tobacco, 9817 (59.3%) had diabetes, and 8450 (51.0%) had critical limb ischemia (CLI). Drug-coated devices were used in 5989 participants (36.2%). The median follow-up was 389 days (interquartile range, 277-508 days). Among all patients, treatment with drug-coated devices was associated with a lower cumulative incidence of all-cause mortality compared with treatment with non-drug-coated devices through 600 days postprocedure (32.5% vs 34.3%, respectively; log-rank P = .007). Similar survival trends were observed when treatment was stratified by using a DCB alone or DES with or without DCB. After multivariable adjustment, drug-coated devices were not associated with a difference in all-cause mortality compared with non-drug-coated devices (hazard ratio [HR], 0.97; 95% CI, 0.91-1.04; P = .43). These findings were consistent among those with CLI (HR, 0.93; 95% CI, 0.85-1.01; P = .09) or without CLI (HR, 0.94; 95% CI, 0.85-1.03; P = .20), and for those treated with DCB alone (HR, 0.94; 95% CI, 0.86-1.03; P = .17) or DES with or without DCB (HR, 0.97; 95% CI, 0.89-1.06; P = .48). Conclusions and relevance In this large nationwide analysis of Centers for Medicare and Medicaid Services beneficiaries, there was no evidence of increased all-cause mortality following femoropopliteal artery revascularization with drug-coated devices compared with non-drug-coated devices.

IMPORTANCE: Lack of insurance is associated with worse care and outcomes among adults hospitalized for acute myocardial infarction (AMI). It is unclear whether states’ decision to expand Medicaid eligibility under the Patient Protection and Affordable Care Act in 2014 were associated with improved quality of care and outcomes among low-income patients hospitalized with AMI. OBJECTIVE: To investigate whether rates of uninsurance, quality of care, and outcomes changed among patients hospitalized for AMI 3 years after states elected to expand Medicaid compared with nonexpansion states. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study completed at hospitals participating in National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry. Participants were patients younger than 65 years hospitalized for AMI from January 1, 2012, to December 31, 2016. EXPOSURES: State Medicaid expansion in 2014. MAIN OUTCOMES AND MEASURES: Rates of uninsured and Medicaid-insured hospitalizations for AMI in states that expanded Medicaid vs those that did not. Comparison of in-hospital care quality, procedure use, and mortality between expansion and nonexpansion states for the years prior to and after Medicaid expansion. Hierarchical logistic regressions models were used to assess the association between Medicaid expansion and outcomes. RESULTS: The initial cohort included 325 343 patients. Uninsured AMI hospitalizations declined in expansion states (18.0% [4395 of 24 358 hospitalizations] to 8.4% [2638 of 31 382 hospitalizations]) and more modestly in nonexpansion states (25.6% [7963 of 31 137 hospitalizations] to 21.1% [8668 of 41 120 hospitalizations]) from 2012 to 2016 (P

Key Points Question What is the association of inferior vena cava filter placement with 30-day mortality in patients with venous thromboembolic disease and a contraindication to anticoagulation? Findings In this cohort study, using 2 different statistical methods with adjustment for immortal time bias, inferior vena cava filter placement in patients with venous thromboembolic disease and a contraindication to anticoagulation was associated with an increased risk of 30-day mortality. Meaning Randomized clinical trials are needed to define the role of inferior vena cava filter placement in patients with venous thromboembolic disease and a contraindication to anticoagulation., Importance Despite the absence of data from randomized clinical trials, professional societies recommend inferior vena cava (IVC) filters for patients with venous thromboembolic disease (VTE) and a contraindication to anticoagulation therapy. Prior observational studies of IVC filters have suggested a mortality benefit associated with IVC filter insertion but have often failed to adjust for immortal time bias, which is the time before IVC filter insertion, during which death can only occur in the control group. Objective To determine the association of IVC filter placement with 30-day mortality after adjustment for immortal time bias. Design, Setting, and Participants This comparative effectiveness, retrospective cohort study used a population-based sample of hospitalized patients with VTE and a contraindication to anticoagulation using the State Inpatient Database and the State Emergency Department Database, part of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, from hospitals in California (January 1, 2005, to December 31, 2011), Florida (January 1, 2005, to December 31, 2013), and New York (January 1, 2005, to December 31, 2012). Data analysis was conducted from September 15, 2015, to March 14, 2018. Exposure Inferior vena cava filter placement. Main Outcomes and Measures Multivariable Cox proportional hazard models were constructed with IVC filters as a time-dependent variable that adjusts for immortal time bias. The Cox model was further adjusted using the propensity score as an adjustment variable. Results Of 126 030 patients with VTE, 61 281 (48.6%) were male and the mean (SD) age was 66.9 (16.6) years. In this cohort, 45 771 (36.3%) were treated with an IVC filter, whereas 80 259 (63.7%) did not receive a filter. In the Cox model with IVC filter status analyzed as a time-dependent variable to account for immortal time bias, IVC filter placement was associated with a significantly increased hazard ratio of 30-day mortality (1.18; 95% CI, 1.13-1.22; P, This comparative effectiveness cohort study explores the association of inferior vena cava filter placement with 30-day mortality in patients with venous thromboembolic disease and a contraindication to anticoagulation.

Importance More than 20 years have passed since public reporting of percutaneous coronary intervention (PCI) outcomes first began in New York State, but reporting remains a polarizing issue. Observations Advocates of public reporting point to the strong incentive that public disclosure of outcomes data provides for institutions and clinicians to improve clinical care and to the importance of enabling patients to make informed choices about their care. Critics highlight the methodological challenges that impede fair and accurate assessments of care quality as well as reporting’s unintended consequences. Public reporting of PCI outcomes has only been implemented in 5 states, but reporting efforts for multiple conditions and procedures are now proliferating nationally, propelled by the notion that transparency improves the quality of health care and fosters trust in health care institutions. Careful evaluation of the evidence to date for PCI in particular, however, suggests that enthusiasm for such efforts should be tempered. Conclusions and Relevance Public reporting has not achieved its primary objectives. Policy makers should consider variations of reporting that might strengthen care quality, empower patients, and mitigate undesirable repercussions.

Importance In 2006, New York began excluding patients with cardiogenic shock from the publicly reported percutaneous coronary intervention (PCI) risk-adjusted mortality analyses. Objective To examine the effects of the New York shock-exclusion policy change on rates of revascularization and mortality for patients with acute myocardial infarction (AMI) complicated by cardiogenic shock. Design, Setting, and Participants This study used several comprehensive statewide hospitalization databases to identify patients with AMI and shock from January 1, 2002, through December 31, 2012, in New York and a series of comparator states (Massachusetts, Michigan, and New Jersey from January 1, 2002, through December 31, 2012, and California from January 1, 2003, through December 31, 2011). Data analysis was performed from October 1, 2015, to March 15, 2016. Main Outcomes and Measures A difference-in-differences approach was used to evaluate whether the likelihood of receiving PCI and surviving to discharge differed after the policy change in New York in 2006 compared with comparator states that did not enact such a change. Results Among 45 977 patients with AMI and cardiogenic shock (11 298 in New York), 21 974 (47.8%) underwent PCI. The mean (SD) age of the patients was 69.7 (13.2) years, and 18 139 (39.5%) were female. After adjusting for patient factors, patients in New York were significantly more likely to undergo PCI after the public reporting policy changes than they were previously (adjusted relative risk [aRR], 1.28; 95% CI, 1.19-1.37; P P P P P P Conclusions and Relevance The exclusion of patients with ongoing cardiogenic shock from New York PCI public reports in 2006 was associated with a significant increase in the use of PCI for cardiogenic shock and a concomitant decrease in in-hospital mortality, exceeding simultaneously observed trends in the comparator states. However, rates of PCI for AMI and shock were lower in New York throughout the study. Alterations in policies related to reporting mortality outcomes after cardiovascular procedures may have significant implications for physician behavior and the public health.

Benefits of drug-eluting stents (DES) in percutaneous coronary intervention (PCI) are greatest in those at the highest risk of target-vessel revascularization (TVR). Drug-eluting stents cost more than bare-metal stents (BMS) and necessitate prolonged dual antiplatelet therapy (DAPT), which increases costs, bleeding risk, and risk of complications if DAPT is prematurely discontinued. Our objective was to assess whether DES are preferentially used in patients with higher predicted TVR risk and to estimate if lower use of DES in low-TVR-risk patients would be more cost-effective than the existing DES use pattern.We analyzed more than 1.5 million PCI procedures in the National Cardiovascular Data Registry (NCDR) CathPCI registry from 2004 through 2010 and estimated 1-year TVR risk with BMS using a validated model. We examined the association between TVR risk and DES use and the cost-effectiveness of lower DES use in low-TVR-risk patients (50% less DES use among patients with10% TVR risk) compared with existing DES use.There was marked variation in physicians' use of DES (range 2%-100%). Use of DES was high across all predicted TVR risk categories (73.9% in TVR risk10%; 78.0% in TVR risk 10%-20%; and 83.2% in TVR risk20%), with a modest relationship between TVR risk and DES use (relative risk, 1.005 per 1% increase in TVR risk [95% CI, 1.005-1.006]). Reducing DES use by 50% in low-TVR-risk patients was projected to lower US health care costs by $205 million per year while increasing the overall TVR event rate by 0.5% (95% CI, 0.49%-0.51%) in absolute terms.Use of DES in the United States varies widely among physicians, with only a modest correlation to patients' risk of restenosis. Less DES use among patients with low risk of restenosis has the potential for significant cost savings for the US health care system while minimally increasing restenosis events.

Nuclear myocardial perfusion imaging (MPI) accounted for much of the rapid growth in cardiac imaging that occurred from the 1990s through the middle 2000s.1,2 Factors potentially discouraging use (including publication of appropriate use criteria) have since emerged,3 and recent data reveal modest declines in MPI use in the Medicare fee-for-service population.4 We investigated temporal trends in MPI use within a large, community-based population that included persons younger than 65 years and explored whether increasing use of other noninvasive imaging modalities potentially offset declining MPI use.

Dr Hawn and colleagues1 evaluated the risk of undergoing noncardiac surgery following coronary stent placement. The analysis, which examines the outcomes of 28 029 veterans undergoing noncardiac surgery within 24 months of coronary stent implantation, found that emergency surgery and severity of cardiac disease were the principal factors associated with postoperative major adverse cardiovascular events (MACE).

Background During the previous decade, many strategies for preventing acute myocardial infarction found to be efficacious in randomized controlled trials have been adopted by physicians in the community. Although evaluations of quality improvement typically focus on process measures at the hospital, practice, or clinician level, assessment of improvements in health outcomes remains the true test for the successful translation of evidence into practice. Methods We performed a review of the current literature examining trends in the incidence of myocardial infarction in communities. We focused specifically on the group of population-based studies that have examined trends in myocardial infarction incidence. Results Few population-based studies have examined recent temporal trends in the incidence of myocardial infarction, overall and by type. Existing studies have been largely limited by modest sample sizes, limited diversity within the study populations, the use of composite end points that combine disparate outcomes, and the inability to characterize the effect of long-term outpatient medication use on observed trends in incidence and severity of myocardial infarction. Conclusion More contemporary assessments of community-wide changes in the epidemiology of myocardial infarction are needed to help assess the effectiveness of primary prevention and to identify areas for potential improvement.