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While factors associated with long COVID (LC) continue to be illuminated, little is known about recovery. This study used national survey data to assess factors associated with recovery from LC. We used data from the 2022 National Health Interview Survey, a cross-sectional sample of noninstitutionalized US adults. Survey analysis was used to account for oversampling and nonresponse bias and to obtain nationally representative estimates. A multivariable logistic regression model was used to identify potential predictors of LC recovery. Among those reporting ever having COVID-19, 17.7% or an estimated 17.5 million American adults reported ever having LC, and among those with LC, 48.5% or an estimated 8.5 million reported having recovered. Multivariable logistic regression analysis showed that Hispanic adults were significantly more likely than White adults to report recovery from LC. At the same time, those with severe COVID-19 symptoms and those who had more than a high school degree, were aged 40 years or older, or were female were less likely to report recovery. Significant variations in LC recovery were noted across age, sex, race and ethnicity, education, and severity of COVID-19 symptoms. Further work is needed to elucidate the causes of these differences and identify strategies to increase recovery rates. [ABSTRACT FROM AUTHOR]

Editorial. Discusses challenges facing those who undertake quality improvement studies in health care. Lack of sufficient statistical power; Vulnerability of studies to contamination; Lack of certainty on the ideal time to assess the effects of an intervention; Scrutiny required of the generalizability of quality improvement studies; Assessing effective aspects of an intervention.

Long COVID is a multisystemic condition that affects the lives of millions of people globally, yet factors associated with it are poorly defined. Our purpose in this study was to identify factors associated with long COVID. This cross-sectional study used data from the 2022 Behavioral Risk Factor Surveillance System (BRFSS) and the 2022 National Health Interview Survey (NHIS). We restricted the sample to individuals aged 18 and older who reported a positive COVID-19 test or doctor's diagnosis. Individuals who reported symptoms of at least 3 months were assumed to have long COVID. We identified demographic and clinical characteristics associated with long COVID, in unadjusted and adjusted analyses. The study included 124,313 individuals in the BRFSS cohort and 10,131 in the NHIS cohort who reported a COVID-19 infection, with 26,783 (21.5%) and 1797 (17.7%) reporting long COVID, respectively. We found middle age, female sex, lack of a college degree, and severity of acute COVID-19 infection to be associated with long COVID. In contrast, non-Hispanic Asian and Black Americans were less likely to report long COVID compared with non-Hispanic White individuals. These findings were consistent across datasets. Several demographic features were associated with long COVID, which may be the result of social, clinical, or biological influences. [ABSTRACT FROM AUTHOR]

Background: Clinicians make a medical diagnosis by recognizing diagnostic possibilities, often using memories of prior examples. These memories, called "exemplars," reflect specific symptom combinations in individual patients, yet most clinical studies report how symptoms aggregate in populations. We studied how symptoms of acute myocardial infarction combine in individuals as symptom phenotypes and how symptom phenotypes are distributed in women and men.Methods: In this analysis of the SILVER-AMI Study, we studied 3041 patients (1346 women and 1645 men) 75 years of age or older with acute myocardial infarction. Each patient had a standardized in-person interview during the acute myocardial infarction admission to document the presenting symptoms, which enabled a thorough examination of symptom combinations in individuals. Specific symptom combinations defined symptom phenotypes and distributions of symptom phenotypes were compared in women and men using Monte Carlo permutation testing and repeated subsampling.Results: There were 1469 unique symptom phenotypes in the entire SILVER-AMI cohort of patients with acute myocardial infarction. There were 831 unique symptom phenotypes in women, as compared with 819 in men, which was highly significant, given the larger number of men than women in the study (P < .0001). Women had significantly more symptom phenotypes than men in almost all acute myocardial infarction subgroups.Conclusions: Older patients with acute myocardial infarction have enormous variation in symptom phenotypes. Women reported more symptoms and had significantly more symptom phenotypes than men. Appreciation of the diversity of symptom phenotypes may help clinicians recognize the less common phenotypes that occur more often in women. [ABSTRACT FROM AUTHOR]

There are concerns that transcatheter or surgical aortic valve replacement (TAVR/SAVR) procedures are preferentially available to White patients. Our objective was to examine differences in utilization of aortic valve replacement and outcomes by race/ethnicity in the US for patients with aortic stenosis. We performed a serial cross-sectional cohort study of 299,976 Medicare beneficiaries hospitalized with principal diagnosis of aortic stenosis between 2012 and 2019 stratified by self-reported race/ethnicity (Black, Hispanic, Asian, Native American, and White). Outcomes included aortic valve replacement rates within 6 months of index hospitalization and associated procedural outcomes, including 30-day readmission, 30-day and 1-year mortality. Within 6 months of an index admission for aortic stenosis, 86.8% (122,457 SAVR; 138,026 TAVR) patients underwent aortic valve replacement. Overall, compared with White people, Black (HR 0.87 [0.85-0.89]), Hispanic (0.92 [0.88-0.96]), and Asian (0.95 [0.91-0.99]) people were less likely to receive aortic valve replacement. Among patients who were admitted emergently/urgently, White patients (41.1%, 95% CI, 40.7-41.4) had a significantly higher aortic valve replacement rate compared with Black (29.6%, 95% CI, 28.3-30.9), Hispanic (36.6%, 95% CI, 34.0-39.3), and Asian patients (35.4%, 95% CI, 32.3-38.9). Aortic valve replacement rates increased annually for all race/ethnicities. There were no significant differences in 30-day or 1-year mortality by race/ethnicity. Aortic valve replacement rates within 6 months of aortic stenosis admission are lower for Black, Hispanic, and Asian people compared to White people. These race-related differences in aortic stenosis treatment reflect complex issues in diagnosis and management, warranting a comprehensive reassessment of the entire care spectrum for disadvantaged populations. [ABSTRACT FROM AUTHOR]

Background: Oldest-old patients (≥85 years) constitute half the acute myocardial infarction hospitalizations among older adults and more commonly have atypical presentation, under-treatment, and functional impairments. Yet this group has not been well characterized. We characterized differences in presentation, functional impairments, treatments, health status, and mortality among middle-old (75-84 years) and oldest-old patients with myocardial infarction.Methods: We analyzed data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study that enrolled 3041 patients ≥75 years of age from 94 hospitals across the US between 2013 and 2016. We performed Cox proportional hazards regression to examine the association between the oldest-old (n = 831) and middle-old (n = 2210) age categories with postdischarge 6-month case fatality rate adjusting for sociodemographic and clinical variables, and mobility impairment.Results: The oldest-old were less likely to present with chest pain (52.7% vs 57.7%) as their primary symptom or to receive coronary revascularization (58.1% vs 71.8) (P < .01 for both). The oldest-old were more likely to have functional impairments and had higher 6-month mortality compared with the middle-old patients (hazard ratio 1.78, 95% confidence interval, 1.39-2.28). This association was substantially attenuated after adjusting for mobility impairment (hazard ratio 1.29, confidence interval, 0.99-1.68).Conclusions: There is considerable heterogeneity in presentation, treatment, and outcomes among older patients with myocardial infarction. Mobility impairment, a marker for frailty, modifies the association between advanced age and treatments as well as outcomes. [ABSTRACT FROM AUTHOR]

Background: Digital health technology is becoming central to health care. A better understanding of the trends and predictors of its use could reflect how people engage with the health care system and manage their health care needs.Methods: Using data from the National Health Interview Survey for years 2011 to 2018, we assessed the use of digital health technology among individuals aged ≥18 years in the United States across 2 domains: 1) search for health information online and 2) interaction with health care providers (eg, fill a prescription, schedule a medical appointment, or communicate with health care providers).Results: Our study included 253,829 individuals; representing nearly 237 million adults in the United States annually; mean age 49.6 years (SD 18.4); 51.8% women; and 65.9% non-Hispanic white individuals. Overall, 49.2% of individuals reported searching for health information online and 18.5% reported at least 1 technology-based interaction with the health care system. Between 2011 and 2018, the proportion who searched for health information online increased from 46.5% to 55.3% (P < .001), whereas the proportion who used technology to interact with the health care system increased from 12.5% to 27.4% (P < .001). Although technology-based interaction with the health care system increased across most subgroups, there were significant disparities in the extent of increase across clinical and sociodemographic subgroups.Conclusions: The use of digital health technologies increased between 2011 and 2018, however, the uptake of these technologies has been unequal across subgroups. Future innovations and strategies should focus on expanding the reach of digital heath technology across all subgroups of society to ensure that its expansion does not exacerbate the existing health inequalities. [ABSTRACT FROM AUTHOR]

Background: Blood pressure is a physiologic measure that reflects cardiac output and systemic vascular resistance. Classification by these components could be useful in characterizing subtypes of hypertension, which may have a role in selecting treatment strategies. However, hemodynamic phenotypes of a large, stable, outpatient population with hypertension remain unknown.Methods: We included 34,238 people with systolic blood pressure of ≥130 mm Hg, who underwent impedance cardiography at 51 sites of iKang Health Checkup Centers throughout China between 2012 and 2018. Hemodynamic parameters measured included stroke volume, stroke volume index, heart rate, cardiac output, cardiac index, systemic vascular resistance, and systemic vascular resistance index. We characterized these by systolic blood pressure categories and assessed patient characteristics associated with the ratio of cardiac index to systemic vascular resistance index.Results: Among the study cohort (n = 33,414; mean age 52 ± 13 years; 36.6% female), 49%, 40%, and 11% had systolic blood pressure130-139, 140-159, and ≥160 mm Hg, respectively. Among patients with systolic blood pressure 140-159 mm Hg, 9353 (70%) had high systemic vascular resistance index but normal/low cardiac index, 1949 (15%) had high cardiac index but low/normal systemic vascular resistance index, and 2053 (15%) had low/normal cardiac index and systemic vascular resistance index. Using multivariable analysis, we found that cardiac index to systemic vascular resistance index ratio was negatively associated with age and body mass index (all P <0.05; R-square 0.16, 0.12, and 0.09 for systolic blood pressure 130-139, 140-159 and ≥160 mm Hg, respectively).Conclusions: Different hemodynamic blood pressure phenotypes were identified across all hypertensive blood pressure categories. Although individual characteristics were associated with the cardiac index to systemic vascular resistance index ratio, they only weakly explained the variation. [ABSTRACT FROM AUTHOR]

Background: Among older adults (age ≥75 years) hospitalized for acute myocardial infarction, acute kidney injury after coronary angiography is common. Aging-related conditions may independently predict acute kidney injury, but have not yet been analyzed in large acute myocardial infarction cohorts.Methods: We analyzed data from 2212 participants age ≥75 years in the Comprehensive Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarction (SILVER-AMI) study who underwent coronary angiography. Acute kidney injury was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria (serum Cr increase ≥0.3 mg/dL from baseline or ≥1.5 times baseline). We analyzed the associations of traditional acute kidney injury risk factors and aging-related conditions (activities of daily living impairment, prior falls, cachexia, low physical activity) with acute kidney injury, and then performed logistic regression to identify independent predictors.Results: Participants' mean age was 81.3 years, 45.2% were female, and 9.5% were nonwhite; 421 (19.0%) experienced acute kidney injury. Comorbid diseases and aging-related conditions were both more common among individuals experiencing acute kidney injury. However, after multivariable adjustment, no aging-related conditions were retained. There were 11 risk factors in the final model; the strongest were heart failure on presentation (odds ratio [OR] 1.91; 95% confidence interval [CI], 1.41-2.59), body mass index [BMI] >30 (vs BMI 18-25: OR 1.75; 95% CI, 1.27-2.42), and nonwhite race (OR 1.65; 95% CI, 1.16-2.33). The final model achieved an area under the receiver operating characteristic curve of 0.72 and was well calibrated (Hosmer-Lemeshow P = .50). Acute kidney injury was independently associated with 6-month mortality (OR 1.98; 95% CI, 1.36-2.88) but not readmission (OR 1.26; 95% CI, 0.98-1.61).Conclusions: Acute kidney injury is common among older adults with acute myocardial infarction undergoing coronary angiography. Predictors largely mirrored those in previous studies of younger individuals, which suggests that geriatric conditions mediate their influence through other risk factors. [ABSTRACT FROM AUTHOR]

Background: Over the past 2 decades, guidelines for digoxin use have changed significantly. However, little is known about the national-level trends of digoxin use, hospitalizations for toxicity, and subsequent outcomes over this time period.Methods: To describe digoxin prescription trends, we conducted a population-level, cohort study using data from IQVIA, Inc.'s National Prescription Audit (2007-2014) for patients aged ≥65 years. Further, in a national cohort of Medicare fee-for-service beneficiaries aged ≥65 years in the United States, we assessed temporal trends of hospitalizations associated with digoxin toxicity and the outcomes of these hospitalizations between 1999 and 2013.Results: From 2007 through 2014, the number of digoxin prescriptions dispensed decreased by 46.4%; from 8,099,856 to 4,343,735. From 1999 through 2013, the rate of hospitalizations with a principal or secondary diagnosis of digoxin toxicity decreased from 15 to 2 per 100,000 person-years among Medicare fee-for-service beneficiaries. In-hospital and 30-day mortality rates associated with hospitalization for digoxin toxicity decreased significantly among Medicare fee-for-service beneficiaries; from 6.0% (95% confidence interval [CI], 5.2-6.8) to 3.7% (95% CI, 2.2-5.7) and from 14.0% (95% CI, 13.0-15.2) to 10.1% (95% CI, 7.6-13.0), respectively. Rates of 30-day readmission for digoxin toxicity decreased from 23.5% (95% CI, 22.1-24.9) in 1999 to 21.7% (95% CI, 18.0-25.4) in 2013 (P < .05).Conclusion: While digoxin prescriptions have decreased, it is still widely prescribed. However, the rate of hospitalizations for digoxin toxicity and adverse outcomes associated with these hospitalizations have decreased. These findings reflect the changing clinical practice of digoxin use, aligned with the changes in clinical guidelines. [ABSTRACT FROM AUTHOR]

Introduction: Older adults are at increased risk of developing deep vein thrombosis. Little is known about national trends of deep vein thrombosis hospitalizations in the context of primary and secondary prevention efforts.Methods: Medicare standard analytic files were analyzed from 2015-2017 to identify Fee-For-Service patients aged ≥65 years who had a principal discharge diagnosis for deep vein thrombosis from 1999 to 2010. We reported the deep vein thrombosis hospitalization rates per 100,000 person-years as well as 30-day and 1-year mortality rates. We used mixed-effects models to calculate adjusted outcomes.Results: Overall, there were 726,423 deep vein thrombosis hospitalizations in Medicare Fee-for-Service from 1999 to 2010. Deep vein thrombosis hospitalization rate adjusted for age, sex, and race decreased from 264 per 100,000 person-years in 1999 to 167 per 100,000 person-years in 2010, a relative decline of 36.7% (P < .0001). Hospitalizations decreased for all subgroups by age, sex, and race with the exception of black patients (316 to 382 per 100,000 person-years, a relative increase of 20.8%) (P < .0001). Hospital length of stay decreased from 6.1 days in 1999 to 5.0 days in 2010, and the proportion of patients discharged to home decreased from 57.2% to 44.1%. Risk-adjusted 30-day, 6-month, and 1-year mortality and 30-day readmission rates remained relatively stable across the study period, but were highest among women in recent years.Conclusions: The overall deep vein thrombosis hospitalization rate decreased from 1999 to 2010, except for black patients. Decreases in hospitalizations may reflect changes in clinical practice with increased outpatient rather than inpatient management, and faster transitions to outpatient care for management of deep vein thrombosis. [ABSTRACT FROM AUTHOR]

Background: Disparities in multimorbidity prevalence indicate health inequalities, as the risk of morbidity does not intrinsically differ by race/ethnicity. This study aimed to determine if multimorbidity differences by race/ethnicity are decreasing over time.Methods: Serial cross-sectional analysis of the National Health Interview Survey, 1999-2018. Included individuals were ≥18 years old and categorized by self-reported race, ethnicity, age, and income. The main outcomes were temporal trends in multimorbidity prevalence based on the self-reported presence of ≥2 of 9 common chronic conditions.Findings: The study sample included 596,355 individuals (4.7% Asian, 11.8% Black, 13.8% Latino/Hispanic, and 69.7% White). In 1999, the estimated prevalence of multimorbidity was 5.9% among Asian, 17.4% among Black, 10.7% among Latino/Hispanic, and 13.5% among White individuals. Prevalence increased for all racial/ethnic groups during the study period (P ≤ .001 for each), with no significant change in the differences between them. In 2018, compared with White individuals, multimorbidity was more prevalent among Black individuals (+2.5 percentage points) and less prevalent among Asian and Latino/Hispanic individuals (-6.6 and -2.1 percentage points, respectively). Among those aged ≥30 years, Black individuals had multimorbidity prevalence equivalent to that of Latino/Hispanic and White individuals aged 5 years older, and Asian individuals aged 10 years older.Conclusions: From 1999 to 2018, a period of increasing multimorbidity prevalence for all the groups studied, there was no significant progress in eliminating disparities between Black individuals and White individuals. Public health interventions that prevent the onset of chronic conditions in early life may be needed to eliminate these disparities. [ABSTRACT FROM AUTHOR]

Abstract: Background: Previous studies have described an “obesity paradox” with heart failure, whereby higher body mass index (BMI) is associated with lower mortality. However, little is known about the impact of obesity on survival after acute myocardial infarction. Methods: Data from 2 registries of patients hospitalized in the US with acute myocardial infarction between 2003-2004 (PREMIER) and 2005-2008 (TRIUMPH) were used to examine the association of BMI with mortality. Patients (n=6359) were categorized into BMI groups (kg/m2) using baseline measurements. Two sets of analyses were performed using Cox proportional hazards regression with fractional polynomials to model BMI as categorical and continuous variables. To assess the independent association of BMI with mortality, analyses were repeated, adjusting for 7 domains of patient and clinical characteristics. Results: Median BMI was 28.6. BMI was inversely associated with crude 1-year mortality (normal, 9.2%; overweight, 6.1%; obese, 4.7%; morbidly obese; 4.6%; P <.001), which persisted after multivariable adjustment. When BMI was examined as a continuous variable, the hazards curve declined with increasing BMI and then increased above a BMI of 40. Compared with patients with a BMI of 18.5, patients with higher BMIs had a 20% to 68% lower mortality at 1 year. No interactions between age (P =.37), sex (P =.87), or diabetes mellitus (P =.55) were observed. Conclusions: There appears to be an “obesity paradox” among patients after acute myocardial infarction such that higher BMI is associated with lower mortality, an effect that was not modified by patient characteristics and was comparable across age, sex, and diabetes subgroups. [Copyright &y& Elsevier]

Abstract: Background: Comorbidity, disability, and polypharmacy commonly complicate the care of patients with heart failure. These factors can change biological response to therapy, reduce patient ability to adhere to recommendations, and alter patient preference for treatment and outcome. Yet, a comprehensive understanding of the complexity of patients with heart failure is lacking. Our objective was to assess trends in demographics, comorbidity, physical function, and medication use in a nationally representative, community-based heart failure population. Methods: Using data from the National Health and Nutrition Examination Survey, we analyzed trends across 3 survey periods (1988-1994, 1999-2002, 2003-2008). Results: We identified 1395 participants with self-reported heart failure (n=581 in 1988-1994, n=280 in 1999-2002, n=534 in 2003-2008). The proportion of patients with heart failure who were ≥80 years old increased from 13.3% in 1988-1994 to 22.4% in 2003-2008 (P <.01). The proportion of patients with heart failure who had 5 or more comorbid chronic conditions increased from 42.1% to 58.0% (P <.01). The mean number of prescription medications increased from 4.1 to 6.4 prescriptions (P <.01). The prevalence of disability did not increase but was substantial across all years. Conclusion: The phenotype of patients with heart failure changed substantially over the last 2 decades. Most notably, more recent patients have a higher percentage of very old individuals, and the number of comorbidities and medications increased markedly. Functional disability is prevalent, although it has not changed. These changes suggest a need for new research and practice strategies that accommodate the increasing complexity of this population. [Copyright &y& Elsevier]

Background: Whether the volume of coronavirus disease 2019 (COVID-19) hospitalizations is associated with outcomes has important implications for the organization of hospital care both during this pandemic and future novel and rapidly evolving high-volume conditions.Methods: We identified COVID-19 hospitalizations at US hospitals in the American Heart Association COVID-19 Cardiovascular Disease Registry with ≥10 cases between January and August 2020. We evaluated the association of COVID-19 hospitalization volume and weekly case growth indexed to hospital bed capacity, with hospital risk-standardized in-hospital case-fatality rate (rsCFR).Results: There were 85 hospitals with 15,329 COVID-19 hospitalizations, with a median hospital case volume was 118 (interquartile range, 57, 252) and median growth rate of 2 cases per 100 beds per week but varied widely (interquartile range: 0.9 to 4.5). There was no significant association between overall hospital COVID-19 case volume and rsCFR (rho, 0.18, P = .09). However, hospitals with more rapid COVID-19 case-growth had higher rsCFR (rho, 0.22, P = 0.047), increasing across case growth quartiles (P trend = .03). Although there were no differences in medical treatments or intensive care unit therapies (mechanical ventilation, vasopressors), the highest case growth quartile had 4-fold higher odds of above median rsCFR, compared with the lowest quartile (odds ratio, 4.00; 1.15 to 13.8, P = .03).Conclusions: An accelerated case growth trajectory is a marker of hospitals at risk of poor COVID-19 outcomes, identifying sites that may be targets for influx of additional resources or triage strategies. Early identification of such hospital signatures is essential as our health system prepares for future health challenges. [ABSTRACT FROM AUTHOR]

Abstract: Background: We studied the relationship between longer delays from symptom onset to hospital presentation and the use of any reperfusion therapy, door-to-balloon time, and door-to-drug time. Methods: Cohort study of patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from January 1, 1995 to December 31, 2004. Delay in hospital presentation was categorized into 1-hour intervals as ≤1 hour, >1-2 hours, >2-3 hours, etc, up to >11-12 hours. The study analyzed 3 groups: 440,398 patients for the association between delay and use of any reperfusion therapy; 67,207 patients for the association between delay and door-to-balloon time; 183,441 patients for the association between delay and door-to-drug time. Results: In adjusted analyses, patients with longer delays between symptom onset and hospital presentation were less likely to receive any reperfusion therapy, had longer door-to-balloon times, and had longer door-to-needle times (all P <.0001 for linear trend). For patients presenting ≤1 hour, >1-2 hours, >2-3 hours, >9-10 hours, >10-11 hours, and >11-12 hours after symptom onset, the use of any reperfusion therapy were 77%, 77%, 73%, 53%, 50%, and 46%, respectively. Door-to-balloon times were 99, 101, 106, 123, 125, and 123 minutes, respectively, and door-to-drug times were 33, 34, 36, 46, 44, and 47 minutes, respectively. Conclusions: Longer delays from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times. [Copyright &y& Elsevier]

Background: Appropriate utilization of acute reperfusion therapy is not a national performance measure for ST-elevation myocardial infarction at this time, and the extent of its contemporary use among ideal patients is unknown.Methods: From the National Registry of Myocardial Infarction, we identified 238,291 patients enrolled from June 1994 to May 2003 who were ideally suited for acute reperfusion therapy with fibrinolytic therapy or primary percutaneous coronary intervention. We determined rates of not receiving therapy across 3 time periods (June 1994-May 1997, June 1997-May 2000, June 2000-May 2003) and evaluated factors associated with underutilization.Results: The proportion of ideal patients not receiving acute reperfusion therapy decreased by one half throughout the past decade (time period 1: 20.6%; time period 2: 11.4%; time period 3: 11.6%; P <.001). Utilization remained significantly lower in key subgroups in the most recent time period: those without chest pain (odds ratio [OR] 0.29; 95% confidence interval [CI], 0.27-0.32); those presenting 6 to 12 hours after symptom onset (OR 0.57; 95% CI, 0.52-0.61); those 75 years or older (OR 0.63 compared with patients <55 years old; 95% CI, 0.58-0.68); women (OR 0.88; 95% CI, 0.84-0.93); and non-whites (OR 0.90; 95% CI, 0.83-0.97).Conclusions: Utilization of acute reperfusion therapy in ideal patients has improved over the last decade, but more than 10% remain untreated. Measuring and improving its use in this cohort represents an important opportunity to improve care. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The study’s purpose was to determine the prevalence and prognostic importance of acute, severe, noncardiac conditions present at the time of an acute myocardial infarction (AMI). Methods: We identified consecutive patients with AMI who were discharged from Yale-New Haven Hospital between January 1, 1997, and June 30, 2000. Acute, noncardiac conditions that were present at admission were abstracted from patient records and graded by severity (imminent threat to life; other significant condition that would warrant admission). We examined the prognostic importance of these conditions on hospital mortality in multivariable logistic models. The study included 1145 patients with AMI, of whom 8.5% (n=97) presented with an acute, life-threatening, noncardiac condition at admission and 19.5% (n=223) presented with another significant noncardiac condition. Results: Hospital mortality was 25.8% and 9.0%, respectively, for patients who presented with life-threatening and other significant noncardiac conditions, compared with 4.6% for patients without either of these conditions. In multivariable analysis, life-threatening noncardiac conditions were associated with increased hospital mortality after adjusting for demographic factors, medical history, clinical presentation, cardiac severity, and initial therapy (odds ratio 2.5; 95% confidence interval [CI], 1.2-5.2). No increased hospital mortality risk was found for other significant noncardiac conditions in the risk-adjusted analyses (odds ratio 1.0; 95% CI, 0.5-1.7). Conclusions: A subgroup of patients with AMI presented with a life-threatening noncardiac condition, which was associated with a marked increase in the risk of death during the hospitalization. Despite the excessive mortality risk associated with concomitant noncardiac conditions, this subset of patients with AMI are poorly described in current literature. [Copyright &y& Elsevier]

Abstract: Background: Whether specialty care improves survival among patients with heart failure remains controversial. Methods: We evaluated specialty care and outcomes in 25869 Medicare beneficiaries hospitalized with heart failure in the United States from 1998 through 1999. Patients were classified based on the specialty of their attending physician: cardiologist, internist, general physician, or family physician. The primary outcome of interest was all-cause mortality within 30 days of admission. Results: Cardiologists were attending physicians for 26%, internists for 50%, and general and family physicians cared for the remainder. Mortality at 30 days was lowest for patients cared for by cardiologists (8.8%), higher for patients cared for by internists (10.0%, relative risk [RR] = 1.07; 95% confidence interval [CI]: 0.97 to 1.19; P = 0.059) and general physicians (11.1%, RR = 1.26; 95% CI: 0.99 to 1.58; P = 0.086), and highest for patients cared for by family physicians (12.0%, RR = 1.31; 95% CI: 1.15 to 1.49; P <0.001). Patients cared for by family physicians remained at higher 30-day mortality rates whether with (RR = 1.30; 95% CI: 1.11 to 1.52) or without consultation with cardiologists (RR = 1.31; 95% CI: 1.13 to 1.52). Conclusion: Hospitalized patients with heart failure had lower 30-day mortality when treated by cardiologists than when they were treated by other physicians. Although these differences were modest (RR = 1.07) for internists, they were substantial for general physicians (RR = 1.26) and family physicians (RR = 1.31); of note was that inpatient cardiology consultation did not appear to change this relation. [Copyright &y& Elsevier]

Purpose: Racial differences in the treatment of patients with myocardial infarction are often presented as nationally consistent patterns of care, despite known regional variations in quality of care. We sought to determine whether racial differences in myocardial infarction treatment vary by U.S. census region.Methods: We conducted a retrospective analysis of medical record data from 138,938 elderly fee-for-service Medicare beneficiaries hospitalized with myocardial infarction between 1994 and 1996. Patients were evaluated for the use (admission, discharge) of aspirin and beta-blockers, and cardiac procedures (cardiac catheterization, any coronary revascularization) within 60 days of admission.Results: Nationally, black patients had lower crude rates of aspirin and beta-blocker use, cardiac catheterization, and coronary revascularization than did white patients. Racial differences in treatment, however, varied by region. Black patients in the Northeast had rates of aspirin use that were similar to those of white patients on admission (50.6% vs. 49.8%, P = 0.58) and at discharge (77.5% vs. 74.2%, P = 0.07), whereas racial differences were observed in the South (admission: 43.7% vs. 48.8%, P <0.001; discharge: 69.5% vs. 73.2%, P <0.001), Midwest (admission: 48.4% vs. 52.3%, P = 0.004), and West (admission: 49.2% vs. 56.2%, P <0.001; discharge: 70.7% vs. 76.2%, P = 0.02). Racial differences in beta-blocker use were comparable across regions (admission: P = 0.59, discharge: P = 0.89). There were no differences in cardiac catheterization use among black and white patients in the Northeast (38.9% vs. 40.5%, P = 0.24), as opposed to the Midwest (43.3% vs. 48.9%, P <0.001), South (39.2% vs. 48.5%, P <0.001), and West (38.3% vs. 48.6%, P <0.001). Similarly, racial differences in any coronary revascularization use were smallest in the Northeast (22.1% vs. 26.7%, P <0.001), greater in the Midwest (24.7% vs. 33.5%, P <0.001), and largest in the South (20.7% vs. 32.0%, P <0.001) and West (22.9% vs. 33.7%, P <0.001). Regional variations in racial differences persisted after multivariable adjustment for aspirin on admission (P = 0.09) and any coronary revascularization (P = 0.10).Conclusion: Racial differences in the use of some therapies for myocardial infarction in patients hospitalized between 1994 and 1996 varied by region, suggesting that national evaluations of racial differences in health care use may obscure potentially important regional variations. [ABSTRACT FROM AUTHOR]

: PurposeDespite increased emphasis on medical ethics and professionalism in medical education, concern about unethical and unprofessional behavior by physicians is widespread. This study sought to identify and classify the range of work-related ethical conflicts experienced by medical house officers.: MethodsWe performed a qualitative study using data from in-depth interviews conducted in 2001 with 31 internal medicine residents in one traditional and one primary care residency. Using the constant comparative method, we explored work-related experiences during housestaff training that involved ethical conflict with patients or colleagues.: ResultsThe interviews revealed five categories of ethical conflict: concern over telling the truth, respecting patients'' wishes, preventing harm, managing the limits of one''s competence, and addressing performance of others that is perceived to be inappropriate. Conflicts occurred between residents and attending physicians, patients or families, and other residents. Many of the conflicts were exacerbated by the function of the hierarchical structure in residency training.: ConclusionsThis study provides a classification of work-related ethical conflicts that houseofficers experience, which may be used to improve the working environment for residents and support their professional development. By attending to the challenges that residents face, particularly previously underemphasized conflicts concerning competence and performance, this framework can be used to enhance education in ethics and professionalism. [Copyright &y& Elsevier]

: PurposeOlder patients are less likely to receive guideline-recommended medical therapies during acute myocardial infarction. However, it is unclear whether the lower rates of treatment reflect elderly patients’ increased number of comorbid conditions, physician or hospital effects, or true age-associated variation. Furthermore, it is unclear whether age-associated variations in care are similar or vary among treatments.: MethodsWe evaluated 146,718 Medicare patients from the Cooperative Cardiovascular Project aged ≥65 years who were hospitalized between 1994 and 1996 with a confirmed myocardial infarction, to ascertain whether rates of acute reperfusion therapy and use of aspirin (admission, discharge), beta-blockers (admission, discharge), and angiotensin-converting enzyme (ACE) inhibitors varied among patients aged 65 to 69 years, 70 to 74 years, 75 to 79 years, 80 to 84 years, and ≥85 years. We identified patients who were considered eligible for each therapy and who had no treatment contraindications. Associations between age and use of therapy were assessed, adjusting for patient, physician, hospital, and geographic factors.: ResultsAdjusted treatment rates were higher for patients aged 65 to 69 years than for patients aged ≥85 years for acute reperfusion therapy (54.4% vs. 31.2%, P <0.0001 for trend), beta-blockers (admission: 52.2% vs. 43.8%, P <0.0001 for trend; discharge: 61.8% vs. 55.3%, P <0.0001 for trend), aspirin at admission (73.8% vs. 71.0%, P <0.0001 for trend), and ACE inhibitors (61.6% vs. 57.1%, P = 0.02 for trend); there were no differences in the prescription of aspirin at discharge (76.0% vs. 73.6%, P = 0.05).: ConclusionElderly patients are less likely to receive guideline-indicated therapies when hospitalized with myocardial infarction. The effects of age were largest for acute reperfusion and smallest for aspirin. [Copyright &y& Elsevier]

: PurposePhysiologic studies have suggested that anemia could adversely affect the cardiovascular condition of patients with heart failure. Yet, the prognostic importance of this treatable condition is not well established by epidemiologic studies. We sought to determine the prognostic value of hematocrit level in a cohort of elderly patients hospitalized with heart failure.: MethodsWe studied a consecutive sample of 2281 patients aged 65 years or older who had been admitted with a principal discharge diagnosis of heart failure. Multivariate Cox proportional hazards regression was conducted to test whether hematocrit level was an independent predictor of 1-year mortality and of hospital readmission.: ResultsThe mean (± SD) age of the patients was 79 ± 8 years; 58% (n = 1324) were women. Their median hematocrit was 38% (25th to 75th percentile, 33% to 42%). Lower hematocrits were associated with a higher mortality. After adjusting for demographic and clinical factors, each 1% lower hematocrit was associated with a 2% greater 1-year mortality (P = 0.007). Compared with patients with a hematocrit >42%, those with a hematocrit ≤27% had a 40% greater 1-year mortality (hazard ratio [HR] = 1.40; 95% confidence interval [CI]: 1.02 to 1.92; P = 0.04). This increased risk was similar to that conferred by traditional risk factors, including a left ventricular ejection fraction ≤20% (HR = 1.50; 95% CI: 1.20 to 1.86). Lower hematocrits were also associated with a greater risk of hospital readmission.: ConclusionAnemia is associated with an increased risk of death and rehospitalization in older patients with heart failure. Whether anemia is a direct cause of worse outcomes, or a marker for other causal factors, is not known. [Copyright &y& Elsevier]

Background: Infection fatality rate and infection hospitalization rate, defined as the proportion of deaths and hospitalizations, respectively, of the total infected individuals, can estimate the actual toll of coronavirus disease 2019 (COVID-19) on a community, as the denominator is ideally based on a representative sample of a population, which captures the full spectrum of illness, including asymptomatic and untested individuals.Objective: To determine the COVID-19 infection hospitalization rate and infection fatality rate among the non-congregate population in Connecticut between March 1 and June 1, 2020.Methods: The infection hospitalization rate and infection fatality rate were calculated for adults residing in non-congregate settings in Connecticut prior to June 2020. Individuals with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies were estimated using the seroprevalence estimates from the recently conducted Post-Infection Prevalence study. Information on total hospitalizations and deaths was obtained from the Connecticut Hospital Association and the Connecticut Department of Public Health, respectively.Results: Prior to June 1, 2020, nearly 113,515 (90% confidence interval [CI] 56,758-170,273) individuals were estimated to have SARS-CoV-2 antibodies, and there were 7792 hospitalizations and 1079 deaths among the non-congregate population. The overall COVID-19 infection hospitalization rate and infection fatality rate were estimated to be 6.86% (90% CI, 4.58%-13.72%) and 0.95% (90% CI, 0.63%-1.90%), respectively, and there was variation in these rate estimates across subgroups; older people, men, non-Hispanic Black people, and those belonging to 2 of the counties had a higher burden of adverse outcomes, although the differences between most subgroups were not statistically significant.Conclusions: Using representative seroprevalence estimates, the overall COVID-19 infection hospitalization rate and infection fatality rate were estimated to be 6.86% and 0.95%, respectively, among community residents in Connecticut. [ABSTRACT FROM AUTHOR]

Background: Temporal changes in the readmission rates for patient groups and conditions that were not directly under the purview of the Hospital Readmissions Reduction Program (HRRP) can help assess whether efforts to lower readmissions extended beyond targeted patients and conditions.Methods: Using the Nationwide Readmissions Database (2010-2015), we assessed trends in all-cause readmission rates for 1 of the 3 HRRP conditions (acute myocardial infarction, heart failure, pneumonia) or conditions not targeted by the HRRP in age-insurance groups defined by age group (≥65 years or <65 years) and payer (Medicare, Medicaid, or private insurance).Results: In the group aged ≥65 years, readmission rates for those covered by Medicare, Medicaid, and private insurance decreased annually for acute myocardial infarction (risk-adjusted odds ratio [OR; 95% confidence interval] among Medicare patients, 0.94 [0.94-0.95], among Medicaid patients, 0.93 [0.90-0.97], and among patients with private-insurance, 0.95 [0.93-0.97]); heart failure (ORs, 0.96 [0.96-0.97], 0.96 [0.94-0.98], and 0.97 [0.96-0.99], for the 3 payers, respectively), and pneumonia (ORs, 0.96 [0.96-0.97), 0.94 [0.92-0.96], and 0.96 [0.95-0.97], respectively). Readmission rates also decreased in the group aged <65 years for acute myocardial infarction (ORs: Medicare 0.97 [0.96-0.98], Medicaid 0.94 [0.92-0.95], and private insurance 0.93 [0.92-0.94]), heart failure (ORs, 0.98 [0.97-0.98]: 0.96 [0.96-0.97], and 0.97 [0.95-0.98], for the 3 payers, respectively), and pneumonia (ORs, 0.98 [0.97-0.99], 0.98 [0.97-0.99], and 0.98 [0.97-1.00], respectively). Further, readmission rates decreased significantly for non-target conditions.Conclusions: There appears to be a systematic improvement in readmission rates for patient groups beyond the population of fee-for-service, older, Medicare beneficiaries included in the HRRP. [ABSTRACT FROM AUTHOR]

Abstract: Background: Substantial hospital-level variation in the risk of readmission after hospitalization for heart failure (HF) or acute myocardial infarction (AMI) has been reported. Prior studies have documented considerable state-level variation in rates of discharge to skilled nursing facilities (SNFs), but evaluation of hospital-level variation in SNF rates and its relationship to hospital-level readmission rates is limited. Methods: Hospital-level 30-day all-cause risk-standardized readmission rates (RSRRs) were calculated using claims data for fee-for-service Medicare patients hospitalized with a principal diagnosis of HF or AMI from 2006-2008. Medicare claims were used to calculate rates of discharge to SNF following HF-specific or AMI-specific admissions in hospitals with ≥25 HF or AMI patients, respectively. Weighted regression was used to quantify the relationship between RSRRs and SNF rates for each condition. Results: Mean RSRR following HF admission among 4101 hospitals was 24.7%, and mean RSRR after AMI admission among 2453 hospitals was 19.9%. Hospital-level SNF rates ranged from 0% to 83.8% for HF and from 0% to 77.8% for AMI. No significant relationship between RSRR after HF and SNF rate was found in adjusted regression models (P =.15). RSRR after AMI increased by 0.03 percentage point for each 1 absolute percentage point increase in SNF rate in adjusted regression models (P =.001). Overall, HF and AMI SNF rates explained <1% and 4% of the variation for their respective RSRRs. Conclusion: SNF rates after HF or AMI hospitalization vary considerably across hospitals, but explain little of the variation in 30-day all-cause readmission rates for these conditions. [Copyright &y& Elsevier]

Abstract: Purpose: Despite dramatic changes in heart failure management during the 1990s, little is known about the national heart failure mortality trends during this time period, particularly among the elderly. The purpose of this study was to determine temporal trends in outcomes of elderly patients with heart failure between 1992 and 1999. Subjects and methods: We analyzed a national sample of 3,957,520 Medicare beneficiaries aged 65 years or more who were hospitalized with heart failure between 1992 and 1999, assessing temporal trends in 30-day and 1-year all-causemortality and 30-day and 6-month all-cause hospital readmission. In risk-adjusted analyses, mortality and readmission for each year between 1994 and 1999 were compared with the referent year of 1993. Results: Crude 30-day and 1-year mortality decreased slightly (range for 1992-1999: 11.0%-10.3% and 32.5%-31.7%, respectively), whereas 30-day and 6-month readmission increased (10.2%-13.8% and 35.4%-40.3%, respectively). After risk adjustment, there was no change in 30-day mortality between 1993 and 1999 (eg, for 1999 vs 1993, odds ratio [OR] 1.01, 95% confidence interval [CI], 1.00-1.02). One-year mortality was lower in 1994 compared with 1993 (OR 0.91, 95% CI, 0.90-0.92), but data from subsequent years suggested no continuous improvement after 1994 (1999 vs 1993: OR 0.93, 95% CI, 0.92-0.94). Thirty-day readmission increased (1999 vs 1993: OR 1.09, 95% CI, 1.07-1.10), but there was no change in 6-month readmission (1999 vs 1993: OR 1.00, 95% CI, 0.99-1.01). Conclusion: We found no substantial improvement in mortality and hospital readmission during the 1990s among elderly patients hospitalized with heart failure. These findings suggest that recent innovations in heart failure management have not yet translated into better outcomes in this population. [Copyright &y& Elsevier]