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Objective: Randomized trials of transcatheter versus surgical aortic valve replacements have excluded bicuspid anatomy. We compared 3-year outcomes of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients aged more than 65 years with bicuspid aortic stenosis., Methods: The Centers for Medicare and Medicaid data were used to identify 6450 patients undergoing isolated surgical aortic valve replacement (n = 3771) or transcatheter aortic valve replacement (n = 2679) for bicuspid aortic stenosis (2012-2019). Propensity score matching with 21 baseline characteristics including frailty created 797 pairs., Results: Unmatched patients undergoing transcatheter aortic valve replacement were older than patients undergoing surgical aortic valve replacement (78 vs 70 years), with more comorbidities and frailty (all P < .001). After matching, transcatheter aortic valve replacement was associated with a similar mortality risk compared with surgical aortic valve replacement within the first 6 months (hazard ratio [HR], 1.08, 95% CI, 0.67-1.69) but a higher mortality risk between 6 months and 3 years (HR, 2.16, 95% CI, 1.22-3.83). Additionally, transcatheter aortic valve replacement was associated with a lower risk of heart failure readmissions before 6 months (HR, 0.51, 95% CI, 0.31-0.87) but a higher risk between 6 months and 3 years (HR, 4.78, 95% CI, 2.21-10.36). The 3-year risks of aortic valve reintervention (HR, 1.03, 95% CI, 0.30-3.56) and stroke (HR, 1.21, 95% CI, 0.75-1.96) were similar., Conclusions: Among matched Medicare beneficiaries undergoing transcatheter aortic valve replacement or surgical aortic valve replacement for bicuspid aortic stenosis, 3-year mortality was higher after transcatheter aortic valve replacement. However, transcatheter aortic valve replacement was associated with a similar risk of mortality and a lower risk of heart failure readmissions during the first 6 months after the intervention. Randomized comparative data are needed to best inform treatment choice., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The influence of socioeconomic disparities on survival after mitral repair is poorly defined. We examined the association between socioeconomic disadvantage and midterm outcomes of repair in Medicare beneficiaries with degenerative mitral regurgitation., Methods: US Centers for Medicare and Medicaid Services data were used to identify 10,322 patients undergoing isolated first-time repair for degenerative mitral regurgitation between 2012 and 2019. Zip code-level socioeconomic disadvantage was dichotomized with the Distressed Communities Index, which incorporates education level, poverty, unemployment, housing security, median income, and business growth; those with Distressed Communities Index score ≥80 were classified as distressed. The primary outcome was survival, censored at 3 years. Secondary outcomes included cumulative incidences of heart failure readmission, mitral reintervention, and stroke., Results: Of the 10,322 patients undergoing degenerative mitral repair, 9.7% (n = 1003) came from distressed communities. Patients from distressed communities underwent surgery at lower volume centers (11 vs 16 cases/year) and traveled further for surgical care (40 vs 17 miles) (both P values < .001). At 3 years, unadjusted survival (85.4%; 95% CI, 82.9%-87.5% vs 89.7%; 95% CI, 89.0%-90.4%) and cumulative incidence of heart failure readmission (11.5%; 95% CI, 9.6%-13.7% vs 7.4%; 95% CI, 6.9%-8.0%) were worse in patients from distressed communities (all P values < .001), whereas mitral reintervention rates were similar (2.7%; 95% CI, 1.8%-4.0% vs 2.8%; 95% CI, 2.5%-3.2%; P = .75). After adjustment, community distress was independently associated with 3-year mortality (hazard ratio, 1.21; 95% CI, 1.01-1.46) and heart failure readmissions (hazard ratio, 1.28; 95% CI, 1.04-1.58)., Conclusions: Community-level socioeconomic distress is associated with worse outcomes in degenerative mitral repair among Medicare beneficiaries., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Myocardial recovery occurs in patients with advanced heart failure on left ventricular assist device (LVAD) support, but there is the premise that it is rare with uncertain results., Objectives: The goal of this study was to investigate the incidence and consequence of LVAD explant after myocardial recovery., Methods: Using the United Network for Organ Sharing registry, LVAD implants in the United States between 2005 and 2020 were tracked until death, transplantation, or explant for myocardial recovery. The cohort undergoing explant was followed up for heart failure relapse (defined as relisting followed by delisting due to death, being too ill, or transplantation; or second durable LVAD implant)., Results: Of 15,728 LVAD implants, 126 patients underwent explant for recovery, which only occurred in 55 (38%) of 145 implanting centers. The crude cumulative incidence was 0.7% at 2 years, whereas the incidence reached 4.7% among designated centers in the selected young nonischemic cohort. Of 126 explanted patients, 76 (60%) were subsequently delisted for sustained recovery. Heart failure relapsing had a relatively higher hazard in the early phase, with a 30-day incidence of 6% (7 of 126) but tapered following with the freedom rate of 72.5% at 4 years., Conclusions: In the United States, LVAD explant for myocardial recovery was underutilized, leading to a very low incidence at the national level despite a realistic rate being achieved in designated centers for selected patients. With follow-up extending up to 4 years after explant, more than one-half were successfully removed and stayed off the waitlist, and approximately 70% were free from heart failure relapse events., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Although the SynCardia total artificial heart (SynCardia Systems, LLC) was approved for use as a bridge to transplantation in 2004 in the United States, most centers do not adopt the total artificial heart as a standard bridging strategy for patients with biventricular failure. This study was designed to characterize the current use and outcomes of patients placed on total artificial heart support., Methods: The United Network of Organ Sharing Standard Transplant Research File was queried to identify total artificial heart implantation in the United States between 2005 and 2018. Multivariable Cox regression models were used for risk prediction., Results: A total of 471 patients (mean age, 49 years; standard deviation, 13 years; 88% were male) underwent total artificial heart implantation. Of 161 transplant centers, 11 centers had cumulative volume of 10 or more implants. The 6-month cumulative incidence of mortality on the total artificial heart was 24.6%. The 6-month cumulative incidence of transplant was 49.0%. The 1-year mortality post-transplantation was 20.0%. Cumulative center volume less than 10 implants was predictive of both mortality on the total artificial heart (hazard ratio, 2.2, 95% confidence interval, 1.5-3.1, P < .001) and post-transplant mortality after a total artificial heart bridge (hazard ratio, 1.5, 95% confidence interval, 1.0-2.2, P = .039)., Conclusions: Total artificial heart use is low, but the total artificial heart can be an option for biventricular bridge to transplant with acceptable bridge to transplant and post-transplant survival, especially in higher-volume centers. The observation of inferior outcomes in lower-volume centers raises questions as to whether targeted training, center certifications, and minimum volume requirements could improve outcomes for patients requiring the total artificial heart., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Heart donation after circulatory death was recently reintroduced in the United States with hopes of increasing donor heart availability. We examined its national use and outcomes., Methods: The United Network for Organ Sharing database was used to identify validated adult patients undergoing heart transplantation using donation after circulatory death donors (n = 266) and donation after brain death donors (n = 5998) between December 1, 2019, and December 31, 2021, after excluding heart-lung transplants. Propensity score matching was used to create more balanced groups for comparison., Results: The monthly percentage of donation after circulatory death heart transplant increased from 2.5% in December 2019 to 6.8% in December 2021 (P < .001). Twenty-two centers performed donation after circulatory death heart transplants, ranging from 1 to 75 transplants per center. Four centers performed 70% of the national volume. Recipients of donation after circulatory death hearts were more likely to be clinically stable (80.4% vs 41.1% in status 3-6, P < .001), to have type O blood (58.3% vs 39.9%, P < .001), and to wait longer after listing (55, interquartile range, 15-180 days vs 32, interquartile range, 9-160 days, P = .003). Six-month survival was 92.1% (95% confidence interval, 91.3-92.8) after donation after brain death heart transplants and 92.6% (95% confidence interval, 88.1-95.4) after donation after circulatory death heart transplants (hazard ratio, 0.94, 95% confidence interval, 0.57-1.54, P = .79). Outcomes in propensity-matched patients were similar except for higher rates of treated acute rejection in donation after circulatory death transplants before discharge (14.4% vs 8.8%, P = .01). In donation after circulatory death heart recipients, outcomes did not differ based on the procurement technique (normothermic regional perfusion vs direct procurement and perfusion)., Conclusions: Heart transplantation with donation after circulatory death donors has short-term survival comparable to donation after brain death transplants. Broader implementation could substantially increase donor organ availability., (Copyright © 2022. Published by Elsevier Inc.)

Background: Simultaneous heart-kidney transplantation has been increasingly performed in end-stage heart failure patients with concurrent kidney dysfunction despite limited evidence supporting its indications and utility., Objectives: The purpose of this study was to investigate the effects and utility of simultaneously implanted kidney allografts with various degrees of kidney dysfunction during heart transplantation., Methods: Using the United Network for Organ Sharing registry, long-term mortality was compared in recipients with kidney dysfunction who underwent heart-kidney transplantation (n = 1,124) vs isolated heart transplantation (n = 12,415) in the United States between 2005 and 2018. In heart-kidney recipients, contralateral kidney recipients were compared for allograft loss. Multivariable Cox regression was used for risk adjustment., Results: Long-term mortality was lower among heart-kidney recipients than among heart-alone recipients when recipients were on dialysis (26.7% vs 38.6% at 5 years; HR: 0.72; 95% CI: 0.58-0.89) or had a glomerular filtration rate (GFR) of <30 mL/min/1.73 m 2 (19.3% vs 32.4%; HR: 0.62; 95% CI: 0.46-0.82) and GFR of 30 to 45 mL/min/1.73 m 2 (16.2% vs 24.3%; HR: 0.68; 95% CI: 0.48-0.97) but not in GFR of 45 to 60 mL/min/1.73 m 2 . Interaction analysis showed that the mortality benefit of heart-kidney transplantation continued up to GFR 40 mL/min/1.73 m 2 . The incidence of kidney allograft loss was higher among heart-kidney recipients than among contralateral kidney recipients (14.7% vs 4.5% at 1 year; HR: 1.7; 95% CI: 1.4-2.1)., Conclusions: Heart-kidney transplantation relative to heart transplantation alone provided superior survival for dialysis-dependent recipients and non-dialysis-dependent recipients up to a GFR of approximately 40 mL/min/1.73 m 2 but at the cost of almost twice the risk of kidney allograft loss than contralateral kidney allograft recipients., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Homebound older adults are medically complex and often have difficulty accessing outpatient medical care. Home-based primary care (HBPC) may improve care and outcomes for this population but data from randomized trials of HBPC in the United States are limited., Methods: We conducted a randomized controlled trial of HBPC versus office-based primary care for adults ages ≥65 years who reported ≥1 hospitalization in the prior 12 months and met the Medicare definition of homebound. HBPC was provided by teams consisting of a physician, nurse practitioner, nurse, and social worker. Data were collected at baseline, 6- and 12-months. Outcomes were quality of life, symptoms, satisfaction with care, hospitalizations, and emergency department (ED) visits. Recruitment was terminated early because more deaths were observed for intervention patients., Results: The study enrolled 229 patients, 65.4% of planned recruitment. The mean age was 82 (9.0) years and 72.3% had dementia. Of those assigned to HBPC, 34.2% never received it. Intervention patients had greater satisfaction with care than controls (2.26, 95% CI 1.46-3.06, p < 0.0001; effect size 0.74) and lower hospitalization rates (-17.9%, 95% CI -31.0% to -1.0%; p = 0.001; number needed to treat 6, 95% CI 3-100). There were no significant differences in quality of life (1.25, 95% CI -0.39-2.89, p = 0.13), symptom burden (-1.92, 95% CI -5.22-1.37, p = 0.25) or ED visits (1.2%, 95% CI -10.5%-12.4%; p = 0.87). There were 24 (21.1%) deaths among intervention patients and 12 (10.7%) among controls (p < 0.0001)., Conclusion: HBPC was associated with greater satisfaction with care and lower hospitalization rates but also more deaths compared to office-based primary care. Additional research is needed to understand the nature of the higher death rate for HBPC patients, as well as to determine the effects of HBPC on quality of life and symptom burden given the trial's early termination., (© 2022 The American Geriatrics Society.)

Introduction: Access to care is essential for patients with diabetes to maintain health and prevent complications, and is important for health equity. New York State's Health Homes (HHs) provide care management services to Medicaid-insured patients with chronic conditions, including diabetes, and aim to improve quality of care and outcomes. There is inconsistent evidence on the impact of HHs, and care management programs more broadly, on access to care., Research Design and Methods: Using a cohort of patients with diabetes derived from electronic health records from the INSIGHT Clinical Research Network, we analyzed Medicaid data for HH enrollees and a matched comparison group of HH non-enrollees. We estimated HH impacts on several access measures using natural experiment methods., Results: We identified and matched 11 646 HH enrollees; patients were largely non-Hispanic Black (29.9%) and Hispanic (48.7%), and had high rates of dual eligibility (33.0%), Supplemental Security Income disability enrollment (49.1%), and multiple comorbidities. In the 12 months following HH enrollment, HH enrollees had one more month of Medicaid coverage (p<0.001) and 4.6 more outpatient visits than expected (p<0.001, evenly distributed between primary and specialty care). There were also positive impacts on the proportions of patients with follow-up visits within 7 days (4 percentage points (pp), p<0.001) and 30 days (6pp, p<0.001) after inpatient care, and on the proportion of patients with follow-up visits within 30 days after emergency department (ED) care (4pp, p<0.001). We did not find meaningful differences in continuity of care. We found small positive impacts on the proportion of patients with an inpatient visit and the proportion with an ED visit., Conclusions: New York State's HH program improved access to care for Medicaid recipients with diabetes. These findings have implications for New York State Medicaid as well as other providers and care management programs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Individuals that have both diabetes and substance use disorder (SUD) are more likely to have adverse health outcomes and are less likely to receive high quality diabetes care, compared with patients without coexisting SUD. Care management programs for patients with chronic diseases, such as diabetes and SUD, have been associated with improvements in the process and outcomes of care., Objective: The aim was to assess the impact of having coexisting SUD on diabetes process of care metrics., Research Design: Preintervention/postintervention triple difference analysis., Subjects: Participants in the New York State Medicaid Health Home (NYS-HH) care management program who have diabetes and a propensity-matched comparison group of nonparticipants (N=37,260)., Measures: Process of care metrics for patients with diabetes: an eye (retinal) exam, HbA1c test, medical attention (screening laboratory measurements) for nephropathy, and receiving all 3 in the past year., Results: Before enrollment in NYS-HH, individuals with comorbid SUD had fewer claims for eye exams and HbA1c tests compared with those without comorbid SUD. Diabetes process of care improvements associated with NYS-HH enrollment were larger among those with comorbid SUD [eye exam: adjusted odds ratio (AOR)=1.08; 95% confidence interval (CI): 1.01-1.15]; HbA1c test: AOR=1.20 (95% CI: 1.11-1.29); medical attention for nephropathy: AOR=1.21 (95% CI: 1.12-1.31); all 3: AOR=1.09 (95% CI: 1.02-1.16)., Conclusions: Individuals with both diabetes and SUD may benefit moderately more from care management than those without comorbid SUD. Individuals with both SUD and diabetes who are not enrolled in care management may be missing out on crucial diabetes care., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The dissemination of mitral valve repair as the first-line treatment and the introduction of MitraClip for patients who have a prohibitive risk for surgery have changed the landscape of mitral valve intervention. The aim of this study is to provide current and generalizable data regarding the trend of mitral valve interventions and outcomes from 2000 to 2016., Methods: Patients ≥18 years of age who underwent mitral-valve interventions were identified using the National Inpatient Sample database. National estimates were generated by means of discharge weights; comorbid conditions were identified using Elixhauser methods. All trends were analyzed with JoinPoint software., Results: A total of 656,030 mitral valve interventions (298,102 mitral valve replacement, 349,053 mitral valve repair, and 8875 MitraClip) were assessed. No changes in rate of procedures (per 100,000 people in the United States) were observed over this period (annual percent change, -0.4; 95% confidence limit, -1.1 to 0.3; P = .3). From 2000 to 2010, the number of replacements decreased by 5.6% per year (P < .001), whereas repair increased by 8.4% per year from 2000 to 2006 (P < .001). MitraClip procedures increased by 84.4% annually from 2013 to 2016 (P < .001). The burden of comorbidities increased throughout the study for all groups, with the greatest score for MitraClip recipients. Overall, length of stay has decreased for all interventions, most significantly for MitraClip. In-hospital mortality decreased from 8.5% to 3.7% for all interventions, with MitraClip having the most substantial decrease from 3.6% to 1.5%., Conclusions: Over a 17-year period, mitral-valve interventions were associated with improved outcomes despite being applied to an increasingly sicker population., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the length of encounter during visits where goals-of-care (GoC) discussions were expected to take place., Methods: Oncologists from community, academic, municipal, and rural hospitals were randomly assigned to receive a coaching model of communication skills to facilitate GoC discussions with patients with newly diagnosed advanced solid-tumor cancer with a prognosis of < 2 years. Patients were surveyed after the first restaging visit regarding the quality of the GoC discussion on a scale of 0-10 (0 = worst; 10 = best), with ≥ 8 indicating a high-quality GoC discussion. Visits were audiotaped, and total encounter time was measured., Results: The median face-to-face time oncologists spent during a GoC discussion was 15 minutes (range, 10-20 minutes). Among the different hospital types, there was no significant difference in encounter time. There was no difference in the length of the encounter whether a high-quality GoC discussion took place or not (15 v 14 minutes; P = .9). If there was imaging evidence of cancer progression, the median encounter time was 18 minutes compared with 13 minutes for no progression ( P = .03). In a multivariate model, oncologist productivity, patient age, and Medicare coverage affected duration of the encounter., Conclusion: Oncologists can complete high-quality GoC discussions in 15 minutes. These data refute the common misperception that discussing such matters with patients with advanced cancer requires significant time.

Background: Limited data inform cerebral protection during circulatory arrest. This study was designed to identify optimal approaches from a national clinical registry., Methods: A total of 7830 adults (mean age, 63.1 years, SD 13.1 years) who underwent hemiarch (n = 6891; 88.0%) or total arch (n = 939; 12.0%) replacement with hypothermic circulatory arrest between 2014 and 2016 were identified from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (version 2.81). Aortic dissections were excluded from the analysis. Multivariable logistic regression was used to adjust for 29 baseline and operative variables, including demographics, comorbidity, surgery, and nadir temperature, comparing outcomes according to protection strategy. The primary end point was a composite of 30-day and in-hospital mortality or major permanent neurologic complications., Results: The rate of death or permanent neurologic complication was 10.9% (n = 850). Antegrade cerebral perfusion was most commonly used (n = 3369; 43%; median nadir temperature 23°C; median arrest time 30 minutes) compared with retrograde cerebral perfusion (n = 1898; 24%; 20°C; 24 minutes) and no cerebral perfusion (n = 2563; 33%; 20°C, 22 minutes). In multivariable analysis, deep hypothermia with antegrade (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52 to 0.81) or retrograde (OR, 0.57; 95% CI, 0.45 to 0.71) perfusion and moderate hypothermia with antegrade perfusion (OR, 0.61; 95% CI, 0.46 to 0.79) were associated with significant reductions in death and stroke compared with deep hypothermia without cerebral perfusion. Risk reduction was greatest in circulatory arrest lasting longer than 30 minutes., Conclusions: For patients without aortic dissection and who require more than 30 minutes of circulatory arrest, optimal cerebral protection strategies are deep hypothermia with either antegrade or retrograde cerebral perfusion and moderate hypothermia with antegrade cerebral perfusion., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Cardiovascular disease (CVD) is a leading cause of mortality in early-stage breast cancer survivors. Recent studies suggest that bisphosphonates may decrease CVD risk in older patients., Objective: This study sought to assess whether bisphosphonate use is associated with lower rates of incident CVD events among early-stage breast cancer survivors., Methods: Longitudinal, population-based cohort study was conducted by using data from the Surveillance, Epidemiology and End Results registry linked to Medicare claims. We identified women >65 years with no history of CVD who were diagnosed with stage 0-III primary breast cancer between 2007 and 2010. Our primary outcome was a composite of incident angina pectoris, myocardial infarction, atrial fibrillation/flutter, heart failure, or stroke within 36 months of cancer diagnosis. Bisphosphonate use was defined as the presence of ≥1 pharmacy claim from 6 months prior to cancer diagnosis to the incident CVD event. We used propensity scores to create a matched group of breast cancer survivors without bisphosphonate exposure to compare rates of incident CVD events., Results: A total of 2178 breast cancer survivors had ≥1 bisphosphonate prescription; the average length of bisphosphonate use was 15 months. Analyses of the matched data showed that 13.0% of bisphosphonate users and 23.4% of non-bisphosphonate users experienced an incident CVD event (p < 0.0001) after breast cancer diagnosis. Bisphosphonate use was significantly associated with fewer incident CVD events (hazard ratio: 0.51, 95% confidence interval: 0.44 to 0.59)., Conclusions: Bisphosphonate use is associated with lower incidence of CVD events among older early-stage breast cancer survivors. Future studies should prospectively evaluate whether bisphosphonate use can decrease CVD incidence., (Published by Elsevier Ltd.)

Under the Affordable Care Act (ACA), more women are insured with Medicaid, which should improve healthcare access. We sought to determine whether there are survival differences among patients with breast cancer undergoing surgery at facilities with varying proportions of Medicaid patients. We used New York State (NYS) Vital Statistics death records data linked with NYS discharge inpatient and ambulatory surgery databases to examine 90-day survival after surgery from 2008 to 2013. We used all Medicaid discharges to calculate and create quintiles of facilities based on Medicaid volume. We calculated survival hazard ratios using a marginal Cox model controlling for clustering of patients within hospitals, age, race, insurance, year of surgery, and comorbidities. Women who received surgery in facilities with the highest quintile of Medicaid volume had higher 90-day mortality (2.1% vs. 0.07%, p < .001) compared with those treated in facilities with lowest Medicaid volume, even after adjusting for multiple confounders. Consequently, although the ACA may improve access, healthcare quality remains questionable because patients treated at facilities with high proportions of Medicaid volume appear to have worse 90-day survival, likely due to quality of surgical and postsurgical care. Policymakers must ensure that quality of care is not negatively impacted by programs to reduce costs.

Objective: To evaluate whether overall survival is improving among women in the United States with advanced ovarian cancer., Methods: This retrospective cohort study evaluated trends in treatment and overall survival for women older than 65 years diagnosed with stage III and IV epithelial ovarian cancer between 1995 and 2008 using Surveillance, Epidemiology, and End Results-Medicare data. Parametric and semiparametric multivariate survival analyses were used to assess comparative treatment survival rates and factors affecting survival and recurrence., Results: Of 7,938 women who met study criteria, 2.9% received no treatment, 15.4% underwent surgery only, 24.8% received chemotherapy only, 41.8% underwent primary debulking surgery and chemotherapy in an optimal timeframe, and 15.1% had primary debulking surgery and chemotherapy, but the timing was not optimal or patients did not complete all six cycles of chemotherapy. Those who underwent surgery only had similar survival as those who received no treatment (2.2 compared with 1.7 months), whereas those who received chemotherapy only had a better overall survival (14.4 months). Optimal treatment was associated with the longest survival time (P<.001, median overall survival 39.0 months). Additionally, survival time associated with optimal treatment increased over the past decade. However, the proportion of women who received optimal treatment has decreased over the past decade., Conclusion: Elderly women with advanced ovarian cancer have the best survival with optimal therapy. When this is not offered or possible, chemotherapy alone offers better survival than surgery alone.

Background: For every maternal death, >100 women experience severe maternal morbidity, which is a life-threatening diagnosis, or undergo a life-saving procedure during their delivery hospitalization. Similar to racial/ethnic disparities in maternal death, black women are more likely to experience severe maternal morbidity than white women. Site of care has received attention as a mechanism to explain disparities in other areas of medicine. Data indicate that black women receive care in a concentrated set of hospitals and that these hospitals appear to provide lower quality of care. Whether racial differences in the site of delivery contribute to observed black-white disparities in severe maternal morbidity rates is unknown., Objective: The purpose of this study was to determine whether hospitals with high proportions of black deliveries have higher severe maternal morbidity and whether such differences contribute to overall black-white disparities in severe maternal morbidity., Study Design: We used a published algorithm to identify cases of severe maternal morbidity during deliveries in the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project for 2010 and 2011. We ranked hospitals by their proportion of black deliveries into high black-serving (top 5%), medium black-serving (5% to 25% range), and low black-serving hospitals. We analyzed the risks of severe maternal morbidity for black and white women by hospital black-serving status using logistic regressions that were adjusted for patient characteristics, comorbidities, hospital characteristics, and within-hospital clustering. We then derived adjusted rates from these models., Results: Seventy-four percent of black deliveries occurred at high and medium black-serving hospitals. Overall, severe maternal morbidity occurred more frequently among black than white women (25.8 vs 11.8 per 1000 deliveries, respectively; P < .001); after adjustment for the distribution of patient characteristics and comorbidities, this differential declined but remained elevated (18.8 vs 13.3 per 1000 deliveries, respectively; P < .001). Women who delivered in high and medium black-serving hospitals had elevated rates of severe maternal morbidity rates compared with those in low black-serving hospitals in unadjusted (29.4 and 19.4 vs 12.2 per 1000 deliveries, respectively; P < .001) and adjusted analyses (17.3 and 16.5 vs 13.5 per 1000 deliveries, respectively; P < .001). Black women who delivered at high black-serving hospitals had the highest risk of poor outcomes., Conclusion: Most black deliveries occur in a concentrated set of hospitals, and these hospitals have higher severe maternal morbidity rates. Targeting quality improvement efforts at these hospitals may improve care for all deliveries and disproportionately impact care for black women., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To examine whether treatment with guideline-recommended care (surgery and chemotherapy) is associated with mortality differences between black and white women with advanced epithelial ovarian cancer., Methods: We conducted an observational cohort study using the Surveillance, Epidemiology, and End Results (SEER) linked to Medicare claims for 1995-2007. We evaluated long-term survival for 4,695 black and white women with stage III or stage IV epithelial ovarian cancer with Kaplan-Meier analysis and Cox regression, and then in patients matched by propensity score to create two similar cohorts for comparison. We investigated the association between race, stage, and survival among women who were treated with guideline-recommended care and those who received incomplete treatment., Results: Black women with advanced epithelial ovarian cancer were more likely to die than white women (unadjusted hazard ratio [HR] 1.27; 95% confidence interval [CI] 1.10-1.46). Black women were less likely than white women to receive guideline-recommended care (54% compared with 68%; P<.001), and women who did not receive recommended treatment had lower survival rates than women who received recommended care. Cox proportional hazards models demonstrated no differences in black women compared with white women regarding mortality among women who were treated with guideline-recommended care (adjusted HR 1.04; 95% CI 0.85-1.26), or among women who received incomplete treatment (adjusted HR 1.09; 95% CI 0.89-1.34). The survival analysis of patients matched by propensity score confirmed these analyses., Conclusions: Differences in rates of treatment with guideline-recommended care are associated with black-white mortality disparities among women with advanced epithelial ovarian cancer., Level of Evidence: III.

Objective: To evaluate trends by race in Agency for Healthcare Research and Quality obstetric-related quality and safety indicators and their relationships to trends in inpatient maternal and neonatal mortality., Methods: We used the Nationwide Inpatient Sample from 2000 through 2009 and calculated obstetric hospital quality and patient safety indicators and inpatient maternal and neonatal mortality stratified by race. We examined differences in age and comorbidity-adjusted trends in black compared with white women over time in the United States and by geographic region. Proportions were analyzed by χ2 and trends by regression analysis., Results: Obstetric quality indicators varied by geographic region, but changes over time were consistent for both races. Cesarean deliveries increased similarly for black and white women, and vaginal births after cesarean delivery declined for both races but more rapidly for white women than for black women. Obstetric safety indicators improved over the study period for black and white women, with obstetric trauma decreasing significantly for both groups (28% compared with 35%, respectively) and birth trauma-injury to neonates declining for both, but changes were not significant. In striking contrast, inpatient maternal and neonatal mortality remained relatively constant during the study period, with persistently higher rates of both seen among black compared with white women (12.0 compared with 4.6 per 100,000 deliveries, P<.001 and 6.6 compared with 2.5 per 1,000 births, P<.001, respectively, in 2009)., Conclusion: Improvements in Agency for Healthcare Research and Quality quality indicators for obstetrics are not reflected in improvements in maternal and neonatal morbidity and mortality and do not explain continued racial disparities for outcomes in pregnancies in black and white women. Quality measures that are related to pregnancy outcomes are needed and these should elucidate obstetric health disparities.

Background: This study evaluated gender-specific trends in the diagnosis and treatment of ruptured abdominal aortic aneurysms (rAAAs) in the United States Medicare population., Methods: The Medicare beneficiary database (1995 through 2006) was examined for patients with rAAAs using International Classification of Diseaes, 9th Edition, Clinical Modification (ICD-9-CM) codes. Codes for endovascular aneurysm repair (EVAR) were only available for the year 2000 forward, and thus, analysis of EVAR was limited to 2000 through 2006. Proportions were analyzed by chi(2) and continuous variables by t-test. Factors associated with 30-day mortality and discharge home after surgery were analyzed by multivariate logistic regression. The effect of gender and repair type (open or EVAR) on death and the probability of discharge to home after repair were also evaluated., Results: The rate of hospitalizations per 100,000 Medicare fee-for-service beneficiaries for men decreased by 52% (from 40 to 19) and by 36% for women (from 11 to 7). The observed 30-day mortality rate was overall 7.7% higher for women vs men. The mortality rate for women was higher by 8.9% for open repair and higher by 7.1% for EVAR vs men. Female gender was associated with increased risk of death in multivariate analysis after controlling for age, year, and type of procedure. Women were 9.8% less likely to be discharged to home after rAAA repair, regardless of the type of repair., Conclusion: In addition to the fact that we have failed to realize a change in the number of women diagnosed with or treated for rAAA, a significant gender difference remains in the outcomes after treatment for rAAA. This differential is present in both the 30-day mortality rate and in the potential to be discharged to home after repair., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Endovascular aneurysm repair (EVAR) is commonly used as a minimally invasive technique for repairing infrarenal aortic aneurysms. There have been recent concerns that a subset of high-risk patients experience unfavorable outcomes with this intervention. To determine whether such a high-risk cohort exists and to identify the characteristics of these patients, we analyzed the outcomes of Medicare patients treated with EVAR from 2000-2006., Methods: We identified 66,943 patients who underwent EVAR from Inpatient Medicare database. The overall 30-day mortality was 1.6%. A risk model for perioperative mortality was developed by randomly selecting 44,630 patients; the other one third of the dataset was used to validate the model. The model was deemed reliable (Hosmer-Lemeshow statistics were P = .25 for the development, P = .24 for the validation model) and accurate (c = 0.735 and c = 0.731 for the development and the validation model, respectively)., Results: In our scoring system, where scores ranged between 1 and 7, the following were identified as significant baseline factors that predict mortality: renal failure with dialysis (score = 7); renal failure without dialysis (score = 3); clinically significant lower extremity ischemia (score = 5); patient age >or=85 years (score = 3), 75-84 years (score = 2), 70-74 years (score = 1); heart failure (score = 3); chronic liver disease (score = 3); female gender (score = 2); neurological disorders (score = 2); chronic pulmonary disease (score = 2); surgeon experience in EVAR <3 procedures (score = 1); and hospital annual volume in EVAR <7 procedures (score = 1). The majority of Medicare patients who were treated (96.6%, n = 64,651) had a score of 9 or less, which correlated with a mortality <5%. Only 3.4% of patients had a mortality >or=5% and 0.8% of patients (n = 509) had a score of 13 or higher, which correlated with a mortality >10%., Conclusion: We conclude that there is a high-risk cohort of patients that should not be treated with EVAR because of prohibitively high mortality; however, this cohort is small. Our scoring system, which is based on patient and institutional factors, provides criteria that can be easily used by clinicians to quantify perioperative risk for EVAR candidates.

Objectives: Endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAA) has been shown to acutely decrease procedural mortality compared to open aortic repair (OAR). However, little is known about the effect of choice of procedure; EVAR vs OAR, or the impact of physician and institution volume on long-term survival and outcome., Methods: Patients hospitalized with rAAA who underwent either OAR or EVAR, were derived from the Medicare inpatient dataset (1995-2004) using ICD9 codes. We evaluated long-term survival after OAR and EVAR in the entire fee-for-service Medicare population, and then in patients matched by propensity score to create two similar cohorts for comparison with Kaplan-Meier analysis. Annual surgeon and hospital volumes of EVAR (elective and ruptured), OAR (elective and ruptured), and rAAA (EVAR and OAR) were divided into quintiles to determine if increasing volumes correlate with decreasing mortality. Predictors of survival were determined by Cox modeling., Results: A total of 43,033 Medicare beneficiaries had rAAA repair: 41,969 had OAR and 1,064 had EVAR. The proportions of patients with diabetes, hypertension, cardiovascular, cerebrovascular, renal disease, hyperlipidemia, and cancer were statistically higher in the EVAR than in the OAR group, whereas lower extremity vascular disease was higher in the OAR group. The initial evaluation of EVAR vs OAR, prior to propensity matching, showed no statistical advantage in EVAR-survival after 90 days. The survival analysis of patients matched by propensity score showed a benefit of EVAR over OAR that persisted throughout the 4 years of follow-up (P = .0042). Perioperative and long-term survival after rAAA repair correlated with increasing annual surgeon and hospital volume in OAR and EVAR and also with rAAA experience. EVAR repair had a protective effect (HR = 0.857, P = .0061) on long-term survival controlling for comorbidities, demographics, and hospital and surgeon volume., Conclusion: When EVAR and OAR patients are compared using a reliable statistical technique such as propensity analysis, the perioperative survival advantage of rAAA repaired endovascularly is maintained over the long term. Institutional experience with rAAA is critical for survival after either OAR or EVAR.

Objective: This study evaluated trends in hospitalizations, treatment, and mortality of ruptured abdominal aortic aneurysms (rAAAs) in the United States Medicare population., Methods: The Medicare inpatient database (1995 through 2006) was reviewed for patients with rAAA and AAA by using International Classification of Disease (9th Clinical Modification) codes for rAAA and AAA. Proportions and trends were analyzed by chi(2) analysis, continuous variables by t test, and trends by the Cochran-Armitage test., Results: During the study period, hospitalizations with the diagnoses of rAAA declined from 23.2 to 12.8 per 100,000 Medicare beneficiaries (P < .0001), as did repairs of rAAA (15.6 to 8.4 per 100,000; P < .0001). No change was observed in AAA elective repairs. The 30-day mortality rate after open repair of rAAA decreased by 4.9% (from 39.6% to 34.7%; P = .0007 for trend) for the age group 65 to 74 and by 2.4% (from 52.9% to 50.5%, P = .0008) for the age group > or =75. Perioperative mortality after endovascular repair diminished by 13.6% (from 43.5% in 2001 to 29.9% in 2006; P = .0020). Mortality among women was higher than among men (51.1% vs 40.0% in 2006). The demographics of patients treated for rAAA changed to include a greater proportion of women and patients aged > or =75 years., Conclusion: A significant decrease has occurred in the number of patients who have a diagnosis of rAAA and undergo treatment, but there has been no change in repairs of AAA. The perioperative mortality rate has improved due to the introduction of endovascular repair and a small but progressive improvement in survival after open repair for patients aged 65 to 74 years.

Objective: To determine if insurance status predicts severity of vascular disease at the time of treatment or outcomes following intervention., Methods: Hospital discharge databases from Florida and New York from 2000-2005 were analyzed for lower extremity revascularization (LER, n = 73,532), carotid revascularization (CR, n = 116,578), or abdominal aortic aneurysm repair (AAA, n = 35,593), using ICD-9 codes for diagnosis and procedure. The indications for intervention as well as the post-operative outcomes were examined assigning insurance status as the independent variable. Patients covered under a variety of commercial insurers, as well as Medicare, were compared to those who either had no insurance or were covered by Medicaid., Results: Patients without insurance or with Medicaid were at significantly greater risk of presenting with a ruptured AAA compared to insured (non-Medicaid) patients; while insurance status did not seem to impact post-operative mortality rates for elective and ruptured AAA repair. The uninsured or Medicaid recipients presented with symptomatic carotid disease nearly twice as often as the insured, but stroke rates after CR did not differ significantly based on insurance status. Patients with Medicaid or without insurance were more likely to present with limb threatening ischemia than claudication. In contrast to AAA repair and CR, the outcomes of LER were worse in the uninsured and Medicaid beneficiaries who had higher rates of post-revascularization amputation compared to the insured (non-Medicaid) group., Conclusion: Insurance status predicts disease severity at the time of treatment, but once treated, the outcomes are similar among insurance categories, with the exception of lower extremity revascularization. This data suggests inferior access to preventative vascular care in the Medicaid and the uninsured populations.

Background: The recent evolution in treatments for peripheral vascular disease has dated available mortality statistics for vascular intervention. Moreover, many of our current mortality statistics are derived from single-institution studies that are often not reflective of outcomes in general practice. To provide current and generalizable data regarding mortality and trends for peripheral vascular interventions, we examined two national data sets (Nationwide Inpatient Sample, 1998-2003, and National Hospital Discharge Survey, 1979-2003) and four states (New York, California, Florida, and New Jersey, 1998-2003)., Methods: Four procedures--abdominal aortic aneurysm repair (nonruptured), lower extremity revascularization, amputation, and carotid revascularization--were selected by cross-referencing International Classification of Diseases, 9th Revision, diagnostic and procedural codes. For significance, the t test was used for continuous variables, the chi2 test was used for dichotomous variables, and the chi2 test was used for mortality trends., Results: From 1998 to 2003, there was a progressive decrease in the national per capita rate of amputations: 13.2% overall and 21.2% for major amputations (P < .0001). Nationally and regionally, mortality has only slightly declined. For lower extremity revascularization, after a sharp increase during the 1980s to 100,000 open procedures, the volume remained constant for 10 years and began to decline in 1998, reaching 70,000 cases in 2003. In contrast, since 1996, endovascular interventions have increased 40%. Mortality during the 1998 to 2003 period remained virtually stable at 1.5% to 2% for endovascular procedures and 3% to 4% for open procedures. The overall volume of abdominal aortic aneurysm repair has not changed substantially for the past 6 years; however, endovascular repair is now used for nearly half the cases (46.5% regional and 43.0% national). Mortality for open repair has not changed, remaining at approximately 5%, whereas for endovascular repair, mortality has declined from 2.6% in 2000 to less than 1.5% in 2003. After the rapid increase in open carotid revascularization in the early 1990s, the total volume has declined 5% nationally from 1998 to 2003. Regional data demonstrated an overall 12% reduction in carotid revascularization volume since 1998; this reduction was due to a 16% decline in open carotid revascularization. During this same period, the use of angioplasty-stent carotid revascularization doubled. Mortality for the open procedures is 0.5% and is significantly higher (2%-3%) for endovascular carotid revascularization. Stroke rates for endovascular carotid revascularization are also higher: 2.13% vs 1.28% for open procedures (P < .0001)., Conclusions: Dramatic shifts in the management of peripheral vascular disease have occurred together with an overall decline in mortality. There seems to be a significant mortality advantage for endovascular as compared with traditional surgery except for carotid endarterectomy. The increasing safety of vascular interventions should be considered when deciding which patients to treat but with the caveat that endovascular interventions are not always safer than open repair.