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Background The angiotensin-receptor/neprilysin inhibitor ( ARNI ) sacubitril/valsartan reduces hospitalization and mortality for patients with heart failure with reduced ejection fraction. However, adoption of ARNI into clinical practice has been slow. Factors influencing use of ARNI have not been fully elucidated. Using data from the Get With The Guidelines-Heart Failure registry, Hospital Compare, Dartmouth Atlas, and the American Hospital Association Survey, we sought to identify hospital characteristics associated with patient-level receipt of an ARNI prescription. Methods and Results We analyzed patients with heart failure with reduced ejection fraction who were eligible for ARNI prescription (ejection fraction≤40%, no contraindications) and hospitalized from October 1, 2015 through December 31, 2016. We used logistic regression to estimate the associations between hospital characteristics and patient ARNI prescription at hospital discharge, accounting for clustering of patients within hospitals using generalized estimating equation methods and adjusting for patient-level covariates. Of 16 674 eligible hospitalizations from 210 hospitals, 1020 patients (6.1%) were prescribed ARNI at discharge. The median hospital-level proportion of patients prescribed ARNI was 3.3% (Q1, Q3: 0%, 12.6%). After adjustment for patient-level covariates, for-profit hospitals had significantly higher odds of ARNI prescription compared with not-for-profit hospitals (odds ratio, 2.53; 95% CI , 1.05-6.10; P=0.04), and hospitals located in the Western United States had lower odds of ARNI prescription compared with those in the Northeast (odds ratio, 0.33; 95% CI , 0.13-0.84; P=0.02). Conclusions Relatively few hospital characteristics were associated with ARNI prescription at hospital discharge, in contrast to what has been observed in early adoption in other disease areas. Additional evaluation of barriers to implementing new evidence into heart failure practice is needed.

BackgroundSex-based differences in acute coronary syndrome (ACS) mortality may attenuate with age due to better symptom recognition and prompt care.HypothesisAge is a modifier of temporal trends in sex-based differences in ACS care.MethodsAmong 104 817 eligible patients with ACS enrolled in the AHA Get With the Guidelines-Coronary Artery Disease registry between 2003 and 2008, care and in-hospital mortality were evaluated stratified by sex and age. Temporal trends within sex and age groups were assessed for 2 care processes: percentage of STEMI patients presenting to PCI-capable hospitals with a DTB time ≤ 90 minutes (DTB90) and proportion of eligible ACS patients receiving aspirin within 24 hours.ResultsAfter adjustment for clinical risk factors and sociodemographic and hospital characteristics, 2276 (51.7%) women and 6276 (56.9%) men with STEMI were treated with DTB90 (adjusted OR: 0.85, 95% CI: 0.80-0.91, P

BackgroundSurveys of patients with cardiovascular disease have suggested that "home-time"-being alive and out of any health care institution-is a prioritized outcome. This novel measure has not been studied among patients with heart failure (HF).ObjectivesThis study sought to characterize home-time following hospitalization for HF and assess its relationship with patient characteristics and traditionally reported clinical outcomes.MethodsUsing GWTG-HF (Get With The Guidelines-Heart Failure) registry data, patients discharged alive from an HF hospitalization between 2011 and 2014 and ≥65 years of age were identified. Using Medicare claims, post-discharge home-time over 30-day and 1-year follow-up was calculated for each patient as the number of days alive and spent outside of a hospital, skilled nursing facility (SNF), or rehabilitation facility.ResultsAmong 59,736 patients, 57,992 (97.1%) and 42,153 (70.6%) had complete follow-up for home-time calculation through 30 days and 1 year, respectively. The mean home-time was 21.6 ± 11.7 days at 30 days and 243.9 ± 137.6 days at 1 year. Contributions to reduced home-time varied by follow-up period, with days spent in SNF being the largest contributor though 30 days and death being the largest contributor through 1 year. Over 1 year, 2,044 (4.8%) patients had no home-time following index hospitalization discharge, whereas 8,194 (19.4%) had 365 days of home-time. In regression models, several conditions were associated with substantially reduced home-time, including chronic obstructive pulmonary disease, renal insufficiency, and dementia. Through 1 year, home-time was highly correlated with time-to-event endpoints of death (tau = 0.72) and the composite of death or HF readmission (tau = 0.59).ConclusionsHome-time, which can be readily calculated from administrative claims data, is substantially reduced for many patients following hospitalization for HF and is highly correlated with traditional time-to-event mortality and hospitalization outcomes. Home-time represents a novel, easily measured, patient-centered endpoint that may reflect effectiveness of interventions in future HF studies.

The present study sought to determine if episodic future thinking (EFT) can decrease delay discounting (DD) and demand for fast food under simulations of economic scarcity in adults at risk for diabetes (i.e., overweight/obese and with hemoglobin A1c values in, or approaching, the prediabetic range). Across two sessions, participants completed assessments of DD and food demand at baseline and while prompted to: (1) engage in either EFT or control episodic recent thinking, and (2) while reading a brief narrative describing either economic scarcity or neutral income conditions. Results showed that EFT significantly reduced DD, whereas the economic scarcity narrative significantly increased DD; no significant interaction between EFT and scarcity was observed. No significant effect of either EFT or scarcity was observed on food demand. We conclude that EFT decreases DD even when challenged by simulated economic scarcity in adults at risk for diabetes. The absence of a significant interaction between EFT and scarcity suggests that these variables operate independently to influence DD in opposing directions. Effects of EFT and economic scarcity on food demand require further study. The present study was registered on clinicaltrials.gov (NCT03664726)., Author(s): Jeffrey S. Stein [sup.1] , William H. Craft [sup.1] , Rocco A. Paluch [sup.2] , Kirstin M. Gatchalian [sup.1] , Mark H. Greenawald [sup.3] , Teresa Quattrin [sup.2] , [...]

Recovery from alcohol use disorder (AUD) is a dynamic process that often entails periods of drinking but has been defined primarily by abstinence. Recently, a broader interpretation of recovery was developed, including meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM) remission criteria and improved psychosocial functioning. This new understanding of recovery has facilitated the development of novel theories and methodologies. This paper reviews a new theoretical perspective of recovery, Reinforcer Pathology, and two novel methodological approaches in light of this broader view of recovery. Using this theoretical framework as a foundation, we propose an alternative perspective to explain the recovery process as it relates to environmental factors and valuation of the future; we suggest that changing the environment in which substances are available (e.g., increasing non‐alcohol‐related activities) and extending one's temporal window are associated with improved recovery outcomes (e.g., remission and quality of life). In this review, we discuss two novel methodological approaches. The first uses latent profile analysis to show that using a measure of Relative Reinforcement Value of Alcohol‐Free Activities is associated with a greater likelihood of belonging to a high functioning/infrequent heavy drinking recovery profile. The second developed an online national sample and used an accelerated longitudinal design to study longer‐term recovery of up to 12 years over a 5‐year study period. Reinforcer Pathology theory, novel methods, and measures may further our understanding of recovery and begin to address critical questions for future studies. Subsequent randomized clinical trials should examine whether the suggested targets and interventions based on the theoretical model improve recovery outcomes prospectively. Measuring and promoting alcohol‐free activity engagement may facilitate improved recovery outcomes, while novel methodologies permit an understanding of returning to use or remission across different recovery durations. [ABSTRACT FROM AUTHOR]

BackgroundWhether heart rate upon discharge following hospitalization for heart failure is associated with long-term adverse outcomes and whether this association differs between patients with sinus rhythm (SR) and atrial fibrillation (AF) have not been well studied.Methods and resultsWe conducted a retrospective cohort study from clinical registry data linked to Medicare claims for 46 217 patients participating in Get With The Guidelines(®)-Heart Failure. Cox proportional-hazards models were used to estimate the association between discharge heart rate and all-cause mortality, all-cause readmission, and the composite outcome of mortality/readmission through 1 year. For SR and AF patients with heart rate ≥75, the association between heart rate and mortality (expressed as hazard ratio [HR] per 10 beats-per-minute increment) was significant at 0 to 30 days (SR: HR 1.30, 95% CI 1.22 to 1.39; AF: HR 1.23, 95% CI 1.16 to 1.29) and 31 to 365 days (SR: HR 1.15, 95% CI 1.12 to 1.20; AF: HR 1.05, 95% CI 1.01 to 1.08). Similar associations between heart rate and all-cause readmission and the composite outcome were obtained for SR and AF patients from 0 to 30 days but only in the composite outcome for SR patients over the longer term. The HR from 0 to 30 days exceeded that from 31 to 365 days for both SR and AF patients. At heart rates

BackgroundResearch grounded in behavioral economics has previously linked addictive behavior to disrupted decision-making and reward-processing, but these principles have not been examined in prescription opioid addiction, which is currently a major public health problem. This study examined whether pre-treatment drug reinforcement value predicted opioid use during outpatient treatment of prescription opioid addiction.MethodsSecondary analyses examined participants with prescription opioid dependence who received 12 weeks of buprenorphine-naloxone and counseling in a multi-site clinical trial (N=353). Baseline measures assessed opioid source and indices of drug reinforcement value, including the total amount and proportion of income spent on drugs. Weekly urine drug screens measured opioid use.ResultsObtaining opioids from doctors was associated with lower pre-treatment drug spending, while obtaining opioids from dealers/patients was associated with greater spending. Controlling for demographics, opioid use history, and opioid source frequency, patients who spent a greater total amount (OR=1.30, p