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Introduction In August 2013, the Centers for Medicare and Medicaid Services (CMS) Open Payments Program (OPP) made eligible payment information publicly available. Data about industry payments to neuromuscular neurologists are lacking. Method Financial relationships were investigated between industry and US neuromuscular neurologists from January 2014 through December 2018 using the CMS OPP database. Results The total annual payments increased more than 6-fold during the study period. The top 10% of physician-beneficiaries collected 80% to 90% of total industry payments except in 2014. In 2018, the most common drugs associated with payments to neuromuscular neurologists were nusinersen, vortioxetine, eteplirsen, alglucosidase alpha, edaravone, and intravenous immunoglobulin. Discussion A substantial increase in the annual payments to neuromuscular physicians during the study period is likely due to the development of new treatments, including gene therapy.

Background and Aim The purpose of this study was to review and analyze the nature of industry payments to gastroenterology and hepatology (GI) physicians. Methods We conducted a retrospective study of open payments (OP) data for the year 2017. Payments to individual physicians were aggregated using a unique physician profile identification number. General payments to Centers for Medicare and Medicaid Services regions were also analyzed. The nature of financial transactions in general payments was reported overall and per physician payment. Research, ownership, and general payments were aggregated and analyzed by drug/device companies. Results During the study period, more GI physicians received contributions in the form of general payments compared to ownership or research payments. A small percentage of physicians received contributions greater than $100 000. The most frequent contributions were for food and beverages. Only 10 manufacturers made about 71% ($43 271 938) of general payments. Conclusions We found that only a small number of GI physicians received a significant portion of industry payments. A large portion of those payments came from drug or device companies. The impact of these payments on gastroenterologists needs to be examined further., We found that only a small number of GI physicians received a significant portion of industry payments. A large portion of those payments came from drug or device companies. The impact of these payments on gastroenterologists needs to be examined further.

Background Previous studies examining the use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) have largely focused on patients newly initiating therapy. Little is known about the prevalence/patterns of switching to DOACs among AF patients initially treated with warfarin. Hypothesis To examine patterns of anticoagulation among patients chronically managed with warfarin upon the availability of DOACs and identify patient/practice‐level factors associated with switching from chronic warfarin therapy to a DOAC. Methods Prospective cohort study of AF patients in the NCDR PINNACLE registry prescribed warfarin between May 1, 2008 and May 1, 2015. Patients were followed at least 1 year (median length of follow‐up 375 days, IQR 154‐375) through May 1, 2016 and stratified as follows: continued warfarin, switched to DOAC, or discontinued anticoagulation. To identify significant predictors of switching, a three‐level multivariable hierarchical regression was developed. Results Among 383 008 AF patients initially prescribed warfarin, 16.3% (n = 62 620) switched to DOACs, 68.8% (n = 263 609) continued warfarin, and 14.8% (n = 56 779) discontinued anticoagulation. Among those switched, 37.6% received dabigatran, 37.0% rivaroxaban, 24.4% apixaban, and 1.0% edoxaban. Switched patients were more likely to be younger, women, white, and have private insurance (all P

Background and Purpose— Industry payments to physicians raise concerns regarding conflicts of interest that could impact patient care. We explored nonresearch and nonownership payments from industry to vascular neurologists to identify trends in compensation. Methods— Using Centers for Medicare and Medicaid Services and American Board of Psychiatry and Neurology data, we explored financial relationships between industry and US vascular neurologists from 2013 to 2018. We analyzed payment characteristics, including payment categories, payment distribution among physicians, regional trends, and biomedical manufacturers. Furthermore, we analyzed the top 1% (by compensation) of vascular neurologists with detailed payment categories, their position, and their contribution to stroke guidelines. Results— The number of board certified vascular neurologist increased from 1169 in 2013 to 1746 in 2018. The total payments to vascular neurologist increased from $99 749 in 2013 to $1 032 302 in 2018. During the study period, 16% to 17% of vascular neurologists received industry payments. Total payments from industry and mean physician payments increased yearly over this period, with consulting fee (31.1%) and compensation for services other than consulting (30.7%) being the highest paid categories. The top 10 manufacturers made the majority of the payments, and the top 10 products changed from drug or biological products to devices. Physicians from south region of the United States received the highest total payment (38.72%), which steadily increased. Payments to top 1% vascular neurologists increased from 64% to 79% over the period as payments became less evenly distributed. Among the top 1%, 42% specialized in neuro intervention, 11% contributed to American Heart Association/American Stroke Association guidelines, and around 75% were key leaders in the field. Conclusions— A small proportion of US vascular neurologists consistently received the majority of industry payments, the value of which grew over the study period. Only 11% of the top 1% receiving industry payments have authored American Heart Association/American Stroke Association guidelines, but ≈75% seem to be key leaders in the field. Whether this influences clinical practice and behavior requires further investigation.

ACC/AHA guidelines support the use of the P2YMulticenter, longitudinal analysis of patients and hospitals in the National Cardiovascular Data Registry (NCDR) Chest Pain - MI Registry from the third quarter of 2013 to the first quarter of 2017.A total of 362,354 AMI patients treated at 801 hospitals were included in our analysis. Ticagrelor use increased over time, from 6.1% in 2013 to 33.7% in 2017, with corresponding reductions in the use of clopidogrel and prasugrel (p 0.001 for all trends). In multivariable models, patients of white race, with private insurance, or STEMI were more likely to receive ticagrelor (p 0.05 for all). Hospitals in the highest quartile of ticagrelor uptake had use rates ranging from 29% to 88%, and were more likely to have the lowest volume of MI patients. The correlation between prasugrel and ticagrelor adoption was weakly positive (correlation coefficient: 0.15, p = 0.004); hospitals with the lowest early adoption of prasugrel started with the lowest rate of ticagrelor use and had the slowest rate of increase in ticagrelor use.There has been a rapid increase in use of ticagrelor since its approval by the FDA and both patient and hospital characteristics were associated with variation in its adoption and utilization. Further examination of the characteristics associated with the rapid adoption of new evidence may provide insights about improving health system performance.

Background: The risk of acute kidney injury (AKI) for percutaneous coronary intervention (PCI) can inform decision-making and mitigation. However, risk assessment is hampered by the burden of manually abstracting and inputting data required by the established model developed on registry data. Accordingly, there is a need to develop AKI models that use automatically extracted electronic health records (EHR) data and evaluate their performance in comparison to the contemporary registry model. Methods: We used EHR data for PCIs performed at Yale New Haven Hospital (YNHH) and the linked local National Cardiovascular Data Registry (NCDR) CathPCI data to develop and compare the EHR models with the NCDR model. AKI was defined as an increase of ≥0.3 mg/dL or 50% in serum creatinine. To maximize interoperability across systems and usability at the point of care, we only considered structured EHR readily extractable before PCI, and implemented simple but universal data preprocessing. Longitudinal data was aggregated into 24h, 7d and 14d prior to PCI. We used Lasso regression and gradient descent boosting (GDB) to train the models and tested their capacity to approximate the NCDR model predictions and predict AKI independently. We evaluated performance via cross-validation by c-statistic, calibration slope, and predictive range defined by event rate difference in the lowest and highest risk deciles. We used paired t tests for model comparison. Results: The cohort included 9,202 PCIs from December 2012 to November 2019 at YNHH for 8,445 patients and had a mean age of 67.0±12.0 years with 27.6% females and 798 (8.7%) AKIs. Evaluated on the same test sets, the EHR models approximating the NCDR model predictions achieved similar performance to that model (all p>0.05). Further, the EHR model employing GDB to independently predict AKI achieved slightly better performance than the NCDR model in c-statistic (0.84 vs 0.83, p=0.02) and predictive range (41.2% vs 39.5%, p=0.13) with similar calibration (slope 0.98 vs 0.99). Conclusion: The automatically extracted EHR data produced models with similar performance to the registry model. These models can automate AKI risk assessment for PCI, alleviating provider burden and increase uptake of risk assessment.

ImportanceMinoritized racial and ethnic groups are generally more likely to experience sleep deficiencies. It is unclear how these sleep duration disparities have changed over recent years.ObjectiveTo determine 15-year trends in the racial and ethnic differences in self-reported sleep duration among adults in the US.DesignSerial cross-sectional study of the National Health Interview Survey from years 2004– 2018. Analyses were performed between July 26, 2021 and February 10, 2022.SettingUS population-based.Participants429,195 non-institutionalized adults.ExposuresSelf-reported race, ethnicity, household income, and sex/gender.Main OutcomesTemporal trends and racial/ethnic differences in short- and long-sleep duration (9 hours in a 24-hour period, respectively), and racial/ethnic differences in the relationship between sleep duration and age.ResultsThe study sample consisted of 429,195 individuals (mean age 46.5 [SE, 0.08] years; 51.7% female) of which 5.1% identified as Asian, 11.8% as Black, 14.7% as Latino/Hispanic, and 68.5% as White. In 2004, the adjusted estimated prevalence of short-sleep duration and long-sleep duration, respectively, were 31.3% and 2.5% among Asian individuals, 35.3% and 6.4% among Black individuals, 27.0% and 4.6% among Latino/Hispanic individuals, and 27.8% and 3.5% among White individuals. Over the study period, there was a significant increase in the short sleep prevalence among Black, Latino/Hispanic, and White individuals (P≤0.001 for each), whereas prevalence of long sleep changed significantly only among Latino/Hispanic individuals (−1.4 points, P=0.01). In 2018, compared with White individuals, short sleep prevalence among Black and Latino/Hispanic individuals was higher by 10.7 points and 2.4 points, respectively(P≤0.03 each), and long sleep prevalence was higher only among Black people (+1.4 points; P=0.01). The short-sleep disparities were the greatest among women and among those with middle/high household income. In addition, across age groups, Black individuals had a higher short- and long-sleep duration prevalence compared with White individuals of their same age. ConclusionsIn this serial cross-sectional study from 2004 to 2018, the prevalence of short and long sleep duration was persistently higher among Black individuals. The Black-White disparities in short-sleep were highest among women, individuals who had middle or high income, and among young or middle-aged adults.KEY POINTSQuestionHow have racial and ethnic differences in self-reported sleep duration among US adults changed between 2004 and 2018?FindingsIn this serial cross-sectional study that included 429,195 adults, the prevalence of both short and long sleep duration were persistently higher among Black individuals over the 15-year study period. The disparities in short sleep duration were highest for Black women, Black individuals with middle or high income, and young and middle-aged Black adults.MeaningThere were marked racial and ethnic differences in sleep duration that persisted from 2004 to 2018, which may be contributing to health disparities.

ImportanceThirty-five years ago, the Heckler Report described health disparities among minority populations in the US. Since then, policies have been implemented to address these disparities. However, a recent evaluation of progress towards improving the health and health equity among US adults is lacking.ObjectivesTo evaluate racial/ethnic disparities in the physical and mental health of US adults over the last 2 decades.DesignCross-sectional.SettingNational Health Interview Survey data, years 1999–2018.ParticipantsAdults aged 18–85 years.ExposureRace/ethnicity subgroups (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Hispanic).Main outcome and measuresProportion of adults reporting poor/fair health status, severe psychological distress, functional limitation, and insufficient sleep. We also estimated the gap between non-Hispanic White and the other subgroups for these four outcomes.ResultsWe included 596,355 adults (mean age 46 years, 51.8% women), of which 69.7%, 13.8%, 11.8% and 4.7% identified as non-Hispanic White, Hispanic, non-Hispanic Black, and non-Hispanic Asian, respectively. Between 1999 and 2018, Black individuals fared worse on most measures of health, with 18.7% (95% CI 17.1–20.4) and 41.1% (95% CI 38.7–43.5) reporting poor/fair health and insufficient sleep in 2018 compared with 11.1% (95% CI 10.5– 11.7) and 31.2% (95% CI 30.3–32.1) among White individuals. Notably, between 1999–2018, there was no significant decrease in the gap in poor/fair health status between White individuals and Black (−0.07% per year, 95% CI −0.16–0.01) and Hispanic (−0.03% per year, 95% CI −0.07– 0.02) individuals, and an increase in the gap in sleep between White individuals and Black (+0.2% per year, 95% CI 0.1–0.4) and Hispanic (+0.3% per year, 95% CI 0.1–0.4) individuals. Additionally, there was no significant decrease in adults reporting poor/fair health status and an increase in adults reporting severe psychological distress, functional limitation, and insufficient sleep.Conclusions and RelevanceThe marked racial/ethnic disparities in health of US adults have not improved over the last 20 years. Moreover, the self-perceived health of US adults worsened during this time. These findings highlight the need to re-examine the initiatives seeking to promote health equity and improve health.

ImportanceRacial and ethnic disparities plague the US health care system despite efforts to eliminate them. To understand what has been achieved amid these efforts, a comprehensive study from the population perspective is needed.ObjectivesTo determine trends in rates and racial/ethnic disparities of key access to care measures among adults in the US in the last two decades.DesignCross-sectional.SettingData from the National Health Interview Survey, 1999–2018.ParticipantsIndividuals >18 years old.ExposureRace and ethnicity: non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, Hispanic.Main outcome and measuresRates of lack of insurance coverage, lack of a usual source of care, and foregone/delayed medical care due to cost. We also estimated the gap between non-Hispanic White and the other subgroups for these outcomes.ResultsWe included 596,355 adults, of which 69.7% identified as White, 11.8% as Black, 4.7% as Asian, and 13.8% as Hispanic. The proportion uninsured and the rates of lacking a usual source of care remained stable across all 4 race/ethnicity subgroups up to 2009, while rates of foregone/delayed medical care due to cost increased. Between 2010 and 2015, the percentage of uninsured diminished for all, with the steepest reduction among Hispanics (−2.1% per year). In the same period, rates of no usual source of care declined only among Hispanics (−1.2% per year) while rates of foregone/delayed medical care due to cost decreased for all. No substantial changes were observed from 2016–2018 in any outcome across subgroups. Compared with 1999, in 2018 the rates of foregone/delayed medical care due to cost were higher for all (+3.1% among Whites, +3.1% among Blacks, +0.5% among Asians, and +2.2% among Hispanics) without significant change in gaps; rates of no usual source of care were not significantly different among Whites or Blacks but were lower among Hispanics (−4.9%) and Asians (−6.4%).Conclusions and RelevanceInsurance coverage increased for all, but millions of individuals remained uninsured or underinsured with increasing rates of unmet medical needs due to cost. Those identifying as non-Hispanic Black and Hispanic continue to experience more barriers to health care services compared with non-Hispanic White individuals.KEY POINTSQuestionIn the last 2 decades, what has been achieved in reducing barriers to access to care and race/ethnicity-associated disparities?FindingsUsing National Health Interview Survey data from 1999–2018, we found that insurance coverage increased across all 4 major race/ethnicity groups. However, rates of unmet medical needs due to cost increased without reducing the respective racial/ethnic disparities, and little-to-no change occurred in rates of individuals who have no usual source of care.MeaningDespite increased coverage, millions of Americans continued to experience barriers to access to care, which were disproportionately more prevalent among those identifying as Black or Hispanic.

Background Outcomes data in patients with cardiac amyloidosis after implantable cardioverter‐defibrillator (ICD) implantation are limited. We compared outcomes of patients with ICDs implanted for cardiac amyloidosis versus nonischemic cardiomyopathies (NICMs) and evaluated factors associated with mortality among patients with cardiac amyloidosis. Methods and Results Using National Cardiovascular Data Registry’s ICD Registry data between April 1, 2010 and December 31, 2015, we created a 1:5 propensity‐matched cohort of patients implanted with ICDs with cardiac amyloidosis and NICM. We compared mortality between those with cardiac amyloidosis and matched patients with NICM using Kaplan‐Meier survival curves and Cox proportional hazards models. We also evaluated risk factors associated with 1‐year mortality in patients with cardiac amyloidosis using multivariable Cox proportional hazards regression models. Among 472 patients with cardiac amyloidosis and 2360 patients with propensity‐matched NICMs, 1‐year mortality was significantly higher in patients with cardiac amyloidosis compared with patients with NICMs (26.9% versus 11.3%, P 2.5 (HR, 4.34; 95% CI, 2.72–6.93). Conclusions Mortality after ICD implantation is significantly higher in patients with cardiac amyloidosis than in patients with propensity‐matched NICMs. Factors associated with death among patients with cardiac amyloidosis include prior syncope, ventricular tachycardia, cerebrovascular disease, diabetes mellitus, and impaired renal function.

Introduction The cardiac catheterization laboratory (CCL) is a focal point for cardiovascular programs and the CCL director represents the key personnel. We outline profiles of CCL directors at the 2017 U.S. News & World Report top 100 U.S. cardiovascular hospitals. Methods Using hospital websites, LinkedIn, Healthgrades, Medicare Provider Utilization and Payment Data 2017, and Scopus, we described CCL directors (in 2017) by age, gender, years since medical graduation, international medical school graduate (IMG) status, academic rank, provider clinical focus, and Hirsch (h)-index. Results Nearly all CCL directors were male (97%). The median age (interquartile range [IQR]) was 53 (49-61) years and median (IQR) years since medical school graduation was 28 (23-35) years. Over a third of CCL directors (39.4%) were IMGs and 38.4% had completed fellowship training at the same facility where they were CCL director. The median (IQR) h-index was 11 (6-22). Of the 69.7% CCL directors who held faculty positions, 60.9% were professors and 30.4% were associate professors. From Medicare data, 45.5% performed only percutaneous coronary interventions, 41.4% performed structural interventions, 3.0% peripheral interventions, and 2.0% performed both structural and peripheral. CCL directors at the top 25 hospitals had higher h-indexes, and more likely to have completed fellowship training at their own institution. Conclusions There are very few women CCL directors at the top U.S. cardiovascular hospitals. A third of the CCL directors were IMGs. A significant proportion of CCL directors primarily performed structural interventions and trained at the same institution, more so at the top 25 hospitals.

Background While optimal cardiovascular risk factor (CRF) profile is associated with lower mortality, morbidity, and healthcare expenditures among individuals with atherosclerotic cardiovascular disease (ASCVD), less is known regarding its impact on financial hardship from medical bills. Therefore, we assessed whether an optimal CRF profile is associated with a lower burden of financial hardship from medical bills and a reduction in cost-related barriers to health. Methods We used a nationally representative sample of adults between 18 and 64 years from the National Health Interview Survey between 2013 and 2017. We assessed ASCVD status and the number of risk factors to categorize the study population into 4 mutually exclusive categories: ASCVD (irrespective of CRF profile) and non-ASCVD with poor, average, and optimal CRF profile. Adjusted logistic regression model was used to determine the association of ASCVD/CRF profile with financial hardship from medical bills and cost-related barriers to health (cost-related medication non-adherence (CRN), foregone/delayed care, and high financial distress). Results We included 119,388 non-elderly adults, representing 189 million individuals annually across the United States. Non-ASCVD/optimal CRF profile individuals had a lower prevalence of financial hardship and an inability paying medical bills when compared with individuals with ASCVD (24% vs 45% and 6% vs 19%, respectively). Among individuals without ASCVD and an optimal CRF profile, the prevalence of each cost-related barrier to health was, Highlights • Nearly 1 in 5 individuals with ASCVD reported an inability to pay medical bills. • Only 6% of those with optimal CRF profile were unable to pay medical bills. • Optimal CRF profile had the lowest odds of all outcomes like high financial distress. • Worse outcomes among individuals with poor/low income and lack of insurance. • Optimal CRF profile was protective despite poor/low income and lack of insurance.

Importance The elimination of racial and ethnic differences in health status and health care access is a US goal, but it is unclear whether the country has made progress over the last 2 decades. Objective To determine 20-year trends in the racial and ethnic differences in self-reported measures of health status and health care access and affordability among adults in the US. Design, Setting, and Participants Serial cross-sectional study of National Health Interview Survey data, 1999-2018, that included 596 355 adults. Exposures Self-reported race, ethnicity, and income level. Main Outcomes and Measures Rates and racial and ethnic differences in self-reported health status and health care access and affordability. Results The study included 596 355 adults (mean [SE] age, 46.2 [0.07] years, 51.8% [SE, 0.10] women), of whom 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White. The estimated percentages of people with low income were 28.2%, 46.1%, 51.5%, and 23.9% among Asian, Black, Latino/Hispanic, and White individuals, respectively. Black individuals with low income had the highest estimated prevalence of poor or fair health status (29.1% [95% CI, 26.5%-31.7%] in 1999 and 24.9% [95% CI, 21.8%-28.3%] in 2018), while White individuals with middle and high income had the lowest (6.4% [95% CI, 5.9%-6.8%] in 1999 and 6.3% [95% CI, 5.8%-6.7%] in 2018). Black individuals had a significantly higher estimated prevalence of poor or fair health status than White individuals in 1999, regardless of income strata (P

Machine learning (ML) techniques have become ubiquitous and indispensable for solving intricate problems in most disciplines. To determine the extent of funding for clinical research projects applying ML techniques by the National Institutes of Health (NIH) in 2017, we searched the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) system using relevant keywords. We identified 535 projects, which together received a total of $264 million, accounting for 2% of the NIH extramural budget for clinical research.

This analysis of 2017 data from the Open Payments Program (OPP) database examines nonresearch industry payments to directors of caronary catheterization and electrophysiology laboratories to characterize payments across 13 OPP-defined categories.

Background: Atherosclerotic cardiovascular disease (ASCVD) remains a nation-wide crisis. Optimal cardiovascular risk factor (CRF) profile has been associated with lower mortality and morbidity, as well as lower healthcare expenditure and resource utilization. In this study, we examined the association of optimal CRF profile to financial hardship and other cost-related barriers to care, both with and without ASCVD. Methods: We used a nationally representative sample of non-elderly adults aged between 18-64 years from the National Health Interview Survey (2013-2017). We assessed atherosclerotic cardiovascular disease (ASCVD) status, CRF profile, financial hardship from medical bills, unable to pay bill at all, cost-related medication non-adherence, forgone/delayed care, and perceived financial distress from self-reported questionnaire. Results: A total of 119,388 individuals were included in the study. Individuals with ASCVD had financial hardship and inability to pay bills at 45% and 19%, respectively, significantly higher than those without ASCVD and optimal CRF profile at 24% and 6%, respectively. Similarly, the prevalence of other cost-related barriers to care was significantly higher among ASCVD (>2-fold) compared to non-ASCVD with optimal CRF profile. Individuals without ASCVD and optimal CRF profile among low/poor income and uninsured had higher prevalence of all the outcomes when compared to ASCVD among high income and insured. Individuals without ASCVD and optimal CRF profile had lowest odds of financial hardship (OR 0.44, 95% CI 0.41, 0.48), inability paying bills (OR 0.30, 95% CI 0.26, 0.34), cost-related medication non-adherence (OR 0.42, 95% CI 0.38, 0.48), foregone/delayed care (OR 0.41, 95% CI 0.37, 0.45), and high financial distress (OR 0.52, 95% CI 0.47, 0.58) (Table). There were no significant differences in these outcomes when comparing individuals without ASCVD and poor CRF profile to those with ASCVD. Conclusion: Optimal CRF profile is strongly associated with lower prevalence of financial hardship and other cost-related barriers to care. Upfront investment of preventive health programs, especially among vulnerable populations, may improve overall health and decrease financial hardship.

Background: Little is known regarding how well the U.S. News & World Report “Top-Ranked Hospitals for Cardiology and Heart Surgery” rankings reflect performance on key measures such as thirty-day risk-standardized mortality, readmissions, and payment. Methods: We used publicly available US News and World Report rankings of the top 50 best hospitals from 2014 to 2017 to stratify hospitals into ranked and unranked hospitals and utilized data from Medicare’s Hospital Compare database. Risk-standardized measures for payments, mortality rates, and readmission rates for Acute Myocardial Infarction (AMI) and Heart Failure (HF) in ranked and unranked hospitals were compared using two-tailed t-tests. Results: There were n=66 ranked hospitals and n=1846 unranked hospitals included in the analysis. As compared with unranked hospitals, top ranked hospitals had significantly lower thirty-day mortality rates for both AMI and HF (p Conclusion: We found that US News and World Report “Best Hospitals” performed significantly better on mortality measures but not on readmission measures. While payment in ranked hospitals may have been significantly higher in 2014 and 2015, greater increases in payments of unranked hospitals closed the gap between payments in ranked and unranked hospitals. As cost-efficiency is an important component of hospital performance, future research should explore how “Best Hospitals” are keeping costs down, and future ranking algorithms should incentivize decreased payments.

Background Despite improvements on individual process of care measures for acute myocardial infarction (AMI), little is known about performance on a composite measure of AMI care that assesses the delivery of many components of high-quality AMI care. We sought to examine trends in patient- and hospital-level performance on a composite defect-free care measure, identify disparities in the performance across sociodemographic groups, and identify opportunities to further improve quality and outcomes. Methods and Results We calculated the proportion of patients in the National Cardiovascular Data Registry-Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (now known as the Chest Pain - Myocardial Infarction Registry) between January 1, 2010, and December 31, 2017, receiving defect-free AMI care including guideline-recommended pharmacotherapy, timely provision of medical and reperfusion therapy, assessment of ventricular function, referral to cardiac rehabilitation, and smoking cessation counseling for patients with AMI. A total of 522 800 patients at 222 hospitals were included. Overall, the proportion of patients receiving defect-free care significantly increased from 66.0% in 2010 to 77.1% in 2017 ( P0.001). Improvements in performance were observed across all sociodemographic subgroups, with the greatest absolute improvement observed for black and Hispanic patients ( P0.001). However, absolute performance was consistently lower among older patients, women, black and Hispanic patients, and those with government insurance in 2017 ( P0.001 for all). Improvements in care and reduced variation in performance were observed at the hospital level overall (2010, median [IQR] 67.2% [40.7%-76.3%]; 2017, median [IQR] 80.7% [73.1%-88.1%]; P0.001) as well as across region, safety net status, teaching status, and proportion of patients who are nonwhite and have Medicaid insurance coverage ( P0.001 for all). Conclusions Despite improvements in the proportion of patients with AMI receiving defect-free care overall and across sociodemographic groups, nearly 1 in 4 patients in 2017 still did not receive optimal care and absolute performance was consistently lower among older patients, women, black, and Hispanic patients. Composite measures of cardiovascular care, which assess the delivery of several evidence-based processes of care, can illuminate opportunities to improve the quality of care beyond that provided by conventional process measures.

Background Despite improvements on individual process of care measures for acute myocardial infarction (AMI), little is known about performance on a composite measure of AMI care that assesses the delivery of many components of high-quality AMI care. We sought to examine trends in patient- and hospital-level performance on a composite defect-free care measure, identify disparities in the performance across sociodemographic groups, and identify opportunities to further improve quality and outcomes. Methods and Results We calculated the proportion of patients in the National Cardiovascular Data Registry–Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines (now known as the Chest Pain - Myocardial Infarction Registry) between January 1, 2010, and December 31, 2017, receiving defect-free AMI care including guideline-recommended pharmacotherapy, timely provision of medical and reperfusion therapy, assessment of ventricular function, referral to cardiac rehabilitation, and smoking cessation counseling for patients with AMI. A total of 522 800 patients at 222 hospitals were included. Overall, the proportion of patients receiving defect-free care significantly increased from 66.0% in 2010 to 77.1% in 2017 ( P P P P P Conclusions Despite improvements in the proportion of patients with AMI receiving defect-free care overall and across sociodemographic groups, nearly 1 in 4 patients in 2017 still did not receive optimal care and absolute performance was consistently lower among older patients, women, black, and Hispanic patients. Composite measures of cardiovascular care, which assess the delivery of several evidence-based processes of care, can illuminate opportunities to improve the quality of care beyond that provided by conventional process measures.

Background Habitual cocoa consumption has been shown to improve cardiometabolic risk. This study compared the effects of two doses of cocoa on blood pressure and other cardiometabolic risk factors in adults with stage 1 hypertension. Methods Randomized, controlled, modified Latin square parallel design to compare effects of two daily doses (i.e., 5 vs. 10 g) of cocoa powder in cocoa-containing products for 8 weeks on cardio-metabolic risk factors in 122 adults (average age 53.6 years; 63 women and 59 men) with stage 1 hypertension on no more than one medication. Results Daily cocoa consumption did not improve (p > 0.05) blood pressure, endothelial function, lipid profile, or insulin resistance in analyses of our entire sample. Daily consumption of cocoa, compared to placebo, reduced blood pressure in participants on ACE inhibitors (24-hour SBP: − 3.2 ± 9.3 vs. 3.6 ± 8.5; p = 0.038, 24-hour DBP: − 2.0 ± 5.0 vs. 2.3 ± 5.6 mm Hg; p = 0.023), beta blockers (− 4.6 ± 3.2 vs. 1.8 ± 2.8 mm Hg; p = 0.009) or diuretics (24-hour SBP 5.5 ± 7.4 vs. − 0.6 ± 4.7; p = 0.022); and improved endothelial function (3.1 ± 2.3 vs. − 3.4 ± 7.4%; p = 0.031) in participants on beta blockers. Dose-response on blood pressure was evident in participants on ACE inhibitors, with more benefit from the high dose compared to the low dose. Conclusions Including cocoa in the diet of patients with stage 1 hypertension seems to exert differential beneficial effects on cardiometabolic risk factors in certain sub-groups of patients.

Background: Industry payments made to physicians and hospitals are publicly disclosed through the Open Payments Program. The objective of this study was to analyze the trends of payments to cardiologists in the United States for 2014, 2015 and 2016. Methods: Descriptive analysis was performed on the non-research, non-ownership Open Payments data. The Gini index, a method to determine income dispersion, was calculated. Results: Cardiologists received a total of $187,180,369 for 2014, $173,309,019 for 2015, and $159,677,844 for 2016. The mean annual payment per cardiologist was $7,571 for 2014, $6,769 for 2015, and $6,309 for 2016 (p Conclusion: The mean annual payment amount per cardiologist decreased from 2014 to 2016; only a few cardiologists were receiving payments of a significant value every year. Further studies are needed to explore the impact of industry-cardiologist relationships on patient care.

Background: The Open Payments Program (OPP) mandates that biomedical companies disclose physician payments. Little is known about the spending characteristics of leading industry spenders. Methods: Using data from the OPP, we aggregated payments to individual cardiologists from 2014-2016, and subsequently studied payment characteristics of 10 leading companies. Results: From 2014-2016, payments totaling $520,167,233 were made to 30,372 cardiologists. The top 10 companies made 60% of total payments ($312,661,029). The companies with highest payment amounts were St. Jude (18%), Medtronic vascular (16%), Janssen pharmaceuticals (13%), Boston Scientific (12%), AstraZenca (11%), Pfizer (7%), Topera (7%), Bristol-Meyer Squibb (6%), Amgen (5%), and Novartis (5%). Majority of the payments were made for services such as speaking at dinner talks (59% of total payments). Other forms of payments were for food and beverages (12%), travel and lodging (10%), ownership interests (8%) and consulting fees (8%). Spending patterns of pharmaceutical companies were similar. Device manufactures such as Boston Scientific and Medtronic had a relatively higher proportion of spending on travel and ownership fees. Conclusion: Few major companies made a significant proportion of payments to cardiologists. Services such as speaking at dinner talks were the largest areas of spending. The impact of the OPP on the patterns of industry spending remains to be seen.

Background: The Sunshine Act mandates that medical product manufacturers disclose payments and other transfers of value made to physicians or teaching hospitals. There is a lack of data characterizing payments received by cardiologists by sub-specialty. Methods: Using data from Open Payments Program for the year 2016 we aggregated payments made to individual cardiologists and analyzed the characteristics and distribution of payments by specialty - general cardiologists (GC), electrophysiologists (EP) and interventional cardiologists (IC). We calculated the Gini index, a measure of income dispersion in a group (index ‘0’ means payments are equally distributed; ‘1’ means one person received all payments). Results: A total of $1,598,677,844 was paid to 25,310 cardiologists in 2016, representing 84% of practicing cardiologists. The median annual aggregate value of payment was $2,245 for EP, $357 for GC and $1,143 for IC (p Conclusion: There is variation in payments among the three cardiology specialties, with EP receiving the highest median number and value of payments. Future analyses are needed to determine if payments are associated with changes in practice patterns.

Background: The presence of comorbid atrial fibrillation (AF) in patients hospitalized for acute coronary syndrome (ACS) and undergoing stent placement may necessitate the need for triple anti- thrombotic therapy including an anticoagulant plus dual antiplatelet therapy. We sought to determine the prevalence of comorbid AF in patients hospitalized for ACS and receiving a coronary stent and comorbid AF’s association with the type of stent implanted. Methods: We performed a retrospective analysis in the 2012 United States Agency for Healthcare Research and Quality National Inpatient Sample dataset. We included adult patients (age ≥18 years) hospitalized for ACS (International Classification of Diseases-Ninth Revision [ICD-9] diagnostic codes=410.x or 411.x in the primary position) who received either a bare-metal stent (BMS)(ICD-9 procedure code=36.06) or drug-eluting stent (DES)(ICD-9 procedure code=36.07). Patients were stratified into 2 cohorts based on the presence or absence of an ICD-9 diagnosis code in any position signifying comorbid AF (427.31 or 427.32). Multivariable logistic regression was performed to determine the association between comorbid AF and the odds of receiving a DES after adjustment for patient- and hospital-level covariates. Results are reported as adjusted odds ratios with accompanying 95% confidence intervals. Results: During the year 2012, there were 66,287 ACS patient admissions, of which, 24.7% received a BMS and 75.3% a DES. Of these admissions, 7,109 (10.9%) were for patients with comorbid AF (median [25%, 75% range] for CHA2DS2-VASc and ATRIA scores =3 [2, 4] and 1 [1, 3]). Following multivariable adjustment, the odds of receiving a DES were lower for ACS patients with comorbid AF (adjusted odds ratio=0.63, 95% confidence interval=0.59-0.67). Conclusions: Comorbid AF is not an uncommon condition in patients hospitalized for ACS and receiving a coronary stent. Our study suggests comorbid AF is associated with a significant 27% decreased odds of receiving a DES versus a BMS. This decreased utilization of DES may be secondary to concerns of increased bleeding from prolonged triple therapy and is not inconsistent with current guidelines.

Implantable cardioverter-defibrillators (ICDs) are recommended for patients with cardiac sarcoidosis with complete heart block, prior ventricular arrhythmias, cardiac arrest, or left ventricular ejection fraction